Accident Investigation Accident Investigation Techniques and ReportingTechniques and Reporting

For

NERI Safety Coordinators

Presented By:

Bill Hettrick

May 23, 2007

Accident InvestigationAccident InvestigationWorkshopWorkshop

Why investigate accidents?Investigation ProcessRoot Cause & Contributing Causes

– Methods Supervision, Policies, Procedures, Rules

– Equipment Materials, Safeguards, Product, Machinery

– Environment Facilities, Heat/Cold, Agents, Atmosphere

– Personnel Training, Fatigue, Protection, Fitness

Corrective Action

Response

Fact-Finding

Analysis

Follow-Up

ACCIDENT INVESTIGATION

THE PRIMARY PURPOSE OF ACCIDENT INVESTIGATION IS TO DETERMINE THE ROOT CAUSES OF ACCIDENTS, SO THAT STEPS CAN BE TAKEN TO REMOVE THESE CAUSES AND PREVENT RECURRENCE OF SIMILAR EVENTS

REPORTING EVALUATING ANALYZING

WHY DO ACCIDENTS OCCUR?WHY DO ACCIDENTS OCCUR? SUPERVISION POLICES

METHODS

PROCEDURES RULES

FACILITIES HEAT/COLD

ENVIRONMENT

AGENTS ATMOSPHERE

MATERIAL SAFEGUARDS

EQUIPMENT

PRODUCT MACHINERY

TRAINING FATIGUE

PERSONNEL

PROTECTION FITNESS

ACCIDENT INPUT OUTPUT

SYSTEM FAULTS

SYSTEM FAULTS

SYSTEM FAULTS

SYSTEM FAULTS

Definition of TermsDefinition of Terms

Incident – A deviation from an acceptable standard

Hazard – An incident without adequate controls

Accident – When the potential of a hazard results in damage

All Accidents come from incidents, but not all incidents result in accidents

90% of all Accidents Result 90% of all Accidents Result from Human Factorsfrom Human Factors

Unsafe Condition

Any condition of tools,

equipment or other

elements in an

employee’s work

environment that may

cause or contribute to

an accident.

Unsafe ActAny hazard created

as a result of a

human action or

behavior

Examples of Unsafe ActsExamples of Unsafe Acts

Lack of adequate training

Poor attitude/behavior Lack of required PPE Working outside of

normal operating procedures

Unclear safety rules Unclear polices and

procedures Poor management

and/or supervision

Additional Benefits of a Good Additional Benefits of a Good InvestigationInvestigation

Demonstrates concern for fellow workers May identify other similar unsafe acts or

conditions Reduces operating costs

The Injured EmployeeThe Injured Employee

Death Pain & suffering Permanent disability Effects on family Loss of earning Inability to resume

occupation Psychological effects Feeling of uselessness Social effects Loss of personal activities

Effects on the SupervisorEffects on the Supervisor

Loss of a trained worker Loss of production Extra work for others Investigations and reports Training a new worker Could I have prevented it? Stress Can’t get job done on time

Three Types of Accident Three Types of Accident CausesCauses

Immediate Cause(s)

Contributing Cause(s)

Root Cause(s)

Immediate CausesImmediate Causes

The unsafe act or condition

Struck against Fall on same level Fall from different

level Caught between Electricity Equipment Material handling

Contributing CausesContributing Causes

Not Following

Standard Practices

Proper use of tools & equipment

Use of PPE Correct lifting Safe work practices Safety policy and

procedures Use of monitor

Not ProvidingStandard Conditions

Adequate warning systems

Equipment in good condition

Good housekeeping Proper guardrail

systems Appropriate fall

protection

Root CausesRoot Causes The origin of the immediate and contributing

causes

Must be eliminated and or controlled to prevent recurrence

Examples of Root CausesExamples of Root Causes Personal Factors

• Lack of knowledge or skill

• Improper motivation• Unfit for job• Lack of training

Job Factors• Unsafe equipment• Inadequate safety

standards• Housekeeping issues• Improper job set-up

Management & Supervision• Inadequate instructions• Lack of enforcement• Safety program not

followed• Hazards not corrected

The Following Statements are The Following Statements are NOT Proper NOT Proper RootRoot Causes Causes

Didn’t pay attention Was careless Poor housekeeping Didn’t climb ladder correctly Bad luck Stupid No cause

These causes are too general no constructive measures were taken

Round Robin Round Robin Accident Investigation Accident Investigation

Accident InvestigationAccident InvestigationCase StudyCase Study

Describe in detail, how the incident occurred and what part of the body it affected:– Employee fractured left foot. Employee slipped while climbing up

ladder.

