Title: ACCIDENT INVESTIGATION
1ACCIDENT INVESTIGATION
2What Is An Incident?
- Unplanned and unwanted event which disrupts the
work process and has the potential of resulting
in injury, harm, or damage to persons or property.
An incident disrupts the work process, does not
result in injury or damage, but 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 occurs.
Employers should investigate an incident to
determine the root cause and use the information
to stop process and behaviors that could just as
easily have resulted in an accident. Example of
an incident A 50 lb carton falls off the top
shelf of a 12 high rack and lands near a worker.
This event is unplanned, unwanted, and has the
potential for injury.
3 What Is An Accident?
- Unplanned, unwanted, but controllable event
which disrupts the work process and causes injury
to people.
Most everyone would agree that an accident is
unplanned and unwanted. The idea that an
accident is controllable might be a new concept.
An accident stops the normal course of events and
causes property damage, or personal injury, minor
or serious and occasionally results in a fatality.
4What Is An Accident?
- An accident is not just one of those things.
- Accidents are predictable and preventable events.
- They dont have to happen.
Most workplace injuries and illness are not due
to accidents. The term accident is defined as
an unexpected or unintentional event, that it was
just bad luck. More often than not it is a
predictable or foreseeable eventuality. By
accidents we mean events where employees are
killed, injured, or become ill from exposure to
toxic chemicals or microorganisms (TB, Hepatitis,
HIV, etc). A systematic plan and follow through
of investigating incidents or disasters and
altering behaviors can help stop a future
accident. Lets take the 50 lb carton falling
12, for the 2nd 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.
5The Tip of the Iceberg
Accidents
Accidents or injuries are the tip of the iceberg
of hazards
Investigate incidents since they are potential
accidents in progress
Incidents
Dont just investigate accidents. Incidents
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
actual accident investigation. The 50 pound
carton falls off the top shelf of a 12 high rack
and lands near a worker. The outcome of an
investigation might include correction of sloppy
storage at several locations in the warehouse,
unstable/heavy items will be stored at floor
level if possible, refresher training of stockers
on proper methods is done, supervisor begins
doing daily checks.
6What is an Accident?
By dictionary definition an unforeseen event,
.chance.., unexpected happening..,
- 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.
Fatalities
Severe Injuries
Minor injuries
Close calls
Hazardous conditions
7Why Investigate?
- Prevent future incidents (leading to accidents).
- Identify and eliminate hazards.
- Expose deficiencies in process and/or equipment.
- You lose money when regular work stops.
- Maintain worker morale.
- The rule requires you to investigate serious
accidents.
8How To Investigate
- The time to develop your companys Accident
Investigation Plan is before you have an - incident or an accident. The who, when, where,
what and how should be developed - before the incident.
- Accident Investigation Training, investigation
tools and policies and procedures should be - developed before the incident or accident.
9How To Investigate
- Assemble an investigation kit
- Investigate all incidents and accidents
immediately
It is important to begin your investigation
immediately. Evidence disappears, the 50 lb
carton of material was cleaned up and memory
fadesthe employee was not encouraged to report
the near-miss incident and forgot about the whole
thing. When investigating incidents or accidents
be thorough in your capture of all available
facts. You might discover that many other items
were also improperly stored and that when
employees were questioned there had been several
other near misses
10How To Investigate
Interview witnesses and victims in a timely
manner. LISTEN Dont blame, dont point out poor
judgment, be sympatheticLISTEN If you know for a
fact that someone broke a rule it is not
important to point that out to them at this time.
Verify with them the training they have received
and ask them if they know what happened to cause
the accident. Again, it doesnt do anyone any
good at this stage to be told it was your fault
or you knew better As an investigator, you
will often come to the conclusion that someone
engaged in an unsafe act. It is most important
to determine why they engaged in an unsafe act as
well as verify that they did or did not know
better.
11How To Investigate
- 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.
12Tips for Developing A Plan
- Develop your action plan ahead of time.
