Accident Investigation DuAll Safety Richard DeBusk

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Accident InvestigationDu-All SafetyRichard
DeBusk
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What is an Accident?

• An unintended happening with __________ results
• An unplanned event that results in personal
  injury or in property damage
• Also called Incident or Mishap
• Near miss

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Accident Investigation

• Most important-Investigation is not intended to
  place blame.
• Determine how and why of failures
• Examine possible corrective action
• Aid in the accident prevention and elimination of
  a clearly identified hazard
• Critique of emergency response may or may not be
  included, but should be if it actually
  contributed to the incident
• (e.g., the fire extinguishers were empty)

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The Three Basic Causes
Equipment and Materials Personnel Processes and
Procedures
Basic Causes
ACCIDENT Personal Injury Property Damage
Unsafe Condition
Unsafe Act
Unplanned Event
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Immediately

• Protect yourself
• Protect evidence
• Identify witnesses
• Document the accident scene before any changes
  are made
• Take photos
• Draw sketchesscaled if possible
• Record measurements

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Record the Facts

• Even the most insignificant detail may be useful
• Document and then document some more

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Record the Facts (cont.)

• Interview witnesses as soon as possible
• Gather support data such as
• maintenance records
• training records
• production schedules
• process diagrams
• weather and rainfall
• etc.

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Record the Facts (cont.)

• Record
• Pre-accident conditions
• Accident sequence
• Post-accident conditions
• Document victim location, witnesses, machinery,
  energy sources and other relevant factors

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Interviewing

• First-hand knowledge
• May present pitfalls in the form of embellishment
  or withholding
• Bias Perspective
• Protecting self or others
• Overly-helpful

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Interviewing

• Identify all witnesses
• Separate witnesses
• Explain the purpose of the investigation and put
  each witness at ease
• Get preliminary statements as soon as possible
  from all witnesses
• Locate the position of each witness on a master
  chart (including the direction of view)

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Interviewing (cont.)

• Let each witness speak freely
• Ask clarifying questions if needed, but do not
  lead
• Use a tape recorder only with consent of the
  witness
• Take detailed notes
• Use sketches and diagrams to help the witness
• Emphasize areas of direct observation and label
  hearsay accordingly
• Unless youve taped the interview, review your
  notes with the witness and have them verify that
  they are accurate

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Interviewing QuestionsAsk Open-Ended Questions,
Not Leading Questions

• Not Did you see the car hit the victim?
• But What did you see?
• Not Was the valve closed?
• But What was the position of the valve?
• Not Were you distracted by something just
  before the accident?
• But What were you doing just before the
  accident?

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Interviewing Questions What would be better
questions than the following?

• Were you taught not to use that tool on that
  material?
• Was the victim wearing the right kind of shoes?
• Did it sound like a hissing noise?
• Did you have a hangover?

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Finding the Cause

• There are many techniques that can be used
• Fault Tree
• Change Analysis
• MORT (Management Oversight and Risk Tree)
• TOR (Technique of Operations Review)
• Ishikawa
• Hartford
• Etc.
• There is no one right method, even within a given
  investigation

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Finding the CauseChange Analysis

• Considers all problems to result from some change
• Work backwards in time
• Examine deviations from the norm
• Analyze the changes to determine their cause and
  effect

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Finding the CauseChange Analysis (cont.)

• Shortcomings
• Focuses on processes and equipment
• Sometimes hard to use for behavior-based causes
• Sometimes hard to use for combined/probabilistic
  causes

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Finding the CauseChange Analysis (cont.)

• Use the following steps in this method
• Define the problem (What sequence of events
  happened?)
• Establish the norm (What sequence of events
  should have happened?)
• Identify, locate, and describe the change (What,
  where, when, to what extent)
• Specify what was and what was not affected
• List the possible causes
• Select the most likely causes

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Finding the CauseEPP (Equipment-People-Process)

• Considers all problems to result from some
  combination of
• Equipment Materials
• People
• Processes Procedures

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Finding the CauseEPP (cont.)

• For each box, consider the who, what, where,
  when and why?

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Investigation Report

• An accident investigation is not complete until a
  report is prepared and submitted to the proper
  authorities
• Report may include reports from other agencies
  such as police or fire
• Your report may become evidence

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Investigation Report

• Background Information
• Where and when the accident occurred
• Who and what were involved
• Operating personnel and other witnesses
• Outside agencies that responded
• Account of the Accident (What happened?)
• Sequence of events
• Extent of damage, loss, injury
• When investigating a Near Miss, report potential
  outcomes of the worst credible case incident

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Investigation Report (cont.)

• Discuss causes of incident
• Recommend changes
• Short and long term
• Prevention of re-occurrence
• Readiness for future such emergencies, if
  appropriate

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Practice Accident 1

• Police officer closed own hand in car door

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Practice Accident 2

• Operator opened the lid of a spray cleaner used
  for automatically cleaning parts. Solvent was
  sprayed in operators eyes

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Accident Prevention
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Steps in preventing reoccurrence

• Be sure incidents are reported
• Perform root cause analysis
• Based on root cause(s), recommend actions that
  will keep the root cause(s) from happening again.

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Root Cause Analysis

• If you havent identified the true root cause,
  you cant properly identify preventive measures.
• Or, said another way
• If you identify the wrong root cause, your
  preventive measures wont work.

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Preventive Measures

• They must be
• PracticalCan they be done?
• EffectiveWill they work?
• ProductiveCan we get our jobs done?
• Otherwise, the accident may be unpreventable.
• BUT . . . You are not responsible for
  inexpensive.

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Preventive MeasuresOK, weve identified the
Root Cause, now lets make recommendations
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Example Slip and Fall

• Incident
• Employee stepped on accumulated debris of pine
  cones and needles. Employee twisted ankle and
  fell.
• NOTE Supervisors report describes this as
  non-preventable.
• Questions to ask?

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Example Slip and Fall

• Questions
• What was the employees condition, i.e., relative
  to attentiveness and/or agility?
• What was the actual condition of the walking
  surface?

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Example Slip and Fall

• Possible recommendations, based on Root Cause
• Increase frequency of cleaning this walking
  surface.
• Signage.
• Practical? Effective? Productive?

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Example 2 Fall from ladder

• While standing on a ladder to wash window,
  employee leaned out too far ladder slipped,
  causing employee to fall.
• Supervisors statement Employee should move
  ladder close to work. Will review at division
  Safety Meeting.

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Example 2 Fall from ladder

• Other possible Root cause analysis questions
• Equipment Condition? Arrangement?
• Employee Training? Motivation?

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Any Questions

• ??