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Accident Reporting & Investigation. Paul Craythorne Health, Safety & Environmental Advisor. Accident Reporting & Investigation. Course Objectives to understand: accident definition accident causation accident costs accident prevention accident reporting/notification

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accident reporting investigation

AccidentReporting& Investigation

Paul Craythorne

Health, Safety & Environmental Advisor

accident reporting investigation1
Accident Reporting & Investigation
  • Course Objectives
    • to understand:
      • accident definition
      • accident causation
      • accident costs
      • accident prevention
      • accident reporting/notification
      • accident investigation
accident reporting investigation2
Accident Reporting & Investigation
  • Common Uninformed Comments
    • accidents just happen
    • we don’t have many accidents
    • safety is expensive
    • the insurance will pay
    • safety is just common sense
accident reporting investigation3
Accident Reporting & Investigation
  • Accident Definition
    • what is an accident?
      • unplanned & uncontrolled event that led to, or could have led to:
        • injury to persons, damage to property/plant/equipment, impairment to the environment or some other loss to the company
accident reporting investigation4
Accident Reporting & Investigation
  • Accident Definition
      • accident types
        • minor dangerous occurrence
        • near miss
        • plant/equipment damage
        • minor injury
        • lost time injury
        • disablement/fatality
accident reporting investigation5
Accident Reporting & Investigation
  • Accident Definition
    • Frank Bird (Accident Triangle)
      • 600 near misses
      • 30 property damage
      • 10 minor injuries
      • 1 serious injury (lost time or fatal)
accident reporting investigation6
Accident Reporting & Investigation
  • Accident Causation
    • environment
    • personal fault
    • unsafe act
    • unsafe condition
    • accident
    • injury/damage
accident reporting investigation7
Accident Reporting & Investigation
  • Accident Causation
    • causal factors
      • individual
      • job
      • organisation
accident reporting investigation8
Accident Reporting & Investigation
  • Accident Causation
    • causal factors
      • individual
        • knowledge
        • skills
        • training
        • experience
        • personality
        • attitude
        • risk perception
accident reporting investigation9
Accident Reporting & Investigation
  • Accident Causation
    • causal factors
      • job
        • task
        • workload
        • equipment
        • controls
        • procedures
        • environment
accident reporting investigation10
Accident Reporting & Investigation
  • Accident Causation
    • causal factors
      • organisation
        • culture
        • leadership
        • resources
        • work patterns
        • communications
accident reporting investigation11
Accident Reporting & Investigation
  • Accident Causation
    • Kings Cross Fire (1987) - 31died
      • discarded cigarette
      • accumulation of rubbish
      • poor cleaning regime
      • wooden escalator
      • failure of fire fighting equipment
      • lack of emergency training
      • poor safety culture
accident reporting investigation12
Accident Reporting & Investigation
  • Accident Causation
    • Herald of Free Enterprise (1987) - 189 died
      • failure to close bow doors
      • no checking/reporting system
      • commercial pressures
      • internal friction
      • disease of sloppiness
accident reporting investigation13
Accident Reporting & Investigation
  • Accident Causation
    • Clapham Junction (1988) - 35 died & 500 injured
      • signal failure
      • incorrect maintenance
      • degradation of working practices
      • training problems
      • communication problems
      • poor supervision
      • excessive working hours
      • failure to learn lessons
accident reporting investigation14
Accident Reporting & Investigation
  • Accident Causation
    • Piper Alpha (1988) - 167 died
      • maintenance error
      • inexperience
      • poor maintenance procedures
      • communications breakdown
      • permit to work system fault
      • safety procedures not practised
accident reporting investigation15
Accident Reporting & Investigation
  • Accident Causation
    • Automotive Supplier (1999) - 1 died
      • poor safety culture
      • lack of guarding
      • lack of training
      • poor perception of risk
      • no safe systems of work
      • no risk assessment programme
      • no effective accident system
      • no communication
accident reporting investigation16
Accident Reporting & Investigation
  • Accident Costs
    • insured costs
    • uninsured costs
accident reporting investigation17
Accident Reporting & Investigation
  • Accident Prevention
    • reasons
      • humane
      • economic
      • legal
accident reporting investigation18
Accident Reporting & Investigation
  • Accident Prevention
    • control measures
      • safety procedures/work instructions
      • adequate training
      • effective communications
      • good housekeeping
      • guards/safety devices/warning signs
      • adequate working environment
      • regular safety inspections
      • risk assessment
accident reporting investigation19
Accident Reporting & Investigation
  • Accident Reporting/Notification
      • internal report form
      • HSE RIDDOR report
      • injury claim requirement
accident reporting investigation20
Accident Reporting & Investigation
  • Accident Investigation
    • reasons
      • identify root causes
      • identify faults
      • identify corrective/preventative action
      • prevent recurrence
accident reporting investigation21
Accident Reporting & Investigation
  • Accident Investigation
    • investigation team
      • supervisor
      • safety rep
      • engineer
      • manager
      • safety officer
accident reporting investigation22
Accident Reporting & Investigation
  • Accident Investigation
    • investigation objectives
      • establish chain of events
      • identify root causes
      • identify faults
      • identify corrective/preventative action
accident reporting investigation23
Accident Reporting & Investigation
  • Accident Investigation
    • investigation techniques
      • attend promptly
      • ensure medical attention
      • leave scene undisturbed
      • take photographs/sketches
      • take measurements
      • take samples
      • gather documentation
      • interview witnesses
accident reporting investigation24
Accident Reporting & Investigation
  • Accident Investigation
    • investigation techniques
      • interviewing witnesses
        • explain purpose
        • their version of events
        • do not listen to ‘hear say’
        • ask open questions
        • avoiding leading or implying
        • do not apportion blame
        • express appreciation
accident reporting investigation25
Accident Reporting & Investigation
  • Accident Investigation
    • investigation report
      • identify team
      • summarise consequential events
      • identify root causes
      • describe other weaknesses
      • identify corrective/preventative action
      • allocate responsibility & timescale