- Your plan might include
- Who to notify in the workplace?
- How to notify outside agencies?
- Who will conduct the internal investigation?
Preplanning will help you address situations
timely, reducing the chance for evidence to be
lost and witnesses to forget. All procedures,
forms, notifications, etc. need to be listed out
as step-by-step procedures. You might wish to
develop a flow chart to quickly show the major
components of program.
13Develop a Plan Tips (continued)
- What level of training is needed?
- Who receives report?
- Who decides what corrections will be taken and
when? - Who writes report and performs follow up?
- Some expansion questions on the above points are
- Who will be trained to investigate?
- Who is responsible for the finished report and
what is the time frame? - Who receives copies of the report?
- Who determines which of the recommendations will
be implemented? - Who is responsible for implementing the
recommendations? - Who goes back and assures that fixes are in
place? - Who assures that fixes are effective?
14What Should Be In The Investigation Kit
- Camera equipment First aid kit
- Tape recorder Gloves
- Tape measure Large envelopes
- High visibility tape Report forms
- Scissors Graph paper
- Scotch tape
- Sample containers with labels
- Personal protective equipment
-
-
These are some common items for a kit. What else
might be useful? Anything for specific business
or workplace that might be needed?
15Investigate All Incidents/Accidents
- Conduct and document an investigation that
answers - Who was present?
- What activities were occurring?
- What happened?
- Where and what time?
- Why did it happen?
Root causes should be determined. Example An
employee gets cut. What is the cause? It is not
just the saw or knife or the sharp nail. Was it
a broken tool and no one reported? Did someone
ignore a hazard because of lack of training, or a
policy that discourages reporting? What are
other examples of root causes? Enforcement
failure, defective PPE, horseplay, no recognition
plan, inadequate labeling.
16Investigate All Incidents/Accidents
- Also answer
- Is this a company or industry-recognized hazard?
- Has the company taken previous action to control
this hazard? - What are those actions?
- Is this a training issue?
17Begin Investigations Immediately
- Its important to collect evidence and interview
witnesses as soon as possible because evidence
will disappear and people will forget.
18How Do You Investigate?
- Notify individuals according to your plan
- You must involve an employee representative, the
immediate supervisor, and other people with
knowledge - Grab your investigation kit
- Approach the scene
19Actions At The Accident Scene
- Check for danger
- Help the injured
- Secure the scene
- Identify and separate witnesses
- Gather the facts
- First, make sure you and others dont become
victims! Always check for still- - present dangerous situations. Then, help the
injured as necessary. - Secure the scene and initiate chains of custody
for physical evidence. - Identify witnesses and physical evidence.
Separate witnesses from one another - If physical evidence is stabilized, then begin
as quickly as possible with interviews. - REMEMBER, BE A GOOD LISTENER
20Fact Finding
- Witnesses and physical evidence
- Employees/other witnesses
- Position of tools and equipment
- Equipment operation record, charts,
- Equipment identification numbers
21Fact Finding
- Take notes on environmental conditions, air
quality - Take samples
- Note housekeeping and general working environment
- Note floor or surface condition
- Take many pictures
- Draw the scene
Some scenes are more delicate then others. If
items of physical evidence are time sensitive
address those first. If items of evidence are
numerous then you may need additional assistance.
Some scenes will return to normal very quickly.
Are you prepared to be able to recreate the scene
from your documentation? Consider creating a
photo log. The plot should describe the date,
time, give a description of what is captured in
the photo and directionality. Link to sketch of
accident scene.
22Interview Witnesses
- LISTEN
- Dont blame, just get facts
- Talk to witnesses as equals
- Keep conversations informal
23Interview Witnesses
- Choose a private place to talk
- Ask open ended questions
- Interview promptly after the incident
- Ask some questions you know the answers to
Your method and outcome of interview should
include who is to be interviewed first who is
credible who can corroborate information you
know is accurate how to determine the truth
bases on a limitation of numbers of witnesses.
