accident investigation
TRANSCRIPT
By: Mr. Eros G. Zuñiga
State the objective of Accident Investigation, Analysis and Reporting. Describe the step-by-step procedure involved in the accident investigation process.
Assess an accident by properly evaluating the underlying
factors that contribute to the accident. Properly investigate a workplace
accident. Comply with the requirement of
the Occupational Safety and Health Standards.
“People become injured, disabled and sometimes killed due to industrial accidents.What can be done to prevent these accidents from recurring?”
ADVANTAGES OF EFFECTIVE INVESTIGATIONS:
They-Described What HappenedDetermined the Real Cause Described the Risks Developed ControlsDefined TrendsDemonstrated Concern
• The Investigator must:– Have first basic understanding of
how accidents could happen– Know the causal factors that lead to
accidents
THE CONDUCT OF ACCIDENT INVESTIGATION
“An unplanned event that may result in personal injury or property damage”
ACCIDENT CAUSES
An Unsafe Act
An Unsafe Condition
Unsafe Behaviour Incident
Training Hazop Audit Maintenance
InductionResources
ProceduresClearances
FAILURE IN ONE OR MORE MANAGEMENT SYSTEMS
ORGANISATIONAL RESPONSIBILITIES
YOUR RESPONSIBILITIES
Mistaken Actions
Lapses ofattention
Wilfulness Mistaken Priority
FAILURE IN BEHAVIOUR
Misperception
SOME COMMON EXCUSES ON CAUSES OF ACCIDENTS:
Carelessness Accident-prone Inattention (distraction) Negligence Not wearing safety equipment
SOME COMMON EXCUSES ON CAUSES OF ACCIDENTS:
Bad luckAct of God Not thinking Laziness Taking short cut
“Unsafe Act-Unsafe Condition”
vs. forces effect outside the workplace”
…”accidents occur within the system and the worker is a part of the system.”
…”it must be understood and accepted that the individual imports into a sterile world of machines and work schedules, influences, which occur outside of work environment.”
…”while it is difficult to find solution to what is perfectly natural occurrence (eg. Bringing our problem to work) we can not ignore the effect, forces outside the workplace have on accident.”
THE WORK SYSTEM
PEOPLE PLANT AND EQUIPMENT PROCEDURES MANAGEMENT MATERIALS ENVIRONMENT
THE WORK SYSTEM
…”When combined, these elements allow for the production process to be carried out.”
..”Work environment is more than the
physical aspects of the Workplace
(eg. Lighting, noise, heat, air quality, etc.).”
….”Given that a work is a system rather than a collection of independent variables, there is a sound reason to believe that an accident is a breakdown in a system rather than a fault in any variable, e.g. the individual.”
..”When a worker has an accident, the first consideration that an investigator has to look into is what the work system where an accident happened look like.”
The Need to Inquire Purpose of Accident Investigation:
Identify accident causes so that similar accidents can be prevented Determine the “change” or “factors”
that produced an “error” that in turn resulted in the accident
AN INVESTIGATION SHOULD BE ABLE TO ANSWER?
WHO was involved? WHAT happened? WHEN did it happened and WHAT are the
the contributing factors WHEN did the accident occur? WHERE did the accident occur? HOW can a similar accident be prevented from happening?
“ PREVENTION OR BLAME
“ If an accident occurs, are the organization’s means of identifying and correcting potential hazards at fault?….
…. Not necessarily... The incident may simply demonstrate the organization’s limited experience”.
CHARACTERISTICS OF GOOD INVESTIGATIONS:
Yield information needed to: determine injury rates identify trends and problem areas permit comparisons satisfy legal requirements
CHARACTERISTICS OF GOOD INVESTIGATIONS:
Identify the basic causes that contributed directly, or directly, to each incident Identify deficiencies in the production
and management system that permitted the accident to occur Suggest specific corrective action alternatives for the management system
“The purpose of conducting investigation is to establish causes.”
Blame can result into: Witnesses not revealing all of the circumstances and events surrounding the accident Deliberate obstruction, or provision of false information Removal of relevant information documents or evidence
For the accident investigation to be successful in identifying all of the causes it will be necessary to establish:
Events leading up to the incident The system of work being carried on The instruction given for the work Variation from instruction or safe work systems
Workplace condition such as lighting, floor surfaces, stairs treads and handrails, warning signs, temperature, weather if incident occurred outside, etc.
