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Accident Investigation Recognize & Investigate. SCF Arizona. Basic Elements of Safe Behavior. Skill. Knowledge. Attitude. Knowledge - Train employees Skill - Provide employees opportunities to acquire it Attitude - Motivate employees. Accident Prevention and Control.

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Accident Investigation Recognize & Investigate


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basic elements of safe behavior

Basic Elements of Safe Behavior

Skill

Knowledge

Attitude

Knowledge - Train employees

Skill - Provide employees opportunities to acquire it

Attitude - Motivate employees

accident prevention and control

Accident Prevention and Control

  • The best way to control costs is to recognize hazards and to prevent accidents from occurring.
  • If an accident does occur, it must be investigated to determine the cause.
vocabulary

Vocabulary

  • Accident
  • Hazard
  • Near miss
  • Unsafe condition/act
  • Hazard inspection
  • Accident investigation
accident

Accident

  • An accident is an unexpected and unplanned event that may result in damage or injury.
accidents

Accidents

  • All accidents are caused.
    • They are the result of an unsafe behavior, an unsafe condition or a combination of both.
  • Other causes of accidents may include policies, procedures and the corporate culture.
hazard

Hazard

  • A hazard is a source of risk or harm.
  • (This can be a physical hazard or an unsafe behavior.)
near miss

Near Miss

  • “Near miss” describes incidents in which, given a slight shift in time or distance, injury or damage could have occurred but did not.
accident investigation

Accident Investigation

  • An effective program provides for investigations of accidents and “near miss” incidents, so their causes and the means to prevent future incidents are identified.
h w heinrich s causation factor model

H.W. Heinrich’s - Causation Factor Model

Unsafe

acts

88%

Machine

related 10%

Acts of

God 2%

10% 20% 40% 60% 80% 100%

the accident pyramid

The Accident Pyramid

Fatality

Result

Severe Injury

Minor Injury

Behavior

Near Miss

Unsafe Acts

h w heinrich accident causation theory 300 29 1 ratio

1

29

300

H.W. Heinrich: Accident Causation Theory 300-29-1 Ratio

Severe injury/fatality

Minor injuries

Near misses,

incidents resulting

in no injuries

common attitudes

Common Attitudes

  • It was “fate.”
  • He was careless.
  • He’s accident prone.
  • She did a stupid thing.
  • She didn’t use common sense.
  • What was the last excuse you had?
unsafe condition

Unsafe Condition

  • Any physical hazard related to equipment, materials, structures or other physical elements of a worker’s environment.
unsafe conditions include

Unsafe Conditions Include:

  • Poor housekeeping
  • Lack of guarding
  • Poor maintenance
  • Defective equipment
  • or tools
  • Improper material storage
  • Slips, trips and fall hazards
unsafe act

Unsafe Act

  • Any hazard
  • created as a
  • result of a
  • human action
  • or behavior.
unsafe acts attributed to

Unsafe Acts Attributed To:

  • Lack of adequate training
  • Improper work techniques
  • Poor attitude
  • Shortcut to save time
  • Lack of proper equipment and tools
  • Poor leadership
symptoms vs causes

Symptoms vs. Causes

  • Symptoms – Unsafe acts/conditions, which we can see, often resulting in accidents.
  • Causes – Underlying reasons for accidents, which we can’t see; They are identified only by investigation.
examples of symptoms

Examples of Symptoms

  • Careless operation of a forklift truck
  • Oil on the floor
  • Standing on the top step of a ladder
  • Improper lifting techniques
  • Not wearing eye protection
examples of causes

Examples of Causes

  • Ineffective employee motivation
  • Lack of accountability
  • Poor maintenance of facilities

or equipment

  • Inadequate employee training
example

Example

  • Symptom – Climbing an unsafe ladder
  • Cause – Having a defective ladder
  • Solution – Replace ladder
  • What are other causes to consider?
    • An improved inspection program
    • Improved training
    • Redefinition of responsibilities
    • Pre-job planning
proactive vs reactive

Proactive vs. Reactive

  • Most accident investigation techniques
  • are reactive.
    • After an accident occurs, the cause and corrective action is identified.
  • Proactive techniques allow you to identify potential hazards before an accident occurs.
accident investigation42

Accident Investigation

Used to determine how and

why an accident occurred.

All accidents, whether they

result in injury or not, must

be investigatedproperly.

accident investigation43

Accident Investigation

  • All accidents must be investigated
  • This should include near misses
  • The extent of the accident will determine the degree of investigation
why are accidents investigated

Why are Accidents Investigated?