Be respectful, are you the best person to conduct
the interview? If the issue is highly technical
consider a specialist, this may be an internal
resource or it may be an outside resource.
24Write 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
Remember that your report needs to be based on
facts. All recommendations should be based on
accurate documented findings of facts and all
findings and recommendations should be from
verifiable sources.
25 Write The Report
Answer the following in 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?
26Report Conclusions
- What should happen to prevent future accidents?
- What resources are needed?
- Who is responsible for making changes?
- Who will follow up and insure implementation
of corrections? - What will be future long-term procedures?
Conclusions must always be based upon facts found
during your investigation. If additional
resources are needed during the implementation of
recommendations then provide options. Having a
comprehensive plan in place will allow for the
success of your investigation. Success of an
investigation is the implementation of viable
corrections and their ongoing use.
27Report A Death or Hospitalization (Catastrophe)
- Report the death, probable death, or the
in-patient hospitalization of 2 or more employees
within 8 hours. -
The required information that must be provided 1-
Name of the work place 2- Location of the
incident 3- Time and date of the incident 4-
Number of fatalities or hospitalized employees 5-
Contact person 6- Phone number 7- Brief
description of the incident
28- The ultimate purpose of incident investigation
and analysis activities is to prevent future
incidents. As such, the investigation or analysis
must produce factual information leading to
corrective actions that prevent or reduce the
number of incidents. - The more complete the information, the easier it
will be for management to take effective
corrective actions. All incidents should be
investigated, regardless of severity of injury or
amount of property damage.
29The minimum data set that investigators should
record includes the following
- If data will be used to compare one company with
another, record data about employer
characteristics. This includes the type of
industry and the size of the company (number of
full-time equivalent employees). - Record employee characteristics. The victim's age
and sex, the department and occupation in which
he or she worked, and whether a full-time,
part-time, or seasonal employee. Questions about
the victim's experience are also asked. - How long has the victim been with the company?
- How long in current occupation?
- How often had the employee repeated the activity
engaged in when the incident occurred? - Employee training records may be examined and
assessed during this part of the investigation. - Record the characteristics of the injury.
Describe exactly the injury or injuries and the
part or parts of the body affected by the
incident.
30- Prepare a narrative description and accident
sequence that provides the exact location of the
incident (attach any maps or diagrams to the
report) - a complete, specific breakdown of the sequence of
events leading to the injury or near-miss - what objects or substances were involved in the
incident - conditions such as temperature, light, noise, and
weather pertaining to the incident - whether any preventive measures had been in
place and - The investigators should include only the facts
obtained during the investigation they should
not record opinions or place blame. - Record the characteristics of the equipment
associated with the incident. These data should
be incorporated into the narrative description on
the report form. Include the type, brand, size,
and any distinguishing features of the equipment,
its condition, and the specific part involved. - Record the characteristics of the task being
performed when the incident happened the general
task (such as repairing a conveyor) and the
specific activity (such as using a wrench).
31- Record the time factors. The investigation should
record the time - of day and whether it was the victim's first
hour of the shift, second hour, or later. - Record the task and activity factors. First,
describe the general type of task the employee
was performing at the time the injury occurred.
Second, record the specific activity in which the
employee was engaged. - Record supervision information. Indicate in the
appropriate place on the form whether the
employee was being supervised directly,
indirectly, or not at all at the time of the
incident. - Record the causal factors. Record the events and
conditions that contributed to the incident. Be
as specific and complete as possible. - Describe the corrective actions taken immediately
after the incident to prevent a recurrence,
including temporary actions.
32- ESTIMATING INCIDENT COSTS
- Although most executives want to make their
company a safe place to work, they also have a
responsibility to run their business profitably. - Definition of Work Incidents for Cost Analysis
- Work incidents, for the purpose of cost analysis,
are unintended occurrences arising in the work
environment. These incidents fall into two
general categories - (1) incidents resulting in work injuries or
illnesses - (2) incidents causing property damage or
interfering with - production.