The exact location of the incident The materials in used or being handled The type of transport or equipment in use
Facts of the incident itself
The state of the systems and the actions that occurred at the moment The persons directly involved, and those involved at a distance, if any The tools, equipment, materials and fixtures directly concerned The time and nature of any injury
WHO SHOULD INVESTIGATE?WHO SHOULD INVESTIGATE?
“ The size and make-up of the investigation team is usually dictated by the accident’s seriousness or complexity”
RISK WHOINVESTIGATES
TYPE OF INVESTIGATION &REPORT
1 -6Supervisor Report only
Use UIR/IR e.g . Broken Door Handle
7 - 10 Supevisor/Manager Report & Investigate Use UIR/IR Use "Basic Investigation Guidelines e.g. First Aid Injury (bruised elbow)
11 - 30 BusinessManager/Factory
Manager
Report & Investigate Use UIR/IR but add supporting documentation Use "Basic Investigation Guidelines e.g MTC /Potential Lost Time
31 - 50 Country Manager Report & Investigate Fully documented report Use "Significant Incident Tool Kit" e. g. Falling off an MMU
51- 100 GMT, e.g. AsiaManager or SHETeam, e.g. AsiaPacific SH&E
Manager
As immediately above e.g. Major Magazine Fire
EXAMPLE: WHO SHOULD INVISTIGATE? EXAMPLE: WHO SHOULD INVISTIGATE? (RISK BASED APPROACH)(RISK BASED APPROACH)
CONDUCTING AN INVESTIGATIONCONDUCTING AN INVESTIGATION
The Team Leader• Should be chosen as soon as
possible• Should have the experience and
the authority to get the job done
His duties include: compilation of the report presiding over meetings controlling scope of the team
activities
The Health & Safety Representative
CONDUCTING AN INVESTIGATION
QUESTIONING THE WITNESSES
2 Types of Witnesses Eye Witness Hearing Witness
CONDUCTING AN INVESTIGATION
INTERVIEW TECHNIQUES Basic approach to “investigation interviewing”:
Conduct the interview in private at workplace
Put the interviewee at ease, don’t hurry things Ask for the interviewee’s story of what version of what has happened
Only ask necessary questions Repeat the interviewee’s story as you understand it Close the interview on a positive note and thank the witness
Conducting the Interview at the Scene of the Accident
“Usually the main advantage in interviewing at the scene is that it usually assists the memory of the person being interviewed if he/she can refer or point to physical conditions at the scene of the accident”
CONDUCTING AN INVESTIGATION
Only Ask “Necessary” Questions Ask Open Questions Repeat Story as you Understand it Close the Interview Positively
CONDUCTING AN INVESTIGATION
Example of an
Investigation Report
O R I C A E X P L O S I V E S P H I L I P P I N E S I N C .
I N C I D E N T I N V E S T I G A T I O N R E PO R T
F O R K L I F T I N C I D E N T
1 . S U M M A R Y
1 . 1 D E P A R T M E N T C O N C E R N E D :O r d e r S e r v i c e & D is p a t c h
1 . 2 C O N T R A C T O R I N V O L V E D :S a n t i e s T r u c k in g
1 . 3 L O C A T I O N O F I N C I D E N T :M a r i v e le s Z ig z a g
1 . 4 D A T E O FO C C U R R E N C E :0 4 / 4 / 0 0
1 . 5 T I M E :+ / - 0 8 0 0 H
I N J U R Y P R O P E R T Y D A M A G E P E R S O N I N V O L V E D1 . 6 P R O P E R T Y D A M A G E D : F o r k l i f t
1 . 1 0 P E R S O N W I T H M O S T C O N T R O L O F E Q U I P M E N T D U R I N G T H E I N C I D E N T : M r . A r n e l S a m b i l e
1 . 7 E s t im a t e d C o s t :
+ / - P 1 0 , 0 0 0 . 0 01 . 1 1 O C C U P A T I O N : D r i v e r
1 . 8 C A U S E O F D A M A G E :E q u i p m e n t f a l l
1 . 6 N o n e
1.9 N A T U R E O F D A M A G E : F o r k c h a in W h e e l A s s e m b l y
b r o k e n - S l i g h t s c r a t c h e s o n b o d y
p a i n t
1 . 1 2 T R U C K N U M B E R : T J L 6 5 1
2 . D E S C R I P T I O N O F T H E I N C I D E N T