  • Determine direct causes
  • Uncover contributing accident causes
  • Prevent similar accidents
  • Document facts
  • Provide information on costs
  • Promote safety
reason for investigating near misses

Reason for Investigating Near Misses

  • Leads to preventing future accidents that could cause serious injuries or property damage.
  • Alerts employees to hazards of which they may not been aware.
fact finding vs fault finding

Fact Finding Vs. Fault Finding

  • The goal of the accident investigation is to discover the facts - not to place blame.
fact finding vs fault finding47

Fact Finding vs. Fault Finding

  • Fact Finding:
  • Worker didn’t wear proper protective equipment.
  • Ladder was not set up properly.
  • Worker tripped over uncoiled hoses.
fact finding vs fault finding48

Fact Finding Vs. Fault Finding

  • Fault Finding:
  • Lazy
  • Careless
  • Stupid
  • Inattentive
  • Accident prone
the investigation process

The Investigation Process

  • Equipment
  • Materials
  • People/Behavior
investigation process

Investigation Process

  • Define the scope of the investigation
  • Select investigators
  • Visit accident site
  • Interview witnesses and victim(s)
investigation process51

Investigation Process

  • Analyze data
  • Determine most likely sequence of events
  • Conduct post accident briefing and prepare report
define the scope of the investigation

Define the Scope of the Investigation

  • How big was the accident
    • Investigating a near miss will not require the same resources or details as investigating an incident with injuries or a fatalities.
    • Can one person investigate or is a team required?
select investigators

Select Investigators

  • The person investigating the accident should have knowledge of the procedures and hazards of the operation.
  • Additional investigators may include
    • Department manager
    • Safety committee members
    • Managers from other departments
    • HR representative
visit the accident site

Visit The Accident Site

  • This should be as soon as possible after the accident.
  • If possible, leave equipment and material in their time-of-accident locations.
  • Take photographs of the accident site for future reference.
visit the accident site55

Visit The Accident Site

  • Your investigation kit should include:
    • Paper/pencils
    • Investigation report
    • Caution tape
    • Camera
    • Sample containers
    • Flashlight/batteries
    • Warning signs
    • Tape measure
    • Cassette recorder
visit the accident site observation recognition techniques

Visit The Accident SiteObservation & Recognition Techniques

  • Understand the work activity objective.
  • Be familiar with the standard/accepted method to complete the task.
  • Look for attitudes, regardless of behavior.
  • Trust your first impression.
  • Know the facility’s accident history.
interview

Interview

  • Interview witnesses and victim(s) as soon as possible.
  • Separate witnesses and victim(s) until each is interviewed.
  • Ask open-ended questions
  • Interview all people who were in the area immediately before or after the accident.
analyze data

Analyze data

  • Analyze data to determine abnormal activities/behaviors before the accident.
  • Determine if any abnormality occurred.
  • Determine how the accident occurred and when it was first noticed.
determine sequence of events

Determine Sequence of Events

  • Make a time line of events leading up to the accident.
  • Consider alternative sequences.
  • Compare sequence to data recovered.
conduct post accident briefing

Conduct Post Accident Briefing

  • Brief Management as to your findings.
  • Prepare a summary report.
  • Make sure recommended actions to prevent reoccurrence are included in the report.
report of investigation

Report of Investigation

  • The investigation is not complete until the report is prepared and submitted.
  • The report should include
    • Background information
    • Accounts of the accident
    • Analysis of the accident
    • Recommendations
corrective action

Corrective Action

  • Once the cause of the accident is determined, correction action must be implemented to prevent reoccurrence.
implementing corrective action change

Implementing CorrectiveAction & Change

  • To implement workers’ changes:
  • Identify behaviors
  • Explain benefits of the changes
  • Hold workers accountable
  • Implement changes immediately
implementing corrective action change64

Implementing CorrectiveAction & Change

  • To implement management’s changes:
  • Retrain employees
  • Relate changes to productivity
  • Obtain approval and “buy-in” of upper management
  • Monitor results
holding employees accountable

Holding Employees Accountable

  • Verbal warning
  • Written warning
  • Suspension
  • Termination
summary

Summary

  • Accidents don’t just happen.
  • The goal of accident investigation is to prevent accidents – not place blame.
  • The investigation process includes:
    • Determining accident facts
    • Draw conclusions about the cause
    • Develop safer ways to perform the task
slide67

Questions?

Questions?

Questions?

Questions?

Questions?

Questions?

Questions?