- Method for Estimating
- To be of maximum usefulness, cost figures should
represent as accurately as possible the specific
experience of the company. - Estimated costs of incidents in general do not
take into account differences in hazards from one
industry to another. - Because of the differences between direct and
indirect costs are difficult to maintain, instead
they use more precise terms "insured" and
"uninsured" costs. Using these data, a company
can estimate its incident cost with reasonable
accuracy.
33- Insured Costs
- Every organization paying compensation insurance
premiums recognizes such expense as part of the
cost of incidents. In some cases, medical
expenses too, may be covered by insurance. These
costs are definite and known. They include the
insured element of the total incident cost. - In addition to these costs, many other costs
arise in connection with incidents. - Although the expense of damaged equipment is
easily identified, others, such as wages paid to
the injured employee for downtime on the day of
the injury, are hidden. These items include the
uninsured element of the total incident cost. - Uninsured Costs
- While insured costs can be determined easily from
accounting records, uninsured (also called
"indirect") costs are more difficult to assess.
The method described here is one way to calculate
these added expenses associated with many
incidents. -
34- The first step is to conduct a pilot study
- Determine approximate averages of uninsured costs
for each of the - following four classes of incidents
- 1. Class 1-Cases involving lost workdays
- days away from work or days of restricted work
activity - 2. Class 2-Medical treatment cases
- requiring the attention of a physician outside
the facility - 3. Class 3-Medical treatment cases requiring only
first aid - local dispensary treatment and resulting in
property damage of less than 100 or loss of less
than eight hours in work time - 4. Class 4-Incidents that either cause no injury
or cause minor injury, not - requiring the attention of a physician, and that
result in property damage of 100 or more, or
loss of eight or more employee-hours. - Once average costs have been established for each
incident class, they can be used as multipliers
to obtain total uninsured costs in subsequent
periods. These costs are then added to known
insurance premium costs to determine the total
cost of incidents.
35- Example of a Cost Estimate
- An estimate of costs made by one company is given
in the following example. First, a pilot study
was conducted to obtain the average cost of each
class of incident. - Included in the study were 20 Class 1 incidents,
30 Class 2 incidents, 50 Class 3 incidents, and
20 Class 4 incidents. Costs were determined and
averages developed in Table 7-A. - During the entire year, the company had 34 Class
1 incidents, 148 Class 2 incidents, and 4,000
Class 3 incidents. No record was kept of the
Class 4 incidents after the pilot study was
completed. Instead, the ratio of the number of
Class 4 to Class 1 incidents found in the pilot
study was used. - This ratio was shown to be about 1 to 1, and
since there were 34 Class 1 incidents during the
year, it was assumed there were about 34 Class 4
incidents. (A separate record could be kept of
the number of Class 4 incidents.)
36- TABLE 7-A Average Cost Determined by Pilot Study
- __________________________________________________
_ - Class of Number of
Average of - Accidents Accident Reported
Uninsured cost - ______________________________________________
- Class 1 20
251.10 - Class 2 30
80.80 - Class 3 50
15.70 - Class 4 20
507.10 - The average cost for each incident class was
applied to these totals to secure the results
shown in Table 7-B. - The estimate should be rounded to three
significant digits-in this case, to the nearest
thousand dollars. As a result, in this instance,
the analyst reported to the plant manager,
"During the past year, incidents cost this
company about 155,000 in compensation, medical
expense, lost time, and property damage." - The average costs determined in this pilot study
represent the actual experience of this
particular organization.
37- Table 7-B. Estimate of Yearly Accident Costs
- __________________________________________________
______ -
Average Cost Total - Class of Number of per Accident
Uninsured - Accident Accidents (from pilot study)
Cost - __________________________________________________
______ - Class 1 34
251.10 8,537.40 - Class 2 148
80.80 11,958.40 - Class 3 4,000
15.70 62,800.00 - Class 4 34
507.10 17,241.40 - Total Uninsured Cost
100,537.20 - Insurance Premiums
54,400.00 - Total Accident Cost for the Period
154,937.20
38- Items of Uninsured Cost
- Important to a pilot study is a careful
investigation of each incident to - determine all the costs arising out of it.
