accident investigation

60
By: Mr. Eros G. Zuñiga

Upload: leo-angelo

Post on 23-Aug-2014

56 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: Accident Investigation

By: Mr. Eros G. Zuñiga

Page 2: Accident Investigation

State the objective of Accident Investigation, Analysis and Reporting. Describe the step-by-step procedure involved in the accident investigation process.

Page 3: Accident Investigation

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.

Page 4: Accident Investigation

“People become injured, disabled and sometimes killed due to industrial accidents.What can be done to prevent these accidents from recurring?”

Page 5: Accident Investigation

ADVANTAGES OF EFFECTIVE INVESTIGATIONS:

They-Described What HappenedDetermined the Real Cause Described the Risks Developed ControlsDefined TrendsDemonstrated Concern

Page 6: Accident Investigation

• 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

Page 7: Accident Investigation

“An unplanned event that may result in personal injury or property damage”

Page 8: Accident Investigation

ACCIDENT CAUSES

An Unsafe Act

An Unsafe Condition

Page 9: Accident Investigation

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

Page 10: Accident Investigation

SOME COMMON EXCUSES ON CAUSES OF ACCIDENTS:

Carelessness Accident-prone Inattention (distraction) Negligence Not wearing safety equipment

Page 11: Accident Investigation

SOME COMMON EXCUSES ON CAUSES OF ACCIDENTS:

Bad luckAct of God Not thinking Laziness Taking short cut

Page 12: Accident Investigation

“Unsafe Act-Unsafe Condition”

vs. forces effect outside the workplace”

Page 13: Accident Investigation

…”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.”

Page 14: Accident Investigation

…”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.”

Page 15: Accident Investigation

THE WORK SYSTEM

PEOPLE PLANT AND EQUIPMENT PROCEDURES MANAGEMENT MATERIALS ENVIRONMENT

Page 16: Accident Investigation

THE WORK SYSTEM

…”When combined, these elements allow for the production process to be carried out.”

Page 17: Accident Investigation

..”Work environment is more than the

physical aspects of the Workplace

(eg. Lighting, noise, heat, air quality, etc.).”

Page 18: Accident Investigation

….”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.”

Page 19: Accident Investigation

..”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.”

Page 20: Accident Investigation

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

Page 21: Accident Investigation

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?

Page 22: Accident Investigation

“ 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”.

Page 23: Accident Investigation

CHARACTERISTICS OF GOOD INVESTIGATIONS:

Yield information needed to: determine injury rates identify trends and problem areas permit comparisons satisfy legal requirements

Page 24: Accident Investigation

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

Page 25: Accident Investigation

“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

Page 26: Accident Investigation

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

Page 27: Accident Investigation

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

Page 28: Accident Investigation

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

Page 29: Accident Investigation

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”

Page 30: Accident Investigation

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)

Page 31: Accident Investigation

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

Page 32: Accident Investigation

His duties include: compilation of the report presiding over meetings controlling scope of the team

activities

The Health & Safety Representative

CONDUCTING AN INVESTIGATION

Page 33: Accident Investigation

QUESTIONING THE WITNESSES

2 Types of Witnesses Eye Witness Hearing Witness

CONDUCTING AN INVESTIGATION

Page 34: Accident 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

Page 35: Accident Investigation

Only ask necessary questions Repeat the interviewee’s story as you understand it Close the interview on a positive note and thank the witness

Page 36: Accident Investigation

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

Page 37: Accident Investigation

Only Ask “Necessary” Questions Ask Open Questions Repeat Story as you Understand it Close the Interview Positively

CONDUCTING AN INVESTIGATION

Page 38: Accident Investigation

Example of an

Investigation Report

Page 39: Accident Investigation

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 .

Page 40: Accident Investigation

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

Page 41: Accident Investigation

6. ATTACHEMENT

Why Analysis of the Incident

Prepared by: J M PERFIÑANSH&E MANAGER

Page 42: Accident Investigation

Rule 1052 - Special Provision 1052.01 Rule 1053 - Report Requirements 1053.01 1053.02

Page 43: Accident Investigation

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

Page 44: Accident Investigation

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

Page 45: Accident Investigation

TO SUMMARIZE:Effective Investigation AccidentThe Work SystemThe Synoptic Accident ModeThe Actual InvestigationConducting an InvestigationLegal Requirement

Page 46: Accident Investigation

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.

Page 47: Accident Investigation

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)

Page 48: Accident Investigation

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.

Page 49: Accident Investigation

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.

Page 50: Accident Investigation

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.

Page 51: Accident Investigation

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

Page 52: Accident Investigation

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.

Page 53: Accident Investigation

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.

Page 54: Accident Investigation

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.

Page 55: Accident Investigation

• 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.

Page 56: Accident Investigation

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

Page 57: Accident Investigation

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.

Page 58: Accident Investigation

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.

Page 59: Accident Investigation

• Second Step: Calculate the Injury-Severity

ISR = Total Days Lost + Time Charges x 1,000,000Total Number of Man-Hours of Exposure

Page 60: Accident Investigation