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ACCIDENT INVESTIGATION

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Presented by: Donald L. Trussell DEP Safety Program Administrator 850-488-0878 or SC 278-0878 – PowerPoint PPT presentation

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Title: ACCIDENT INVESTIGATION


1
Presented by Donald L. Trussell DEP Safety
Program Administrator 850-488-0878 or SC 278-0878
2
ACCIDENT INVESTIGATION
  • The Basics

3
Introduction
  • BABYLONIAN LAW
  • WHY PRACTICE SAFETY?
  • SAFETY EXCELLENCE

4
SAFETY CULTURE
  • CULTURE
  • PARK SAFETY CULTURE
  • WAY OF LIFE
  • TEAMWORK/PARTNERSHIP

5
RISK
  • DEFINITION
  • IDENTIFY POTENTIAL PROBLEMS

6
Responsibility/Accountability
  • BASIC CONCEPT
  • MEASURE PERFORMANCE
  • ACCOUNTABILITY
  • Put the I back in

7
ACCIDENTS
  • DONT JUST HAPPEN
  • ARE THE LEADING CAUSE OF DEATH
  • RESULT OF UNSAFE OR SUBSTANDARD ACTS AND
    CONDITIONS

8
ACCIDENTS/INCIDENTS
  • ACCIDENTS ARE INCIDENTS
  • HAVE THE POTENTIAL TO HARM
  • SHOULD ALWAYS BE INVESTIGATED

9
What is an accident?
  • An accident is..????

10
An accident is
  • Unwanted
  • Unplanned
  • Unforeseen
  • Disruptive
  • Can be major or minor

11
Is an accident and an injury the same thing?
  • NO!

12
Obvious Injury Costs
  • Insurance Premiums
  • Medical Expenses
  • Worker Compensation
  • Rest of work crew takes up the slack
  • Accident Cost Iceberg

13
Hidden Injury Costs
  • Lost time at work
  • Reduced or lost income
  • Pain and suffering
  • Possibly having to learn a new job
  • Training costs to the company
  • Administrative costs (Investigation, ESH, HR)

14
Actions vs. Attitudes
  • Which is easier to see and report?

15
Actions vs. Attitudes
  • Which is easier to change?

16
What we would like to see.
  • That you understand why people do the things they
    do.
  • That you know there are many factors that cause
    an accident.
  • But mostlyThat you look deeply into why
    accidents happen!

17
Why do we investigate??
  • Prove the victim was at fault? ..no
  • CYA .no
  • Avoid law suits against the company.no
  • Try to make the work place safer!!

18
Accident Investigation An opportunity to change
the work climate by correcting unsafe conditions,
procedures, or actions.
19
Elements of the Investigation
  • Describe who was involved
  • Describe what happened
  • Establish a time line
  • Determine location of accident all factors
  • Establish a chain of events to understand how the
    accident occurred
  • Determine the cause root cause

20
First Goals of the Investigation
  • Establish the following
  • 1. Who
  • 2. What
  • 3. When
  • 4. Where
  • 5. How
  • 6. Why

21
Who
  • Establish the person(s) who were involved in the
    accident, including witnesses. This includes all
    persons and not just an injured employee.

22
What
  • Describe in detail what happened.

23
When
  • Ensure times and dates are included in the
    statements.

24
Where
  • Get specific about the location, to include what
    Site, what facility, road name, etc.

25
How
  • Make sure your description of the incident is
    clear and describes the factors that caused the
    accident.

26
Why
  • Based on who/what/when/where/ how, you should be
    able to piece together why the accident happened.
    This involves piecing information together to
    form a conclusion of the cause root cause of
    the accident.

27
Drawing Conclusions
  • From the who/what/when/where/how why that you
    just gathered, you now need to determine both the
    cause and root cause of the accident.

28
All things are hidden, obscure, and debatable
if the cause of the phenomena be unknown, but
everything is clear if this cause be
known.Louis Pasture
29
Cause of the Accident
  • The cause of the accident should describe what
    the immediate symptoms are of the accident.
  • Example An employee slipped on the floor
    because there was spilled coffee that made the
    floor slippery.

30
Root Cause
  • The root cause of the accident is the basic
    underlying reason, not always apparent, that
    caused the accident.
  • Example The root cause of the accident was that
    the person who spilled the coffee did not clean
    it up or establish a warning method to alert
    others of a hazard.