T h e t r u c k l e f t B A S E C O P ie r a t a r o u n d 0 7 4 5 H , l o a d e d w i t hO E P f o r k l i f t m a c h i n e w i t h s e r i a l n o . 5 1 7 7 2 1 . T h e f o r k l i f tw a s a n c h o r e d t o t h e b o d y o f t h e t r u c k w i t h a n y lo n r o p e o fa r o u n d 1 / 2 - i n c h in d i a m e t e r . T h e f o r k l i f t f o u r w h e e ls w e r ea p p a r e n t l y b l o c k e d w i t h w o o d e n c h o c k a n d t h e e q u i p m e n tp a r k in g b r a k e w a s e n g a g e d . M r . J o e y V a ld o z w h o w a so v e r s e e in g t h e l o a d in g o f e x p l o s i v e s in M V T a k a t o r ie n s u r e d t h a t t h e e q u ip m e n t w a s t i e d o f f , a l t h o u g h h e d i dn o t r e a l i z e t h a t t h e s l i n g s i z e i s t o o s m a l l . D u r in g t h et r a n s p o r t o f t h e f o r k l i f t t o t h e F a c t o r y b y t h e s u p p l i e r , i t w a sa n c h o r e d u s in g b i g m e t a l c h a i n .
1. ANALYSIS
The immediate cause of the incident was apparently the sudden braking of thetruck while climbing uphill in order to avoiding collision with a descendingspeeding vehicle. On the other hand, the underlying causes for the equipment tofall was improper anchoring of the forklift and undersize sling, which attributedfurther to having no standard procedure on anchoring forklift to the truck duringtransport.
(Please see attached Why Analysis of the incident).
2. EVALUATION
2.1 Loss Severity Potential
Serious - There could have been a major damage to equipment and shouldthere was a vehicle following the truck, it might also inflict serious damage tothe other vehicle and likewise serious injury to the driver and /or its passenger/s.
2.2 Probable Recurrence Rate
Frequent - Should there will be no standard procedure of anchoring theEquipment during transport, a similar incident can occur on its futuretransportation.
3. PREVENTIVE ACTION
ACTION BY WHO BY WHEN3.1 Establish procedure on anchoring forklift during transportation from the Factory to the pier or when being loaded to the truck.
DIS Before nextshipment(07/00)
3.2 Establish procedure on anchoring forklift duringtransportation from the Factoryto the pier or when being loaded to the truck
DIS Before nextshipment(07/00)
5.3 Train supervisors and drivers on the procedure DIS Before nextshipment(07/00)
5.4 Ensure proper anchoring is done and the righttype of sling is used before transporting
forklift as per standard procedure
DIS/Supervisors
Always everyshipment
5.5 Ensure truckers are given safety induction on transport operation
DIS Always everyshipment
5.6 Audit truck condition and transport DIS/EKP/MG Always every
6. ATTACHEMENT
Why Analysis of the Incident
Prepared by: J M PERFIÑANSH&E MANAGER
Rule 1052 - Special Provision 1052.01 Rule 1053 - Report Requirements 1053.01 1053.02
Rule 1054 - Keeping RecordsRule 1055 - Evaluation of Disability Rule 1056 - Measurement of Performance 1056.01 - Exposure to Industrial Injuries 1056.02 - Determination of Employee-Hours Exposure
Rule 1056.03 - Measurement of Injury/Illness Disabling Injury/Illnesses Frequency
Rate (FR) Disabling Injury/Illnesses Severity Rate
(SR) Average Days Charge Per Disabling
Injury/Illnesses
TO SUMMARIZE:Effective Investigation AccidentThe Work SystemThe Synoptic Accident ModeThe Actual InvestigationConducting an InvestigationLegal Requirement
WORKSHOP:
ACCIDENT INVESTIGATION & REPORTING
Write an investigation report of of an accident, involving a company personnel service vehicle inside the plant premises, during the night shift. The CAR hit the corner of a building injuring the DRIVER, suffering a medical treatment case (MTC). The car sustained a major damage. No passenger during the time of accident.
