95122230-accident

Accident /Incident Investigation

Overview

Purpose of Investigation

Managing the Accident Scene

Steps in Conducting Investigation

Investigations are conducted to:

Prevent recurrence

Comply with policies and regulatory requirements

Maintain employee awareness

ACCIDENT

An undesired event that results

in harm to people, damage to

property, or loss to process

ILO Accident Report

• Accidents - 250 M/year or 685 T/day or

475/minute or 8/second

• Working children - 12 M (recorded),

12,000 are fatal

• Working Adults - 3,000/day = 2/min.

Types of Accident

1. Personal injury or illness

2. Property damage

3. Combination of items 1 & 2

4. Near-miss (actually an

incident)

INCIDENT

An undesired event which,

under slightly different

circumstances, could have

resulted in harm to people,

damage to property, or loss to

process

Accidents are the result of: :

Unsafe Acts

Unsafe Conditions

UNSAFE ACTS

Behaviors which could permit

the occurrence of an accident or

incident

Deviation from standard

procedures or practices

UNSAFE CONDITIONS

Circumstances which could

permit the occurrence of an

accident or incident

Deviation from

standard conditions

(equipment, materials,

or environment)

Unless the unsafe acts/conditions are:

Prevention is the reason for conducting an Accident

Investigation

Identified and

Eliminated or controlled

… similar mishaps will occur

LTI

Non-LTI

Near Miss

Chemical Spill

Property Damage

Fire and Explosion

All accidents must be investigated:

Accident Investigations are

usually considered a

Supervisor’s responsibility

More familiar with the people involved

Better understanding of the operations

Personal interest in investigations

Advantages of Supervisors over other investigators:

Team Effort

All employees should

understand :

What to report

How to report

LTI

Non-LTI

Near Misses

Property Damage

Chemical Spill

Fire or Explosion

What to Report

Medical

Safety

Environmental Control

Management

Whom to Report to:


Two Priorities:

Care & treatment of the injured

Elimination or control of remaining hazards

Training in First Aid

Drills under normal and abnormal conditions

Liaison with hospitals

Care & Treatment of Injured

Supervisors can increase their ability to respond to Medical Emergencies by:

Notify necessary personnel

Provide PPE to potentially

exposed

Refer to MSDS

Controlling Remaining Hazards

If a hazardous environment or toxic materials exist:

Isolate the site

To protect people from further

injury

To preserve evidence and

valuable clues

Successful investigation is done ...

Immediately

Completely

Thoroughly

Investigate immediately, because:

Operations are disrupted

Memories fade

Employees are at risk

Conducting the Investigation

Gather information

Analyze the facts

Make recommendations

ACCIDENT INVESTIGATION

Guidelines: 1. Investigate immediately

2. Ensure immediate treatment

3. Secure the area

4. Record details of event (photo, sketch, etc.)

5. Collect physical evidence

6. Review other sources (victim’s record, friends, etc.)

7. Interview witnesses (5Ws + 1H)

8. Write causal factors (man, machine, material, method)

9. Make recommendations (effective/reliable results)

Gathering Information

NOI, POI, DOI, TOI

personnel involved

property damage

environmental harm

Preliminary Facts:

Accident Investigation Equipment

Report form

Notebook or pad of paper

Tape recorder

Camera (instant or digital)

Measuring equipment

Sources of Information

Witnesses

Physical evidence at the

scene

Existing records

Victim and onlookers

Those who heard what happened

Saw area prior to incident

Others with info about involved

individuals, equipment or

circumstances

Witnesses

Interviewing Witnesses

1. Reassure the witness

2. Let the witness tell the story

3. Begin with open-ended questions

4. Don’t ask leading questions

Interviewing Witnesses

5. Summarize

6. Ask for recommendations

7. Get written statements

8. Close on a positive note


Questions for reporting: WHO

- was injured?

- saw the accident?

- was working with the injured?

- had instructed/assigned the job to the injured?

- else was involved?

- has the information of events prior to the accidents?


Questions for reporting: WHAT

- is the injury?

- is the damage or loss?

- was the injured doing?

- had the injured been

instructed to do?

- tools/equipment/machinery

were being used?

- did the injured & any

witnesses saw?

- training had been given?

- were the contributory causes

of the accident?

- communication system was

used?

- is the state of health of the

injured?

- safety rules were violated?

- safety system and procedures

were there?


Questions for reporting: WHEN

- did the accident occur?

- did the damage become evident?

- did the injured start the job?

- was the explanation of hazard given?