- The following items of uninsured or indirect
costs are clearly the result of - work incidents and are subject to reasonably
reliable measurement. - 1. Cost of Wages Paid for Time Lost by Workers
Who were not Injured. - These are employees who stopped work to watch or
assist after the incident or who lost time
because they needed the equipment damaged in the
incident or because they needed the output or the
aid of the injured worker. - 2. Nature and Cost of Damage to Material or
Equipment. - The validity of property damage as a cost can
hardly be questioned. Occasionally, there is no
property damage, but a substantial cost is
incurred in reorganizing material or equipment. - 3. Cost of Wages Paid for Time Lost by the
Injured Worker, other than Workers' Compensation
Payments. - Payments made under workers' compensation laws
for time lost after the waiting period are not
included in this element of cost. - 4. Extra Cost of Overtime Work Necessitated by
the Incident. - The charge against an incident for overtime work
is the difference between normal wages and
overtime wages for the time needed to make up
lost production, and the cost of extra
supervision, and other extra services.
39- 5. Cost of Wages Paid to Supervisors for Time
Spent on Activities Concerning - the Incident. The most satisfactory way of
estimating this cost is to charge the wages - paid to the supervisor for the time spent away
from normal activities as a result of the - incident.
- 6. Wage Cost Caused by Decreased Output of
Injured Worker after Return to Work. - If the injured worker's previous wage payments
are continued despite a 40 reduction - in output, the incident should be charged with
40 of the worker's wages during the - period of low output.
- 7. Cost of Learning Period of New Worker.
- If a replacement worker produces only half as
much in the first two weeks as the injured - worker would have produced in the same time for
the same pay, then half of the new - worker's wages for the two weeks' period should
be considered part of the cost of the - incident.
- 8. Uninsured Medical Cost Borne by the Company.
- This cost is usually that of medical services
provided at the plant dispensary. There is no
40- Conducting a Pilot Study
- The purpose of the pilot study is to develop
average uninsured costs for different classes of
incidents that can be applied to future incident
totals. - Therefore, it is desirable not to include the
costs of deaths and permanent total disabilities.
Such incidents occur so seldom that the costs
should be calculated individually and not
estimated on the basis of averages. - OFF - THE - JOB DISABLING INJURY COST
- When incidents take place off the job, a major
portion of the costs are borne by employers. Some
of the costs are obvious, such as insurance
premiums and wages paid to absent employees. - Some of the costs are hidden, such as training
for new or transferred workers and medical staff
time demanded for workers returning to work after
an incident. - For example, a new worker does not produce at the
same level as an experienced worker thus, the
decreased productivity of the new worker
indirectly increases the manufacturing overhead.
41- Categorizing OTJ Disabling Injury Cost
- The cost of off the job disabling injuries (O T J
DI) to an organization falls into the following
two categories insured and uninsured. - Most uninsured costs are hidden. Aside from wage
costs, most organizations do not keep records of
uninsured costs. However, these costs are
associated with all O T J D I incidents and,
therefore, affect profit margins. - Insured Costs worker productivity cost,
product loss, and equipment damage. directly
associated with the employee who sustained the O
T J D I injury are included in this expense
subcategory. - Uninsured Costs worker productivity cost,
product loss, equipment damage, and
administrative cost. incurred by personnel
other than the employee who sustained the OTJ DI
injury are included in this subcategory. - Miscellaneous costs This subcategory includes
loss of profit for cancelled contracts or orders
and the costs of demurrage (compensation),
telephone calls, transportation, or other
miscellaneous expenses.
42- Estimating O T J D Costs
- Some experts say the ratio of insured cost to
uninsured cost is 32. In order to estimate a
company's losses from employee OTJ D I s,
management must first determine the insured cost.
