Welcome to MECC’s Web Seminar:Accident Investigation

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AccidentInvestigation

AccidentAccidentInvestigationInvestigation

Best Practice Web Seminar Series

Best Practice Web Seminar Series

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Today’s Host and Presenter:

Dan Sulzner, MS, CRM, ARM CSP, OHSTMidwest Employers Casualty CompanyAccount Manager

o 14+ years in insurance industry specializing inworkers’ compensation and risk management

o Brokerage Experience: Aon Risk Services – LossPrevention

o Manufacturing Experience: General Motors -Safety Director

Accident InvestigationAccident Investigation

An Accident Waiting to Happen . . .

I’ve got good balance, just hold it forsecond…..

Do not standhigher than thesecond step fromthe top of astepladder.

Especially, do notstand or sit on thetop cap, or standon the pail shelf, oron the back of astepladder.

Don’t worry, I use ladders like this allthe time….

Never splice or tietwo short ladderstogether to makea long section.

If you can just lift me a little higher…

Do not liftpersonnelwithout use ofa safety cageand belt.

Hay isn’t just for horses anymore…

Farmer’sAlmanacstates, “Haybales are notintended to beutilized forscaffoldingpurposes…..”

This boulder won’t move….

One stick for oneton of rock, twosticks for up tothree tons ofrock…..

“I don’t need no stinking tie downs..”

Just keep it under thirty!!!

Row, row, row your boat....

Safely down the stream!!

Objectives

• Understand the difference between a nearmiss and an accident

• List the components of an accident

• Look at different types of root cause analysistools

• Examine the 5 Why’s to root causeidentification

• Differentiate between proactive and reactivesteps following an accident

• Discuss investigative procedures following anaccident

Definition of an Incident

Some publications suggest that the term "incident"includes undesired circumstances and “near

misses” with the potential to cause accidents.

The key term here being "potential", it is particularlyimportant to investigate incidents which had thepotential to cause severe harm even if the actual

harm caused was minimal.

Near Misses/Hits Are Warnings

Near Misses – have the potential to cause accidents –an accident is narrowly avoided!!!

How about the view from the JapanAirlines passenger window?

Things that go boom!!!!

The “near misses” at the base of the accident triangles offer preventativeopportunities. If action can be taken at this level, the chances of more

serious injuries occurring will be greatly reduced.

1

Fatality

30Lost Time Injury

300

Medical Treatment Injury

3,000

Near-Miss or First Aid

30,000

Unsafe Behaviors

Employee slips on floor, hitshis head and dies.

Employee slips and fractures hisarm. Two weeks out of work.

While falling, employee hits a pieceof machinery and lacerates hishand. Five sutures.

Employee slips on floor andbruises his hip.

Employee spills water onfloor and walks away.

Why focus on Near-Misses?

Heinrich

Injury and Illness Pyramid

Definition of an Accident

Successful Health and SafetyManagement defines “accident” as:"any undesired circumstances which

give rise to ill health or injury;damage to property, plant, products

or the environment; productionlosses, or increased liabilities".

What type of Losses?

• AutomobilePhysical Damage

• Auto Liability

• Products

• Workers’Compensation

• Property Damage

What Causes Accidents?

• 95-98% of all illnesses and injuries occur as aresult of unsafe behavior of employees.

• Organizational causes of accidents occur whenbusinesses follow unsafe practicessuch as:

Insufficient engineering and purchasing controls

Inadequate standards for hiring, placement, andupgrading of workforce

Lack of or inadequate supervisory training ofemployees

Failure to enforce job procedures

Lack of or inadequate PPE

Task

Components of an Accident

• Were safe workprocedures used?

• Had conditionschanged to make thenormal procedureunsafe?

• Were the appropriatetools and materialsavailable?

• Were safety devicesworking properly?

Task

Material

• Was there anequipment failure?

• Was the machinerypoorly designed?

• Was the raw materialsub-standard?

• Was the PPE usedand used properly?

Components of an Accident

Task

Material

Environment

• What were theweather conditions?

• Was poorhousekeeping aproblem?

