slide1 l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Presented by: Donald L. Trussell DEP Safety Program Administrator 850-488-0878 or SC 278-0878 PowerPoint Presentation
Download Presentation
Presented by: Donald L. Trussell DEP Safety Program Administrator 850-488-0878 or SC 278-0878

Loading in 2 Seconds...

play fullscreen
1 / 49

Presented by: Donald L. Trussell DEP Safety Program Administrator 850-488-0878 or SC 278-0878 - PowerPoint PPT Presentation


  • 154 Views
  • Uploaded on

Presented by: Donald L. Trussell DEP Safety Program Administrator 850-488-0878 or SC 278-0878. INCIDENT INVESTIGATION. “The Basics”. Introduction. BABYLONIAN LAW WHY PRACTICE SAFETY? SAFETY EXCELLENCE. SAFETY CULTURE. CULTURE PARK SAFETY CULTURE WAY OF LIFE TEAMWORK/PARTNERSHIP.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Presented by: Donald L. Trussell DEP Safety Program Administrator 850-488-0878 or SC 278-0878' - sandra_john


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide1

Presented by:

Donald L. Trussell

DEP Safety Program Administrator

850-488-0878 or SC 278-0878

incident investigation

INCIDENT INVESTIGATION

“The Basics”

introduction
Introduction
  • BABYLONIAN LAW
  • WHY PRACTICE SAFETY?
  • SAFETY EXCELLENCE
safety culture
SAFETY CULTURE
  • CULTURE
  • PARK SAFETY CULTURE
  • WAY OF LIFE
  • TEAMWORK/PARTNERSHIP
slide5
RISK
  • DEFINITION
  • IDENTIFY POTENTIAL PROBLEMS
responsibility accountability
Responsibility/Accountability
  • BASIC CONCEPT
  • MEASURE PERFORMANCE
  • ACCOUNTABILITY:
    • Put the “I” back in
accidents
ACCIDENTS
  • DON’T JUST HAPPEN
  • ARE THE LEADING CAUSE OF DEATH
  • RESULT OF UNSAFE OR SUBSTANDARD ACTS AND CONDITIONS
incidents
INCIDENTS
  • ACCIDENTS ARE INCIDENTS
  • HAVE THE POTENTIAL TO HARM
  • SHOULD ALWAYS BE INVESTIGATED
what is an incident

What is an incident?

An incident is………..????

an incident is
An incident is:
  • Unwanted
  • Unplanned
  • Unforeseen
  • Disruptive
  • Can be major or minor
obvious injury costs
Obvious Injury Costs
  • Insurance Premiums
  • Medical Expenses
  • Worker Compensation
  • Rest of work crew “takes up the slack”
  • Accident Cost Iceberg
hidden injury costs
Hidden Injury Costs
  • Lost time at work
  • Reduced or lost income
  • Pain and suffering
  • Possibly having to learn a new job
  • Training costs to the company
  • Administrative costs (Investigation, ES&H, HR)
actions vs attitudes

Actions vs. Attitudes

Which is easier to see and report?

actions vs attitudes15
Actions vs. Attitudes
  • Which is easier to change?
what we would like to see
What we would like to see….
  • That you understand why people do the things they do.
  • That you know there are many factors that cause an incident.
  • But mostly………That you look deeply into why incidents happen!
why do we investigate
Why do we investigate??
  • Prove the victim was at fault? …..no
  • CYA …….no
  • Avoid law suits against the company….no
  • Try to make the work place safer!!
slide18
Incident Investigation =An opportunity to change the work climate by correcting unsafe conditions, procedures, or actions.
elements of the investigation
Elements of the Investigation
  • Describe who was involved
  • Describe what happened
  • Establish a time line
  • Determine location of incident & all factors
  • Establish a chain of events to understand how the incident occurred
  • Determine the cause & root cause
first goals of the investigation

First Goals of the Investigation

Establish the following:

1. Who

2. What

3. When

4. Where

5. How

6. Why

slide21

Who

Establish the person(s) who were involved in the incident, including witnesses. This includes all persons and not just an injured employee.

slide22

What

Describe in detail what happened.

slide23

When

Ensure times and dates are included in the statements.

where

Where

Get specific about the location, to include what Site, what facility, road name, etc.

slide25

How

Make sure your description of the incident is clear and describes the factors that caused the incident.

slide26

Why

Based on who/what/when/where/& how, you should be able to piece together why the incident happened. This involves piecing information together to form a conclusion of the cause & root cause of the incident.

drawing conclusions

Drawing Conclusions

From the who/what/when/where/how & why that you just gathered, you now need to determine both the cause and root cause of the incident.

slide28

“All things are hidden, obscure, and debatable if the cause of the phenomena be unknown, but everything is clear if this cause be known.”Louis Pasture

cause of the incident

Cause of the incident

The “cause” of the incident should describe what the immediate symptoms are of the incident.