31
Casual Factors Incident
  • Precedes The loss
  • Slip, Trip, Fall
  • Loss Causation

32
Causal FactorsBasic Causes
  • THE DISEASE
  • THIS IS THE WHY IT HAPPENED
  • PEOPLE, EQUIPMENT, MATERIALS, ENVIRONMENT
  • PERSONAL JOB FACTORS

33
Causal FactorsLack of Control
  • STARTS THE SEQUENCE
  • 3 WAYS TO GAIN CONTROL
  • PROGRAM
  • STANDARDS
  • COMPLIANCE

34
Multiple SourceCauses-Controls
  • CHAIN
  • 90/10 RULE
  • 3 STAGES OF CONTROL
  • PRE-CONTACT
  • CONTACT
  • POST CONTACT

35
So how do I use this information when an accident
occurs?
?
?
?
?
36
Begin Your Investigation
  • Get the affected persons statement.
  • Get onlookers statements.
  • Note the positions of people and things.
  • Gather other information as needed, like manuals,
    records of training, safety, and maintenance.
  • Get pictures when needed (picture
    worth 1000 words)

37
Interview Tips
  • Need information - not placing blame.
  • Try to form open ended, non-judgmental questions.
  • Ask as many questions as it takes to clarify your
    understanding.

38
Begin Your Written Report
  • Gather all of your facts previously obtained, in
    particular who/what/when/where/how/why,
  • and the cause/root cause of the accident.
  • Additionally, gather written statements,
    information on similar incidents, and pictures to
    support your position when needed.

39
Example of Fact GatheringOn July
29, 1999, on or about 1045 am, Joe Employee was
stacking concrete blocks and walked into a piece
of steel re-enforcing bar that was protruding out
of the end of the pipe storage shelving unit
located inside the Project Materials compound,
striking him in the face. A 1 cut was received
across the middle of Mr. Employees forehead. He
proceeded directly to the dispensary, where he
received 4 sutures to close the laceration, then
was released at 1141am in a full duty status.
He went to lunch, then informed his immediate
supervisor of the incident upon returning to work
at 1230.
40
Your ConclusionsCause The accident was caused
by Joe not paying attention to his surroundings
and striking his head on the rebar.Root Cause
1 Somebody didnt properly store the rebar and
left it in a haphazard state that was obviously
unsafe.Root Cause 2 The supervisor has not
been taking responsibility for his work area by
monitoring for unsafe conditions.
41
So Now What?
  • At this point you have gathered facts,
    interviews, pictures, and all pertinent
    information. You have made conclusions and
    determined what the cause and root cause of the
    accident was.
  • Question What do you do with this information?

42
Corrective Action
  • You take corrective action that would prevent the
    reoccurrence of this type of injury in the
    future, such as
  • 1. You look around for similar things in your
    work center that would present the same type of
    hazard and implement corrective action.
    Examples pipe storage, lumber storage, conduit
    storage, etc.
  • 2. You should counsel the work center supervisor
    on proper storage methods and his
    responsibilities.

43
Finish Your Written Report
  • Now write your conclusions (cause root cause)
    in your report, and finally wrap up your report
    by a Corrective Actions Taken paragraph.
    Attach all supporting documentation to the back
    of the report. You are now done with your
    written report.

44
To Recap Your Investigation
  • Who/what/when/where/how/why
  • Conclusions (cause root cause)
  • Corrective Actions Taken

45
Uses of the Report
  • 1. Toolbox Talks/Departmental Training
  • 2. Use your written report to complete the
    Supervisors Accident Investigation Report

46
Supervisors Accident Investigation Report
  • Now that you have completed your written report,
    you are finally ready to complete the
    Supervisors Accident Investigation Report.
  • This piece of paper is merely a standardized form
    to document your accident investigation. Filling
    out the form before doing an investigation is
    putting the cart before the horse and does not
    constitute an investigation.

47
Why Investigate All Accidents and not just
Injuries?
  • Because for every Serious Injury, there are
  • Fatality
  • 10 minor injuries
  • 30 property damages
  • 600 near misses
  • So where should you be looking?

48
Conclusion
  • ATTITUDE
  • AWARENESS
  • RESOURCES

49
Thats All Folks!
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