• Was there adequatelight?

• Were toxic orhazardous gases,dust or fumespresent?

Components of an Accident

Task

Material

Environment

Personnel

• Were workersexperienced in thework being done?

• Had they beenadequately trained?

• Can they physically dothe work?

• Were they tired?

Components of an Accident

Task

Material

Environment

Personnel

Management

• Were safety rulescommunicated to andunderstood byemployees?

• Were they beingenforced?

• Were workers trainedto do the work?

• Was regularmaintenance ofequipment carriedout?

ACCIDENT!

Components of an Accident

Causes of Loss

• Direct causesWhen a person or object receives an amount of energy

or hazardous material that cannot be absorbed safely

• Indirect causesUnsafe acts or conditions

• Basic causesPoor management policies /

decisionsPersonal or environmental factors

• Root causes If corrected will prevent

reoccurrence

Systems and methods

Management Safety Policy & DecisionsPersonal Factors

Environmental Factors

Unsafe Condition

Unplanned Release of Energyand/or Hazardous Material

Unsafe Act

AccidentPersonal Injury / Property Damage

Purpose of Accident Investigation

The primary purpose of accidentinvestigation is to find the

“Root or Primary Cause”,correct it and prevent

reoccurrence.“Why do we fall, Bruce?So we can learn to pick ourselves up.”

Root Cause Analysis Tools

• Flow charts

• Cause and effect “fish-bone” diagrams

• Pareto charts

• Scatter diagrams

• Failure mode, effect and criticality analysis

• Fault tree analysis

• Barrier analysis

• 5 WHYs

Flow chart

Cause and Effect “Fish-Bone” Diagrams

• Cause and effect “fish-bone” diagrams

Pareto Charts

Scatter Diagrams

Strong Correlation No Correlation

Failure Mode, Effect and Criticality Analysis

ApproachCounter

Old Process Improved Process

Finish Order

Finish Order

ApproachCounter

Want Burger

Want drink

Want fries?

Combonumber?

Order burger

Order fries

Order drink

No

Yes

No

No

Yes

Yes

Fault Tree Analysis

Barrier Analysis

Risk Man.Committee

LowMediumYes‘Time Gap’ between drawingup drug, check andadministration

MediumYesWard basedpharmacychecks

Wrong doseetc

Trust BoardHighStrongYesElectronic prescribingWeakYesPatient IDchecks

Wrongpatient

Clinical Gov.Committee

MediumStrongYesBar-codingWeakYesTwo personchecks

Wrong drug

Whoseresponsibility

Costimplications

Failsafe?Importanceto safepractice?

Improve by additional B/C/DFailsafe?Importanceto safepractice?

What B/C/Dare in place?

Hazard(s)

Target: PatientIncident: Giving a controlled drug to a specified person

The 5 Whys

The first step is to identify the initial cause of anadverse event and then to probe further by askingthe question “why is this the cause”?

WHY?WHY?

WHY?WHY?

WHY?

• Analysis of adverse events which are notcomplicated can be achieved by using the “fivewhys” approach.This approach involves asking the question why

at each stage of the analysis.

The Five WHYs of Accident Investigation

ACCIDENT DESCRIPTION:Employee fell in water by the water fountain.

Water was on floor

Water fountain was leaking water

Water fountain was struck by fork truck

Operator was not certified to drive

Trainer was out on vacation

Supervisor’s Report: Employee was not paying attention.

The Five WHYs of Accident Investigation

ACCIDENT DESCRIPTION:Employee broke nose while attempting to exit the cafeteria.

Door struck employee in face

Employee did not see other employee coming

Door was a solid wood door

Doors were installed when office was built

Wood doors are aesthetically pleasing

Supervisor’s Report: Employee was standing in front of door.

Direct and Indirect Accident Effects

• Direct

The injury

Psychological effects ofan injury

• Indirect

Loss of earnings

Disrupted family life

Disrupted personal life

• Direct Loss of a human resource

Property damage to tools,materials, product, equipment, orfacility

• Indirect Company Loss of business customers

Poor customer relations

Negative media coverage

Poor reputation

Higher insurance costs

Injured Worker Organization

“On average, disabled workers earn 46% less than non-disabledworkers. Those who receive a partial disability due to a workplace

injury lose about 40% of their income over five years.”

