ACCIDENT RESPONSE AND INVESTIGATION...Accident Response Protocol Incident Occurs Respond & Assess...
Transcript of ACCIDENT RESPONSE AND INVESTIGATION...Accident Response Protocol Incident Occurs Respond & Assess...
ACCIDENT RESPONSE AND INVESTIGATION
Presenters
• Torrance McDonald – City of Phoenix
• Joey Catone – City of Mesa
• Armando Sapien- City of Mesa
Rules of Engagement
• Feel free to interrupt – you’re important
• Phones
• Breaks
• Procedures Booklet
• Documents on SWANA Website
Objectives
• Understand the need to investigate
• Incident Response
• Know what to investigate
• Determine the cause(s) of accidents
• Identify the methods of investigations
• Understand the need to be thorough and comprehensive
• Identify prevention methods
The Basics
• Accident?
The final event in an unplanned
process that results in injury or illness
to an employee or property damage.
The Basics
Are accidents always unplanned?
Are accidents unplanned?
Why Conduct “Investigation”
• Save lives
• Prevent future accidents/injuries/illnesses
• Save money
• Determine the “Root Cause”
• Document Accident
• Identify corrective actions
• OSHA Regulations
OSHA Wants to Know
NOTIFY OSHA w/in 8 hours
• Fatality
NOTIFY OSHA w/in 24 hours- March 2016
• All in-patient hospitalizations (a person is admitted)
• All amputations
• All loss of eye injuries
Fatality from a motor vehicle accident on a public street or highway – NOT REPORTED
Employers do not have to report an inpatient hospitalization if it was for diagnostic testing or observation only.
What do accidents cost your company?Direct -
Insured Costs“Just the tip of the iceberg”
Indirect - Uninsured, Hidden Costs - Out of Pocket
Examples:
1. Lost time by fellow employees and supervisor.
2. Investigation of accident.
3. Schedule delays.
4. Legal fees.
5. Training costs for new/replacement workers.
6. Damage to tools and equipment.
7. Lower morale.
8. Increased absenteeism.
9. Poor customer relations.
10. Public Relations-Brand Image
Unseen costs
can sink the
ship!
OSHA’S RATIOS
2014 Frequency Analysis
Bodily Fluid Exposure 1
Bodily React (1-ASL, 1-Roll Off) 2
Chemical Exposure 2
Fire (2-FEL, 3-ASL) 5
Foreign Body in Eye (FEL) 1
Illness 1
Inhalation 1
Insect Bite 1
Lifting (2-Office Staff, 1-QA) 3
MVA (8-ASL, 5-Roll Off, 9-FEL) 22
Push/Pull (SS) 1
Repetitive Motion (5-ASL) 5
Slip/Trip/Fall (2-Operators) 2
Struck By/Against (Employee) 5
Struck By/Against w/ Equipment 69
Unknown 2
Vehicle Body Overturn (Roll Off) 1
124
Accident Investigation
• A systematic approach to the identification of causal factors and implementation of corrective actions WITHOUT placing blame on or finding personal fault.
Effective Program
Written procedures
Responsibility for conducting
investigation
Training plan
Separation from disciplinary
procedures
Written report
Follow-up procedures
Annual review of accident reports
THINGS TO REMEMBER
• Don’t move the vehicle unless directed by officer/unsafe to remain in place.
• NEVER leave the scene of the accident.
• DO NOT discuss the incident with anyone except Police Officer, Supervisor, Foreman, Safety Coordinator
Nanny’s Lawyer
TRAFFIC CONE PLACEMENT
•TWO-WAY DIVIDED ROADWAY
a) 1 cone- 100 feet in front of vehicle
b) 1 cone – 10 feet behind vehicle
c) 1 cone – 100 feet behind vehicle
•ONE-WAY DIVIDED ROADWAY
a) 1 cone – 10 feet behind vehicle
b) 1 cone – 100 feet behind vehicle
c) 1 cone – 200 feet behind vehicle
Investigation Plan - Lay the Groundwork
• Who to notify
• Who contacts police, fire, etc.
• Who conducts investigation
• Conduct investigator training
• Who receives/acts on reports
• Timetables for investigation and follow-up
Types of Accidents
Minor Accidents
• Accidents that cause minor injury/illness, requiring little or no treatment, or minor property damage.