WORKSHOP:
ACCIDENT INVESTIGATION & REPORTING Format: Description of the accident (Basic information, WHO, WHEN, WHERE, WHAT, HOW) Accident analysis; causation - root causes Recommendation to prevent recurrence; (RECOMMENDED ACTIONS, BY WHO, BY WHEN)
Case #1Case #1• The Accident:
Driver J. Cruz and J. Reyes were unloading bulk feed from their truck into the feed bin of house #5. The truck’s feed compartment was on a dumping tilted position. The truck was directly under the electrical high-tension wires, with 1.2kva, supplying power to the poultry houses. While unloading, J. Cruz noticed the feed was not flowing smoothly inside the compartment. He climbed above and looked into the manhole. When he raised his hand, he momentarily forgotten the electric wire above him. His nape got in contact with the wire and shock threw him into the manhole. Helper J. Reyes, who was standing at the tail of the truck was also thrown against the compartment.
Continuation of accident case #1Continuation of accident case #1
J. Cruz suffered burns on the nape and buttocks. While J. Roxas suffered cut on the forehead.
The high tension wire diagonally crossed the road fronting house #5. Because of the terrain and the sag, the wires has a clearance of 18 feet from the ground level at the point in front of house #5 or where the truck was parked. The truck has a clearance height of about 12 feet, untitled, from the ground. If the bulk feed inside the truck compartment gets stucked, the driver dislodge by means of using poles through the manhole.
According to Mr. Rodriguez, Farm Superintendent, this is the second time incident of this nature happened on the same spot.
Case #2Case #2• The Accident:
In a ship repair company, a welder was working on the side of a barge. The platform on which he was standing was almost touching the water. The platform was supported by rope on each end. While he was operating the electric welding machine, a motorboat passed by creating waves that caused the welder to off-balanced. He held on to the electric cable of the welding machine, still, fell into the water and got drowned. His body was recovered only the following day. Investigation revealed that the victim was an assistant to the regular welder, who was absent. When asked for written procedure, the company could not present one.
Injury Frequency and Severity RatesInjury Frequency and Severity Rates
These are important to enable a company or operating unit to determine how effectively its employee injury problem is being met and what progress is being made
What is “Injury Frequency Rate”?What is “Injury Frequency Rate”?
• Is based upon the total number of disabling injuries such as deaths, permanent total, permanent partial and temporary total disabilities which occur during the period covered by the rate.
Injury Frequency Rates are used to determine:Injury Frequency Rates are used to determine:
• Whether the number of work injuries in any particular operating unit is lesser or greater than in other operating units in the same industry.
• Whether a given operating unit is having more or less injuries when compared to a previous period of time and similar operations.
• Whether an industry has a better or worse injury experience than other industries or than the average for all industries.
Injury Frequency Rate ComputationInjury Frequency Rate Computation
First Step : Gather Information• Obtain the number of employee – man-
hours of exposure, preferably direct from the time records. When this cannot be done, the exposure may be estimated on an annual basis as follows;– The average employee who works a 40-
hour a week can be assumed to worked a total of 2,000 man-hours per year.
• Obtain the number of disabling injuries from the employee injury record. If such record is maintained, an estimate may be developed by adding the disabling injury reports and fatalities that have occurred during a period of time covered by the number of man-hours exposure
• Add these two figures and you have a fairly accurate estimate of the total annual number of hours in which employees have been exposed to injury for that year.
• Multiply the number of full-time employees by 2,000• Estimate the number of hours worked by part-time
employees and the number of hours overtime.
Second Step: Calculate the Injury – Second Step: Calculate the Injury – Frequency RateFrequency Rate
IFR = Number of Disabling Injury x 1,000,000 Total Number of Man-Hours of Exposure
What is “Injury Severity Rate”?What is “Injury Severity Rate”?
• Is based upon the total number of disabling injuries such as deaths, permanent total, permanent partial and temporary total disabilities, plus the total actual days of the disabilities of all temporary total disabilities which occur during the period covered by the rate.
Injury Severity Rate ComputationInjury Severity Rate Computation
• First Step: Gather Information
– Obtain the man-hour of exposure by the same method used for computing injury frequency rate.
– Obtain total days lost due to injuries for the corresponding period of man-hours exposure.
• Second Step: Calculate the Injury-Severity
ISR = Total Days Lost + Time Charges x 1,000,000Total Number of Man-Hours of Exposure