- Next, using the 32 factor, it must rise the
insured cost to determine the total (insured and
uninsured) employee costs. The insured cost for
injuries to dependents of employees is then added
to the total employee cost to determine total
losses. The following examples illustrate
calculation procedures.
43- Example 1
- Company A is insured by an outside carrier.
Twenty percent or 225,000 of its annual premium
charge was required to pay for its previous
calendar year OTJ DI incident experience. Of that
total, 75,000 was required for 11 employee
injuries and the remaining 150,000 was required
for 22 employee-dependent injuries. These figures
include the administrative fee paid by the
company to the carrier. - The total cost for employee-dependent injuries is
a conservative figure, since it does not include
the administrative cost incurred by the company's
insurance office staff to process claims. If this
cost is known, it should be added to the employee
dependent injury expense category. - When the 75,000 insured cost category is
escalated to include the uninsured cost category,
the total expense for employee injuries becomes
125,000. - Company A Estimated OTJ DI Costs
- Insured cost for employee injuries 75,000
- Uninsured cost for employee injuries 50,000
- Insured cost for
- Employee dependent injuries 150,000
- Total annual estimated OTJ DI cost 275,000
44- Example 2
- Company B is insured by an outside carrier. Its
carrier stated that 850,000 was paid for 138
employee injuries and 1,800,000 was paid for 279
employee-dependent injuries for its previous
calendar year OTJ DI incident experience. - Their administrative fee to the carrier was 6 of
the total cost, resulting in a cost of
approximately 900,000 for employee injuries and
1,900,000 for employee dependent injuries. If
the cost for insurance office staff
claim-processing is known, it should be added to
the total employee-dependent cost. - Escalation of the insured cost category for
employee injuries include the uninsured cost
category indicated a total of 1,500,000. - Company B Estimated OTJ DI Costs
- Insured cost for employee injuries
900,000 - Uninsured cost for employee injuries
600,000 - Insured cost for
- employee-dependent injuries
1,900,000 - Total annual estimated OTJ DI cost
3,400,000
45- Example 3
- Company C is self-insured. Insurance office
records indicated that for the previous calendar
year, OTJ DI incident experience for the amount
of medical and health claims paid for 350
employee injuries was 2,280,000, and 4,700,000
was paid for 690 employee-dependent injuries. - Insurance office staff administrative costs for
claim processing should be added to the employee
dependent cost category if that cost is known.
- Thus, 2,280,000 escalated to include the
uninsured cost category for employee injuries
resulted in a total cost of approximately
3,800,000. - Company C Estimated OTJ DI Costs
- Insured cost for employee injuries
2,280,000 - Uninsured cost for employee injuries
1,520,000 - Insured cost for
- employee-dependent injuries
4,700,000 - Total annual estimated OTJ DI cost
8,500,000
46- Measuring the Effects of OTJ Safety Programs
- Calculations of average costs are useful tools to
support initiating or accelerating off the job
safety awareness programs. The calculations also
can be used to measure the effects of safety
programs. - For example, 350 employees of Company C
experienced OTJ injuries during the previous year
for a total of approximately 3,800,000 and an
average cost per incident of approximately
10,860. - Based upon the OTJ DI loss experience, top
management allocated 50,000 from the budget to
initiate a safety awareness program. - At the end of the year, the 10,860 average cost
figure will be escalated to adjust for inflation
and, in turn, the new figure will be used to
calculate losses. - For illustration purposes, it is assumed that the
new average cost per incident figure is 11,500
and that employee injuries were reduced from 350
to 300. - Calculations (300 x 11,500) indicate losses of
3,450,000, a savings of approximately 350,000
from last year's total. The estimated net return
is 300,000, which is a 600 return on
investment. - To further support justification for operating
funds, safety personnel can add savings realized
from reduced employee-dependent injuries to the
employee savings total. - This type of analysis provides a management tool
to evaluate the impact of off-the-job disabling
injuries on profit margins thus, it can be used
to gain management commitment to support
operating budgets for safety awareness programs.