Accident Investigation & RCA - Demoura Lawson Consulting

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ACCIDENT INVESTIGATION AND ROOT CAUSE ANALYSIS
AWARENESS
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2021 De Moura Lawson Consulting
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OBJECTIVES
The purpose of this presentation is to provide
participants with a basic awareness necessary to
conduct an effective accident investigation in
the workplace.
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WHEN ACCIDENTS OCCUR

• The points to consider after any accident are
• When an accident happens, the most important
  thing is taking care of the victim or victims.
• Everyone within an organization needs help and
  advice to identify the causes of accidents.

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IMPORTANCE OF ACCIDENTS

• By the end of this training session, delegates
  will identify the following
• Benefits of Accident investigation and Root Cause
  Analysis
• Employer responsibilities for Accident
  Investigation
• Steps of Accident Investigation
• When Root Cause Analysis is required
• Incident Management Systems

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WHAT IS AN ACCIDENT?

• An accident can be explained as an event that
  results in unintended harm or damage
• From experience and analysis they are caused
  occurrences.
• Predictable - the logical outcome of hazards
• Preventable and avoidable - hazards do not have
  to exist. They are caused by things people do -
  or fail to do.

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WHAT IS AN INCIDENT?

• A specific event, or sequence of events, or
  extended condition that had or could have had
  unwanted or unintended impact on the production
  or safety or health of people, property, or the
  environment, or on legal/regulatory compliance.
• An incident may disrupt the work process but does
  not result in injury or damage. It should be
  looked as a wake up call. It can be thought of
  as the first of a series of events which could
  lead to a situation in which harm or damage does
  occur.

Example of an incident A 20kg box falls off
the top shelf of a 2.5m rack and lands near a
worker. This event is unplanned, unwanted, and
has the potential for injury.
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EXPLAINING THE DIFFERENCES

• A Near miss is an unplanned event that did not
  result in injury, illness, or damage, but had the
  potential to do so.
• A Near Miss can in some situations be classed as
  an Incident as well.

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INCIDENT CLASSIFICATIONS AND DEFINITIONS

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ACCIDENTS DONT JUST HAPPEN

• By accidents we mean events where employees are
  killed, injured, or become ill from exposure to
  toxic chemicals or microorganisms.
• A systematic plan and follow through of
  investigating incidents and altering behaviors
  can help stop a future accident.
• An accident is not just one of those things
• Accidents are predictable and preventable events.
• They dont have to happen
• Lets take the 25kg box falling 2.5m for the
  second time, only this time it hits a worker,
  causing injury. Predictable? Yes. Preventable?
  Yes. Investigating why the carton fell will
  usually lead to solution to prevent it from
  falling in the future.

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THE TIP OF THE ICEBERG

• Accidents Accidents or injuries are the tip of
  the iceberg of hazards.
• Incidents and Near Misses Investigate incidents
  and near misses since they are potential
  accidents in progress.
• At ORYX GTL, we do not only investigate
  accidents. Incidents and high potential near
  misses should also be reported and investigated.

Criteria for investigating an incident What is
reasonably the worst outcome, equipment damage,
or injury to the worker? What might the severity
of the worst outcome have been? If it would have
resulted in significant property loss or a
serious injury, then the incident should be
investigated with the same thoroughness as an
accident investigation.
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ROOT CAUSE ANALYSIS

• Direct Cause (Immediate Cause) Unplanned release
  of energy or hazardous materials
• Indirect Cause (Basic Cause) Unsafe acts and/or
  unsafe conditions
• Root Cause (Lack of Control) policies and
  decisions, personal factors, environmental factors

• Root cause analysis is a systematic technique
  that focuses on finding the real cause of a
  problem and dealing with it, rather than just
  dealing with its symptoms.
• A root cause is the cause that, if corrected,
  would prevent recurrence of this and similar
  occurrences.
• A root cause of a consequence is any basic
  underlying cause that was not in turn caused by
  more important underlying causes.

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CONDUCTING AN INVESTIGATION

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QUESTIONS DISCUSSION
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Contact Us

• This presentation is owned by De Moura Lawson
  Consulting, available to the general public.
  Reproduction and distribution of this document is
  subject to local and international copyright
  laws.
• For further information on training and services
  provided by De Moura Lawson Consulting, please
  contact us at
• info_at_demoura-lawson.com
• 974 4423 1298

Copyright 2021 by DMLC, Subject to the
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