Title: ACCIDENT INVESTIGATION
1Presented by Donald L. Trussell DEP Safety
Program Administrator 850-488-0878 or SC 278-0878
2ACCIDENT INVESTIGATION
3Introduction
- BABYLONIAN LAW
- WHY PRACTICE SAFETY?
- SAFETY EXCELLENCE
4SAFETY CULTURE
- CULTURE
- PARK SAFETY CULTURE
- WAY OF LIFE
- TEAMWORK/PARTNERSHIP
5RISK
- DEFINITION
- IDENTIFY POTENTIAL PROBLEMS
6Responsibility/Accountability
- BASIC CONCEPT
- MEASURE PERFORMANCE
- ACCOUNTABILITY
- Put the I back in
7ACCIDENTS
- DONT JUST HAPPEN
- ARE THE LEADING CAUSE OF DEATH
- RESULT OF UNSAFE OR SUBSTANDARD ACTS AND
CONDITIONS
8ACCIDENTS/INCIDENTS
- ACCIDENTS ARE INCIDENTS
- HAVE THE POTENTIAL TO HARM
- SHOULD ALWAYS BE INVESTIGATED
9What is an accident?
10An accident is
- Unwanted
- Unplanned
- Unforeseen
- Disruptive
- Can be major or minor
11Is an accident and an injury the same thing?
12Obvious Injury Costs
- Insurance Premiums
- Medical Expenses
- Worker Compensation
- Rest of work crew takes up the slack
- Accident Cost Iceberg
13Hidden 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)
14Actions vs. Attitudes
- Which is easier to see and report?
15Actions vs. Attitudes
- Which is easier to change?
16What 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!
17Why 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!!
18Accident Investigation An opportunity to change
the work climate by correcting unsafe conditions,
procedures, or actions.
19Elements 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
20First Goals of the Investigation
- Establish the following
- 1. Who
- 2. What
- 3. When
- 4. Where
- 5. How
- 6. Why
21Who
- Establish the person(s) who were involved in the
accident, including witnesses. This includes all
persons and not just an injured employee.
22What
- Describe in detail what happened.
23When
- Ensure times and dates are included in the
statements.
24Where
- Get specific about the location, to include what
Site, what facility, road name, etc.
25How
- Make sure your description of the incident is
clear and describes the factors that caused the
accident.
26Why
- 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.
27Drawing 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.
28All 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
29Cause 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.
30Root 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.
31Casual Factors Incident
- Precedes The loss
- Slip, Trip, Fall
32Causal FactorsBasic Causes
- THE DISEASE
- THIS IS THE WHY IT HAPPENED
- PEOPLE, EQUIPMENT, MATERIALS, ENVIRONMENT
- PERSONAL JOB FACTORS
33Causal FactorsLack of Control
- STARTS THE SEQUENCE
- 3 WAYS TO GAIN CONTROL
- PROGRAM
- STANDARDS
- COMPLIANCE
34Multiple SourceCauses-Controls
- CHAIN
- 90/10 RULE
- 3 STAGES OF CONTROL
- PRE-CONTACT
- CONTACT
- POST CONTACT
35So how do I use this information when an accident
occurs?
?
?
?
?
36Begin 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)
37Interview 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.
38Begin 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.
40Your 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.
41So 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?
42Corrective 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.
43Finish 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.
44To Recap Your Investigation
- Who/what/when/where/how/why
- Conclusions (cause root cause)
- Corrective Actions Taken
45Uses of the Report
- 1. Toolbox Talks/Departmental Training
- 2. Use your written report to complete the
Supervisors Accident Investigation Report
46Supervisors 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.
47Why 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?
48Conclusion
- ATTITUDE
- AWARENESS
- RESOURCES
49Thats All Folks!