Major Accidents
Fatality, illness, fire, explosion, collapse, and any similar event that results in significant personal injury to an employee/pedestrian/driver or in significant damage to buildings, equipment, or property.
Minor Accidents
Major Accidents
Who Investigates?
• Major Accidents
- Local Police Department, Safety Coordinator, Supervisor, or Subject Matter Expert
• Minor Accidents
- Foremen, Supervisor
Accident Response Protocol
Incident OccursRespond & Assess
Situation scene safety
Secure SceneIncident
Investigation to include photos
Determine if Drug Testing Required
Damage AssessmentFollow Up
Communication
Complete Incident Investigation /
gather supporting reports
Discuss Incident Investigation at
Accident Review Board
Present signed Incident
Investigation to Employee
INCIDENT OCCURS
• Gather as much information as possible for Alpha page-Who? What? When? Where? Why
• If necessary, call 911, or for smaller emergencies, Police Non-Emergency #
• Contact Administrator, Administrator contacts Safety Coordinator, Deputy Director, Director
• If you are in the field, ask for assistance to send out SW Alpha
• Respond to the scene of the incident immediately
• During Summer months, take ice chest with drinks for major incidents/inoperative vehicles, floor dry for spills
Investigator’s Qualifications
• Understand important role of accident investigation
• Have authority and accountability
• Have skills to evaluate the incident
• Communicate details
Key Attributes of Competent Investigators
•Assumes all accidents have a cause
•Looks for many causes not just the first, most obvious cause
•Be a good listener
•Never attempts to find a culprit
• Is as objective as possible
•Always keeps the purpose of the investigation in mind
Accident Investigator Attitude
Two different viewpoints:
‘This is an opportunity to prevent the next accident.’
‘This is unnecessary paperwork and an improper use, waste of my time’
What Should Be In The “Investigation Kit”
Report forms First aid kit
Gloves-latex/leather Camera
Tape measure Large envelopes
Caution tape Claim Forms
Flashlight Graph paper
Scotch tape Straight Edge RulerPPE – Hard Hat/Boots LadderMeasuring StickBiohazard KitSpare batteriesDigital/Tape Recorder/Spare TapesCrawler
Actions At The Accident Scene
• Check for danger
• Help the injured
• Secure the scene
• Identify and separate witnesses
• Gather the facts
Check for Danger
WHAT ARE THE HAZARDS?
Assess Incident Scene Reminder
• Ensure personal safety, do not approach vehicle with electrical wire contact, stay at least 100 feet upwind from burning trash heap/vehicle
• If employee is injured, follow “Injured Employee Procedures”
• Secure scene-use caution tape, cones, etc.
• For motor vehicles w/ minor damages/impeding traffic, move to safe area
Policy for Injured Employees
• The foreman and/or supervisor on duty should ensure contacts are made to the:
• Employee’s family• All levels of management staff and Safety Coordinator
• If the injured employee is in the field:
• The foreman or supervisor on duty will arrive at the incident location and transport the employee for medical attention unless it is a life threatening emergency, in which case an ambulance should be called.
• The employee should be taken to the nearest Banner Occupational Health Clinic for examination/treatment.
• An injured employee should never be behind the wheel of a vehicle.
MOTOR VEHICLE ACCIDENTS
• Determine if DOT Mandatory Drug Testing is necessary.
• Fatality? Driver Cited & Vehicle Towed/Person transported by ambulance?
• Contact Information of Drug Testing Program
• Fatality? COM MVA Resulting in Fatality/Catastrophic Injury Procedures
• Reasonable Suspicion
Six Step Process
Gather
information
Analyze
the facts
• Implement
solutions
1. Preserve and document the scene
2. Seek Sources of Relevant Information
5. Recommend improvements
6. Write report
3. Develop event sequence
4. Determine causes
Preserve and Document the Scene
• Why begin immediately?
1. Materials. Things disappear as the
employer/employee is anxious to
get back to work/police need to
clear traffic obstruction.
2. Memory fails or gets altered.
What are effective methods to
secure or preserve an accident
scene?
Preserve and Document the Scene
• Caution Tape
• Barricades
• Cones
• Guarded
• Vehicles
Fact Finding
• Witnesses and physical evidence
• Employee – D & A Recognition
• Position of injured/tools and equipment
• Equipment operation logs, charts, records
• Equipment identification numbers
• LOOK FOR CAMERAS
Don’t Judge too Quickly!