- did the supervisor last see the injured?

- did the persons involved last have food & rest?


Questions for reporting: WHY

- did the injury occur?

- did the communication fail?

- was the training not given?

- were the unsafe condition

permitted?

- was the hazard not spotted at

previous inspection?

- was PPE not provided?

- was PPE not used?

- was there no safe system of

work?

- was there no safety

instruction given?

- was the supervisor not

consulted when things

started go wrong?

- was the supervisor not there

at the time?


Questions for reporting: WHERE

- did the accident occur?

- did the damage occur?

- was the supervisor at that time?

- was the witnesses at that time?


Questions for reporting: HOW

- did the injury occur?

- could the accident have been avoided?

- could have been the injury avoided?

- could the supervisor have prevented the

accident?

- could better design help?

Physical Evidence

Provides information about an

accident that witnesses may

overlook or take for granted

Sketches

To record important details at the

accident site for later study

Electrocution

victim

Comfort

Room

Floor plan from overhead view

Location of involved man,

machine, tool

Size and location of transient

evidences (spills, dust,

footprints, skid marks)

Include everything that could be important:

AHU

X

X

Photographs

detail

color differences

complex shapes difficult to recall

Photographs

General area

Detailed shots

Show scale on small objects

Indicate reference point

Better to take too many than

too few

Materials

Tools

Machines EXAMINING

Examining Physical Evidence

Physical condition

Position of switches/levers

Reading of gauges

Safeguards

Warning devices

Machines & Tools

Misuse

Abuse

Disuse

Improper handling

Damage

Material

Position and condition can indicate

If chemicals are involved:

correct item used

correct concentration

expired

contaminated

MSDS availability

Material - Chemical

Log and label

Secure storage & transport

Avoid contamination

Guard against tampering and loss

Appropriate HSE warnings

If items have to be removed from the scene for detailed examination:

Environment (Work)

Weather condition

Illumination

Noise

Housekeeping

Existing Records

Employee records

Equipment records

Job or Task records

Previous Accident Investigation

reports

Workshop I - Gathering of Facts

I. Actual Accident or Simulated Accident

- Nature of Accident

- Parties involved/responsible person(s)

- Place of Accident

- Time and Date of Accident

II. Interview witnesses/victims

- 5W’s and 1 H develop at least 20 questions

III. Collected evidences, photographs, records review

15 minutes

IV. Presentation: Dramatization

10 minutes

Analyzing the Facts

Cause Analysis (root)

Change analysis

UNAWARE

UNABLE

UNMOTIVATED

HAZARDOUS

ACTS

UNNOTICED

UNCORRECTED

HAZARDOUS

CONDITIONS

ACCIDENT / ILLNESS

Immediate and Basic Causes

Look beyond the direct causes of

the accident …

Find out what can be done to

eliminate the underlying reason for

the hazardous behaviors and

conditions that led to the mishap

Direct

Causes

Basic

(root)Causes

Direct Causes

• caught in, between, or under

• struck against or struck by

• fall from or fall on

• overexertion or stress

Basic (Root) Causes

• inadequate maintenance of equipment

• inadequate codes and standards

• insufficient employee safety training

• safe work practices inadequately followed

• faulty design of work area

• supervisors not performing duties

Change Analysis

Compares how a job was

actually performed with the way

it should have been performed

Change Analysis

ACTUAL

BEHAVIORS or

CONDITIONS

STANDARD

BEHAVIORS or

CONDITIONS

SAFE BEHAVIORS or

CONDITIONS

ACTUAL

BEHAVIORS or

CONDITIONS

STANDARD

BEHAVIORS or

CONDITIONS

UNSAFE BEHAVIORS or

CONDITIONS

Recommending Corrective Actions

Specific Measurable Attainable Realistic Time-bound

Follow-up

It’s the best way to ensure that

recommendations are carried

out

General information

A Summary

An Analysis

Recommendations

Report forms require four basic types of information

Reports should be

Clear

Detailed

Neat

Legible

Management Approach

Training

Inspections

Hazard analysis

Safety Meetings

Not just for incidents

involving serious injury, its

for ANY occurrence that has

the POTENTIAL of causing

harm

Accident Investigation...

Review

Purpose of Investigation


Steps in Conducting Investigation


(General Process Flow)

Secure

the area

Document

the facts:

hard

evidence,

witness

Ensure

immediate

medical

treatment

Gather

facts

about the

accident:

witnesses

Identify

the root

cause

(causal

factors)

Corrective

action

Follow-

up

95122230-accident

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