accident investigation: why similar accidents keep duplicating themselves prevent recurrence of the...

Accident Investigation:

Why Similar Accidents Keep Duplicating Themselves

The Goal: Prevent Prevent Recurrence ofRecurrence of

Similar Accidents Similar Accidents and Injuriesand Injuries

Why do the same accidents happen over and over?

Time is dedicated. Reports are written. Follow-up is

completed. Yet in a little while

a similar accident and an exact injury occurs again.

Traditional Accident Investigation

•Who caused it? Place Blame.•Emphasis on causes.•Root cause correction.

In the early 1980’s people began talking about In the early 1980’s people began talking about Root CausesRoot Causes and had the audacity to suggest that and had the audacity to suggest that management might be at fault.management might be at fault.

Words Of Wisdom:

A “Good Ol’ Boy” from Georgia once said….

“If the same accident happens again------- Shame On Us!”

Course Objectives

LEARN HOW TO OBTAIN INFORMATION from which RECOMMENDATIONS FOR CORRECTIVE ACTION can be made to PREVENT SIMILAR OCCURRENCES, either in same area or elsewhere.

Actions Or Outcomes

To STRENGTHEN and refine accident INVESTIGATION SKILLS and capabilities and ESTABLISH a basic STANDARD accident investigation PROCEDURE.

Accidents The consequences

of an unplanned event. The consequences may be personal injury or illness, property damage, or all, or none of these.

Example # 1 An employee was

using a ladder to reach a valve when the ladder slipped. The employee fell, striking his head on the curb causing a concussion.

Example # 2 An employee was

operating a forklift at an excessive speed. While turning a corner the forklift overturned causing $1,000 damage to the truck. The employee received no injuries.

Example # 3 While changing a

belt on a vacuum pump, the pump inadvertently started, but there were no injuries.

What is the unplanned event? The consequences?

Define Accident Investigation

“A determination of all the events that led to an accident including understanding causal relationships between events.”

WHY DO WE INVESTIGATE ACCIDENTS?

Relationship Between Accident Investigation & Accident Prevention?

Planned safe design. Enforcement. Audit/Inspection. Positive Feedback System. Hazard Recognition. Safe Operating Methods and

Practices.

Prevention activities continued:

•Education and Training.•Accountability Systems.•Effective Accident Investigation.

Note that all, with the exception of Accident Investigation, are done prior to an accident, are (pro-active) activities. Although Accident Investigation is re-active, its value is that it can identify deficiencies, especially those in the management system.

Examples:•Poor Housekeeping•Hoses left in aisles•Failure to lock out•Machine guarding not in place•Failure to follow procedure•Horseplay•Failure to use protective equipment

Those actions or deficiencies that directly led to the unsafe act or unsafe condition.

Contributory Causes

Actions or deficiencies that permit the contributory causes to exist and when corrected result in long term solutions to similar accidents. Root Causes are often related to how our work activities are planned and managed.

Root Causes

Examples of Root Causes

•No Enforcement•No Accountability•Poor Example•Poor Observation Techniques•Poor Communication Procedures•Tolerance

Unsafe Act

Any behavior which is outside standard or acceptable practice which could increase the possibility of an unplanned event and possible accident.

Unsafe Condition

Any departure from the designed or expected conditions which could increase the probability of an unplanned event.

First-Aid Case One-time treatment,

and follow-up visit for the purpose of observation of minor scratches, cuts, burns splinters or other minor injuries which do not ordinarily require medical care.

Recordable Case Work- related fatalities Work-related illnesses Work-related injuries which require

medical treatment (other than first aid) Injuries which involve days away from

work; restriction of work or motion Transfer to another job; or loss of

consciousness.

Lost Work Day Case Any work-related

recordable injury or illness which prevents the employee from being able to work the next scheduled shift or future workdays.

Restricted Activity Case

Any Work-related injury or illness which prevents the employee from completing any or all of the tasks required by the job, or from completing an entire work shift.

More Definitions(See p.2 of HIS-13)

Incident Serious Incident Incident Investigation Report Motor Vehicle Accident Near Miss-”An incident that does not

result in injury, but has the potential for serious bodily harm or results in property or product damage.”

Accident Investigation is a Logical Flow of Events:

The accident happens. You become aware of it. Gather data to define the problem. Define problem. Determine the need to investigate and who investigates. Gather more specific data. Analyze what happened to determine causes. Conclude causes. Ask “why” questions in three distinct areas- “what was

going on?”, “What went wrong?” And “the consequences”. (Ask at least 5 why’s)

LOGICAL STEPS, (Cont.)

Analyze causes for corrective actions.Determine the most effective actions.Set completion dates.Implement corrective actions.Follow-up on corrective actions.

Don’t Confuse FACTS and CAUSES.

Investigative Corrective

Phase Phase

CAUSES

FACTS RECOMMENDATIONS

Difference Between a Computer & a Human.

A Computer will not attempt to answer a question until it has sufficient data.

Humans don’t let a lack of information stop them from making conclusions.

FLOW OF EVENTS CHART

Notice the investigative and corrective phases.

Don’t try to make judgmental decisions or conclude causes before you have sufficient data.

This is a logical flow of events.

The Written Report

It should describe:

• What Happened?• Why Did It Happen?• What Will Be Done About It?• When and by Whom?

Management Commitment

“The fact that an accident occurred usually means something went wrong in the management system. There was an oversight, an omission, or a lack of control of circumstances that permitted the accident to occur. The AI process must determine not only causes but also the deficiencies in the management system that permitted the accident to occur.” *

* National Safety Council-1983

Summary

Remember the definition of an Accident: “The Consequences of an Unplanned Event”.

Incident vs Accident- Why our definition includes Incidents.

Near-Misses are unplanned events. They must be investigated.

So, Why do the same accidents and injuries happen again and again?

Not Investigated and Documented. Poor Quality. Not Publicized. Root Causes are not found and

ELIMINATED! No one is held accountable.

Change The System! If our results do not

effect long term changes in the system, we are doomed to committing the same errors.

People want to do well. If they don’t its because management and the system do not allow it.