Include photo direction slide
• City of Phoenix Training
What do you see?
Purpose of Photographs
• To show what the investigator saw to someone else.
• Record what the investigator observes so that he/she can recall details at a later date/time.
• To assist in writing the report / reconstruction.
• Should not take the place of measurements or written descriptions.
• A dozen pages of written description can not equal one photograph.
Does this help?
Photograph Basics
• Record details before moving anything, if possible.
• Also consider photographing scene after it is cleaned up.
• If pictures are taken incorrectly, valuable evidence will be lost.
• More photographs are better than not enough photographs.
Ta da!!
Problems in Photography
• Pressure to take the pictures
• Weather conditions
• Lighting
• Protecting the equipment
• Surface reflections
• Photobombs
Proper Ordering of Photographs
• Start taking photographs of things that change quickly.
• Next, record marks on the surface such as fluid, tire marks, gouges, and scrapes.
• Finish with more permanent subjects.
Scene Photography
• Overall incident scene.
• Approach path leading up to incident.
• Obstructions to view.
• Four-Point the subject.
Damage / Injury Photography
• It’s a step process that slowly gets closer.
• Document damage or injury by including the
injury in an overall photo of the subject.
• The next photo will be closer to see more
detail of the damage or injury.
• The last photo is a close-up, using a
measurable scale if available.
Step 2 – Collect the Facts through Interviews
When is it best to interview?
Whom should we interview?
Where should we interview?
Interviewing Techniques
• What should we say?
• What should we do?
• What should we not say?
• What should we not do?
INTERVIEW DO’S
• Put the witness, who is probably upset, at ease
• Emphasize the real reason for the investigation, to determine what happened and why
• Let the witness talk, you listen
• Confirm that you have the statement correct
• Try to sense any underlying feelings of the witness
• Make short notes only during the interview
• Tape record the interview
• Ask open ended questions
Interview Video Good Example
INTERVIEW DO NOTS
• Intimidate the witness
• Interrupt
• Prompt
• Ask leading questions
• Show your own emotions
• Make lengthy notes while the witness is talking
Bad Example
INTERVIEWING QUESTIONS HANDOUT
• Who? What? Where? When? Why? How?
• It’s crucial to collect evidence and interview witnesses as soon as possible because evidence will disappear and people will forget.
• Conduct interviews separately
• Make it clear that the investigation is used to avoid recurrence and not to place blame
Develop the Sequence of Events
Analyze by breaking
down the accident
processes into
component parts
Events prior to …
Event during …
Events immediately after …
Develop the Sequence of Events
Each event in the unplanned accident
process describes one:
Actor - Individual or object that is initiating
action.
Action - The thing being done
"Bob unhooked the lifeline from the harness.“
Mary Conlin Excercise
• Pass out sequence of event exercise
Root Cause Analysis
• Direct Cause – Unplanned release of energy or hazardous materials
• Indirect Cause – Unsafe acts and/or unsafe conditions
• Root Cause – policies and decisions, personal factors, environmental factors
ROOT CAUSE IS THE CAUSE THAT, IF
CORRECTED, WOULD PREVENT RECURRENCE
OF THIS AND SIMILAR INCIDENCES.
1. Injury Analysis-
Direct Causes
2. Event Analysis-
Indirect Causes
3. System Analysis-
Root Causes
3 Levels
Multiple Causation and the Accident Weed
Injury Analysis
• Acoustic
• Chemical
• Electrical
• Kinetic
• Potential (Stored)
• Radiant
• Thermal
Direct Cause:
A harmful transfer of
energy that produces
injury or illnessCuts
Burns
Strains
Accident Types
Struck by
Struck against
Contact with
Caught on-in-between
Fall to surface-fall to below
Exposure
Exertion
Event Analysis
Indirect Causes of
Accident –
Specific
hazardous
conditions or
unsafe behaviors
that result in an
accident
CONDITIONS
ACTS
Fail to enforceLack of time
Unsafe Acts
• An unsafe act occurs in approx 85%- 95 of all analyzed accidents with injuries
• An unsafe act is usually the last of a series of events before the accident occurs (it could occur at any step of the event)
• By stopping or eliminating the unsafe act, we can stop the accident from occurring
Unsafe Acts/Behaviors
• Actions we take or don't take that increase risk of injury or illness.