Describe the root causes and how they contributed to this accident:– Employee failed to maintain three points of contact.

What should be done, and by whom to prevent recurrence of this type of incident in the future:– Employee should be more careful while on ladders.

Accident InvestigationAccident InvestigationCase StudyCase Study

Describe in detail, how the incident occurred and what part of the body it affected:– Employee sustained burns to hands and face while filling the hot

lugger for the fill pipe.

Describe the root causes and how they contributed to this accident:

– Employee failed to wear proper clothing and PPE while working with hot materials.

What should be done, and by whom to prevent recurrence of this type of incident in the future:– Face shields should be placed near fill-pipe.

Accident InvestigationAccident InvestigationCase StudyCase Study

Describe in detail, how the incident occurred and what part of the body it affected:– 65 year-old male struck in the head and neck from debris that blew

off the scaffold system. Claimant was walking across the parking area at time of accident.

Describe the root causes and how they contributed to this accident:– Foreman did not secure debris against high winds.

What should be done, and by whom to prevent recurrence of this type of incident in the future:– Crew should review housekeeping practices and weather forecasts.

Accident InvestigationAccident InvestigationCase StudyCase Study

Describe in detail, how the incident occurred and what part of the body it affected:– While traveling back from the jobsite, the foreman was involved in

a three vehicle accident. Pete, who was sitting in the passenger seat sustained a neck strain.

Describe the root causes and how they contributed to this accident:

– Driver was not at fault – no further actions required.

What should be done, and by whom to prevent recurrence of this type of incident in the future: None

Accident InvestigationAccident InvestigationCase StudyCase Study

Describe in detail, how the incident occurred and what part of the body it affected:– Employee was carrying 5-gallon buckets of bonding adhesive from the

loading area to the work area. Employee claims he felt soreness in his back two days later.

Describe the root causes and how they contributed to this accident:

– No specific incident event identified. Employee may have tried to hurry to move buckets without using proper body mechanics.

What should be done, and by whom to prevent recurrence of this type of incident in the future:

– Employees should be reminded to lift with their legs, keep stomach tight, and inspect their path of travel.

A Complete Investigation A Complete Investigation Includes:Includes:

All factsAll opinionsWitness statementsJob site observationsReview of policies and proceduresReview of training records

Why the Superintendent and/or Why the Superintendent and/or Foreman are the Key Professionals Foreman are the Key Professionals to Conduct Accident Investigationsto Conduct Accident Investigations

They knows the job requirements and expectations

They knows their fellow co-workers

The Supervisor’s RoleThe Supervisor’s Role

The Supervisor’s attitude determines the success of the investigation and the employee’s return to work experience ……..

How to Complete the How to Complete the Accident Investigation ReportAccident Investigation Report

When to Conduct an When to Conduct an InvestigationInvestigation

ASAPASAP

Less physical evidence removed or altered More details remembered Haven’t had time to be biased by others

ACCIDENT QUESTIONS GUIDEACCIDENT QUESTIONS GUIDE

A CONDITION AN ACTIONWHY DID IT EXIST?

WHY WASN’T IT CORRECTED?

WHY WAS IT BEING DONE?

WHY WAS IT NECESSARY?

WHAT CAUSED IT TO EXIST? WHAT WAS ITS PURPOSE?

WHAT DETAILS NEED ELIMINATION?

WHERE WAS IT?

WHERE WAS ITS SOURCE?

WHERE SHOULD IT BE DONE?

WHERE ELSE IS IT BEING DONE?

WHEN DID IT OCCUR?

WHEN DO SIMILAR CONDITIONS OCCUR?

WHEN SHOULD IT BE DONE?

WHO WAS RESPONSIBLE?

WHO CAN GIVE ME ANSWERS?

WHO CAN GIVE ME ANSWERS?

WHO CAN SHOW ME WHAT WAS DONE?

HOW SHOULD IT BE CORRECTED?

HOW CAN IT BE AVOIDED?

HOW IS THE BEST WAY TO DO IT?

HOW CAN IT BE IMPROVED?

Can Accidents be Prevented?Can Accidents be Prevented?

Effective Management and Supervision Commitment to accident prevention Effective policies and procedures Effective reporting Employee training Job hazard analyses & inspections Safety culture

QUESTIONS & ANSWERSQUESTIONS & ANSWERS