Proactive vs. Reactive Strategies

The primary purpose of Proactive monitoring is to measuresuccess and to reinforce positive achievements in orderto nurture a positive safety culture. It is not intended as ameans of identifying and punishing failure.

Proactive (sometimes termed Active) measuresprovides feedback on safety performance within anorganization before an accident, case of ill-health or anincident. It involves measuring compliance withperformance standards and achievement of specificobjectives.

Proactive Measures

• Proactive measures aims to ensure that:

Inspections and reports are of adequate quality

Common problems / weaknesses are identified

Training needs are met

Deficiencies previously reported are rectified

• Examples of Proactive measures:

Safety Inspections

Safety Tours

Safety Audits - The compliance audit

Reactive Measures

• Measures accidents, cases of ill-health andincidents. The idea being to identify the causesof these failures and to take remedial actionwhich will prevent them occurring again

• Reactive measures deal with:

Details of any injured people

Descriptions of the circumstances

Details of events

Details of the outcomes

Details of remedial actions

Integration of Proactive and Reactive

Results & Analysis

Review

Take ImmediateAction

Investigate

Assess level & nature ofinvestigation

Active Measures Reactive Measures

Assess action necessary to dealwith immediate risks

First AidResponse

Claim Reporting vs. Incident Investigation

• Claim Reporting Injured worker to

supervisor

Employer to TPA

Triggers benefitpayments

• Medical bills

• Lost wages

• InvestigationNo legal requirement

beyond reporting toTPA

Supports claimadjusting process

Right thing to do

• Preventreoccurrence

• Triggers correctiveaction

ScopeFollow Up

Analyze Information

Investigative Procedures

– Define the scope

– Select the investigators

– Present a preliminarybriefing

– Interview each injuredworker and witness

– Inspect theaccident site

– Visit theaccident site

– Determine the sequence ofevents and probable causes

– Determine why theaccident occurred

– Determine wherethe abnormalityoccurred

– Conduct a post-investigationbriefing

– Prepare a summary report

– Include recommendationsto prevent reoccurrence

– Follow up onrecommendations

A Picture is Worth a Thousand Words

• Take pictures of the accident scene– Close up pictures: 3-5 feet

– Medium range pictures: 10 feet

– Distance: 20-40 feet

• Keep a common landmark in the photo

• Automobile accident– Pictures of skid marks

– Pictures of all cars, road signs, intersection

– Subrogation possibilities

– Do not put yourself in harm’s way to take pictures

Why Investigations Fail

• Jump to conclusion

• PreconceptionsEmployee wants to be hurt

Hazards faced

Injured employee

• Limit corrective action to direct causes (immediate)or weak solutions “told employee not to stick hand in machine…”

“retrained employee…”

• No follow up on corrective actions (maintenance log)

ConclusionTask

Material

Environment

Personnel

Management

WHYWHY

WHYWHY

WHY

Follow Up

InformationAnalyze

Scope

How can we help?

MECCOnline

Resourcesand

Tools

SafetyCornerstones

• Analysis, Compliance, Training & Research

ResearchLink• Disability duration and absence management

Safety Trainer• Online training by topic/industry

Web Events• Accident Investigation• Near Misses• Prompt Reporting

Upcoming Web Events 2008

Combative Patients May 28

Heat Stress June 10

EAPs and Behavioral Risk Management June 25

Aging Workforce July 9

Is Your Employee’s Back Injury Really Work-related? July 22

60 Safety Tips in 60 Minutes August 6

Ergonomics September 9

Business Continuity Planning September 25

Questions and Answers

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Online Resources: meccwebinars@mwecc.com

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Dan Sulzner, MS,CSP,OHST,ARM,CRMLoss Prevention Consultant

Midwest Employers Casualty Company

Phone: 636-449-7157dsulzner@mwecc.com