• Examples:• Failing to comply with rules
• Failing to report injuries
• Failing to supervise
• Ignoring hazards
1. Task
• Ergonomics
• Safety work procedures – missing?
• Condition changes
• Process
• Materials
• Workers – Unsafe behavior
• Appropriate tools/materials
• Safety devices (including lockout)
2. Material
• Equipment failure
• Machinery design/guarding
• Hazardous substances
• Substandard material
3. Environment
• Weather conditions
• Housekeeping
• Temperature
• Lighting
• Air contaminants
• Personal protective equipment
4. Human Factor
• Level of experience
• Level of training
• Physical capability
• Health
• Fatigue
• Stress
5. Management/Process Failure
• Visible active senior management support for safety – LEADING BY EXAMPLE
• Safety policies – do they exist
• Enforcement of safety policies - LOTO
• Adequate supervision – work observations
• Knowledge of hazards
• Corrective coaching of Operator
• Preventive maintenance
• Regular audits
No accountability policy
No, or outdated policyInadequate human-machine interface
No inspection policy
No, or inadequate, standardsNo, or outdated procedures
Inadequate training
La
ck
of
vis
ion
No
mis
sio
n s
tate
me
nt
No work direction (supervision,
selection, preparation)
• Implementation
• Design
Root Causes of the
Accident – Common
behaviors or
conditions that
ultimately result in
an accident
System Analysis
Developing Solutions & Getting Results
The last two steps help you develop
and propose solutions that correct
hazards and design long-lasting system
improvements.
Lack of safety leadership
Lack of supervision
Lack of Training
Missing guard
Rules not enforced
Poor work proceduresPurchasing unsafe equipment
No follow-up/feedback
Poor safety
managementPoor safety leadership
Didn’t follow procedures
Poor housekeeping
Horseplay
Ignored safety rules
Defective tools
Don’t know howNo Safety Data Sheet
(SDS)
The “Accident Weed”
Hazardous
Conditions
Hazardous
Practices
Did not report hazardEquipment failure
Root Causes
Step 5 – Develop Recommendations
Use Control Strategies
Engineering Controls
Management Controls
Personal Protective Equipment
Interim Measures
Engineering Controls
• Eliminate/reduce hazard by design, enclosure, substitution, replacement, etc.
• 3 principles
1. Removal or substitution
2. Enclosure
3. Barriers or local ventilation
Management Controls
Eliminate/reduce exposure by
controlling behavior
Two primary strategies:
• Safety rules and safe work
practices/ procedures
• Scheduling
Personal Protective Equipment (PPE)
• Used along with engineering and management controls
• Legal requirements
• Limitations
Write The Report
• How and why did the accident happen?
• A list of suspected causes and human actions
• Use information gathered from sketches, photographs, physical evidence, witness statements
Step 6 - Write a Report
The report should include:
• An accurate narrative of “what happened”
• Clear description of unsafe act or condition
• Recommended immediate corrective action
• Recommended long-term corrective action
• Recommended follow up to assure fix is in place
• Recommended review to assure correction is
effective.
Preparing a Recommendation
1. Pinpoint the problem• Hazardous condition, unsafe behavior, etc.
• System components
2. Find out problem history
3. Pinpoint the solution• Engineering, administrative, PPE
• System improvements
Write The Report
• When and where did the accident happen?
• What was the sequence of events?
• Who was involved?
• What injuries occurred or what equipment was damaged?
• How were the employees injured?
Answer the following in the report:
Step 4- Report Writing Material
• Injured Employee Packet
- (green packet material)
• City of Mesa Incident Report
• Solid Waste Incident Investigation Form
Conclusions of Report
• What should happen to prevent future accidents?
• What resources are needed?
• Who is responsible for making changes?
• Who will follow up and insure changes are implemented?
• What will be the future long-term procedures?
Report conclusions should answer the following:
The report is an open document
until all actions are complete!
Follow Up!
Take corrective action
Conduct follow up evaluation
Conduct annual review of reports
Discuss Mary Alice Conlin Case
• Mary Alice Conlin Handout