Zenith Incident Investigation

8/10/2019 Zenith Incident Investigation

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Incident Investigation


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Topics

Establish an efective incident investigationprogram

Learn efective analysis tools relating toincident investigations

Learn how to conduct an incidentinvestigation that identies the contributingactors to the incident

Minimize the recurrence o workplaceincidents that are contributing to injuries andillnesses


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Why Should We Investigate?

To prevent or decrease the likelihood outure injury or illness

To identiy and correct unsae behaviors

and conditions To identiy training needs


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Steps to Assure a GoodInvestigation

Emphasize that saety is a value! not just a priority

#emind employees to report incidents immediately

E$plain how accident investigations are critical to

the organization Ensure %uality orms e$ist to guide your eforts and

provide necessary reminders&

'i$ the cause! not the blame

The (nd! )rdand *thitems are part o groundworkthat needs to be laid beore an incident occurs&

These can also be reiterated as part o theinvestigation&


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Steps to Assure a GoodInvestigation

Emphasize that saety is a value! not justa priority

+,alues do not readily change and remainunafected by the competing! daily-uctuation o other actors in the workenvironment&.

+"riorities can change daily in response tosituational demands&.

+/hen saety is a basic value! it becomes the0natural way1 o perorming a job! anythingless is unacceptable&.Making Safety a Basic Value; R.E. Earnest; Professional Safety, August 2000; American Society ofSafety Engineers


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Unsae Act,iolation o established saetypolicies2procedures which could result inan incident&

Unsae Condition mechanical or physical condition which

i not eliminated! guarded or altered couldresult in and incident&

Unsae Acts and Conditions


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Unsafe Acts:

Cause !"# o A$$ incidents %

Unsafe Conditions:

Cause &"# o A$$ incidents

*Industrial Safety and Health Management; Liberty Mutual , 1995


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Unsafe Acts Vs Unsafe Conditions

3.4ndustrial 5aety and 6ealth Management. by7& #ay sahl cites 6&/& 6einrich! whose researchconcluded that 889 o all industrial incidents arerom unsae acts& :;;< survey completed by

Liberty Mutual o *== #isk Managers and 5aety7onsultants ound that! e$cluding +acts o >od.!;(9 o all workplace incidents result rom+perormance decit. ?unsae behavior@&

*Industrial Safety and Health Management; Liberty Mutual , 1995


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'eore an Incident

(stablish

/ho should conduct the investigation

5upervisor! oreman! saety committee!saety director27oordinator&

/hyA 5upervisors know the job&

/hen incident investigations are to becompleted

5" ater the incident 6ow the investigation will be conducted

'orms used

"rocedures


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'eore an Incident

(stablish

/hat will be done with ndings

#eviewed by senior management

5aety committee discussion

)ollo* up on corrective actions

4ncident trend analysis


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Ater an Incident

7onduct investigation 5"

7ontrol B preserve the scene

4nterview injured worker promptly while

inormation is clear 4nterview witnesses individually

sk open ended%uestions

/ho! /hat! /hen! /here! /hy! and 6owA

7ompile background inormation

5eek actsnot ault


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Ater an Incident

Cocument investigation

Cetermine cause?s@ o incident

Cetermine what can be done to prevent asimilar incident rom happening again

4mplement corrective actions

)ollo*+up


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General Causal Categories

Materials2e%uipment

Environment

"ersonnel

Management Task


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Incident Scene

/here did the incident occurA

/hat was the employee doing when the

incident occurredA

/hat steps did the employee take while

perorming the taskA

/hat e%uipment2tools were being usedA

6ow were the e%uipment2tools usedA


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Incident Description

/hat task was being perormedA

/hat were nearby employees ?i any@ doingA

/hat happened with the e%uipment2tools

being usedA

/hat was the injury or damageA

/hat steps should be taken to perorm this

task saelyA


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Wor, environment and e-uipment

/as work environment saeA

6ousekeepingA dditional actorsA

oise! heat! lighting! atigue! height

/ere e%uipment2tools in good conditionA CeectiveA

Missing guardsA

Identiy Unsae Conditions .Unsae Acts


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/rocedures

re there inspection procedures to detect

hazardA

#ushed jobA

/ere task procedures ollowedA

/ere correct e%uipment2tools usedA

/as employee authorized to perorm taskA

Identiy Unsae Conditions .

Unsae Acts


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'ehavior

/as employee supposed to be in vicinity o

incident areaA

/as ""E wornA

Coes employee know ""E is re%uiredA

Cid employee know where ""E is storedA

/as ""E ade%uateA

/ere saety rules brokenA

/ere shortcuts takenA

Identiy Unsae Conditions .Unsae Acts


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)ind the 4oot Causes

/hen you have determined the contributingactors! dig deeperG

4 employee error! what caused that behaviorA

4 deective machine! why wasn1t it $edA 4 poor lighting! why not correctedA

4 no training! why notA


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man alls of an unstable step ladder with adamaged rung

Hnsae ct

7limbing a deective ladder Hnsae 7ondition

deective ladder

The 7orrection

>et rid o the deective ladder

6ave the root causes been identiedA


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/hat are some o the contributing actorsA

/hy was the deective ladder not ound innormal inspectionsA

/hy did the supervisor allow its useA Cid the employee involved know not to use

itA

/as the employee properly trainedA

Cid the supervisor e$amine the job rstAHae the r!!t "auses been identified#


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#esultD

piece o metal becomes imbedded in the eyeo the employee using the grinder&

sk yoursel! +/hat were the #oot 7auses othe 4njuryA.


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Identiy /ossible CorrectiveActions

Engineering controls

dministrative controls

"ersonal protective e%uipment

$! n!t st!% at familiar !r fa!rite "!rre"tie a"ti!nsLet&s l!!' at a fe()


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5anaging 4ecommendations orCorrective Action

5hould a policy be revised or developedA

5hould the monthly selJinspection checklist bemodiedA

5hould training be conducted and will retraining on thattopic be needed2providedA

5hould a work practice be modied or eliminatedA

5hould the supervisor monitor the work practice and iso! how will this be accomplishedA


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Conclusion

4ncident 4nvestigation is both a reactive andproactive process in that it uncovers the rootcause and other contributory actors as well asproviding valuable inormation to prevent similar

incidents rom occurring in the uture&

/e cannot aford! nor is it acceptable to wait orhazards to identiy themselves through

someone1s accident


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6uestions

Zenith Insurance Company

!r%!rate +ffi"e -1-55 alifa Street

.!!dland Hills, / 9102

3 -449 enith Insuran"e !m%any6 /ll 7ights 7esered6

8 enith and heenith are registered :6S6 seri"e mar's6

Zenith Incident Investigation

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