Example: An employee slipped on the floor because there was spilled coffee that made the floor slippery.

root cause

Root Cause

The “root cause” of the incident is the basic underlying reason, not always apparent, that caused the incident.

Example: The root cause of the incident was that the person who spilled the coffee did not clean it up or establish a warning method to alert others of a hazard.

slide31

Causal Factors Incident

  • Precedes The loss
  • Slip, Trip, Fall
  • Loss Causation
causal factors basic causes
Causal FactorsBasic Causes
  • THE DISEASE
  • THIS IS THE “WHY” IT HAPPENED
  • PEOPLE, EQUIPMENT, MATERIALS, ENVIRONMENT
  • PERSONAL & JOB FACTORS
causal factors lack of control
Causal FactorsLack of Control
  • STARTS THE SEQUENCE
  • 3 WAYS TO GAIN CONTROL:
  • PROGRAM
  • STANDARDS
  • COMPLIANCE
multiple source causes controls
Multiple SourceCauses-Controls
  • CHAIN
  • 90/10 RULE
  • 3 STAGES OF CONTROL:
  • PRE-CONTACT
  • CONTACT
  • POST CONTACT
begin your investigation
Begin Your Investigation
  • Get the affected person’s statement.
  • Get onlookers’ statements.
  • Note the positions of people and things.
  • Gather other information as needed, like manuals, records of training, safety, and maintenance.
  • Get pictures when needed (picture worth 1000 words)
interview tips
Interview Tips
  • Need information - not placing blame.
  • Try to form open ended, non-judgmental questions.
  • Ask as many questions as it takes to clarify your understanding.
begin your written report

Begin Your Written Report

Gather all of your facts previously obtained, in particular who/what/when/where/how/why,

and the cause/root cause of the incident.

Additionally, gather written statements, information on similar incidents, and pictures to support your position when needed.

slide39

Example of Fact GatheringOn July 29, 1999, on or about 10:45 am, Joe Employee was stacking concrete blocks and walked into a piece of steel re-enforcing bar that was protruding out of the end of the pipe storage shelving unit located inside the Project Materials compound, striking him in the face. A 1” cut was received across the middle of Mr. Employee’s forehead. He proceeded directly to the dispensary, where he received 4 sutures to close the laceration, then was released at 11:41am in a full duty status. He went to lunch, then informed his immediate supervisor of the incident upon returning to work at 12:30.

slide40

Your Conclusions:Cause: The incident was caused by Joe not paying attention to his surroundings and striking his head on the rebar.Root Cause #1: Somebody didn’t properly store the rebar and left it in a haphazard state that was obviously unsafe.Root Cause #2: The supervisor has not been taking responsibility for his work area by monitoring for unsafe conditions.

so now what

So Now What?

At this point you have gathered facts, interviews, pictures, and all pertinent information. You have made conclusions and determined what the cause and root cause of the incident was.

Question: What do you do with this information?

corrective action

Corrective Action

You take corrective action that would prevent the reoccurrence of this type of injury in the future, such as:

1. You look around for similar things in your work center that would present the same type of hazard and implement corrective action. Examples: pipe storage, lumber storage, conduit storage, etc.

2. You should counsel the work center supervisor on proper storage methods and his responsibilities.

finish your written report

Finish Your Written Report

Now write your conclusions (cause & root cause) in your report, and finally wrap up your report by a “Corrective Actions Taken” paragraph. Attach all supporting documentation to the back of the report. You are now done with your written report.

to recap your investigation
To Recap Your Investigation
  • Who/what/when/where/how/why
  • Conclusions (cause & root cause)
  • Corrective Actions Taken
uses of the report

Uses of the Report

1. Toolbox Talks/Departmental Training

2. Use your written report to complete the Supervisor’s Incident Investigation Report

supervisor s incident investigation report

Supervisor’s Incident Investigation Report

Now that you have completed your written report, you are finally ready to complete the Supervisor’s Incident Investigation Report.

This piece of paper is merely a standardized form to document your incident investigation. Filling out the form before doing an investigation is putting the cart before the horse and does not constitute an investigation.

why investigate all incident and not just injuries

Why Investigate All Incident and not just Injuries?

Because for every Serious Injury, there are:

Fatality

10 minor injuries

30 property damages

600 near misses

So where should you be looking?

conclusion
Conclusion
  • ATTITUDE
  • AWARENESS
  • RESOURCES