ACCIDENT INVESTIGATIONS & ANALYSIS

1. ACCIDENT INVESTIGATIONS & ANALYSIS (UNIT-I)

2. ACCIDENT INVESTIGATIONS • A successful accident investigation determine what happened that leads to discovering how and why an accident occurred. • Why? • discovering and analyzing causal factors. • organizational improvement as the key objective. • focuses on determining some level of fault. • Organizational benefit? • Seek to understand the event to prevent similar occurrences. • Initial investigation - responsible supervisor • Organizations Support • must work to reduce the time between the reporting of a serious accident and the start of the investigation. • Provide investigators with all the necessary tools and equipment to conduct a thorough investigation.

3. Accident causal factors • Identifying and understanding causal factors must include a strong focus on how human behaviors contributed to the accident. • Organizations must conduct comprehensive investigations when preliminary information reveals inconsistencies with written policies and procedures. • CF Vary in terms of importance because applying a value to them remains a very difficult challenge. • Overvaluecausal factors immediately documented after the accident. These reveal details about the situation at the time of occurrence. • Devalue less obvious causes that remained removed by time and location from the accident scene. • Using sound investigational techniques -help determine all major causal factors. • Investigator Support • seek to find out what, when, where, who, how, and most of all why. • seek to identify any failures of organizational-related management systems that contribute directly or indirectly to many accident events.

4. How to do? • Before attempting to discover and document causal factors, examine the site and take steps to preserve any important evidence. • Attempt to identify and document a list of witnesses. • Apply, a particular physical or chemical law, an engineering principle, or equipment operation may explain a sequence of events. • Investigators use diagrams, sketches, and measurements to support their understanding of what happened. This can also assist in future analysis. • Consider using video recorders or cameras when conducting investigations. • Use charts or sequence diagrams to help develop a probable sequence of events. • Attempt to look beyond the obvious to uncover direct and indirect causal factors. • Evaluate all known human, situational, and environmental factors. Research studies indicate that most workplace accident investigations reveal 10 or more causal factors. • Determine what broken equipment need removal from the scene for further analysis. Investigators should develop written notes about items removed from the scene including their positions at the accident scene. • Interview as many witnesses as possible before leaving the scene. These witnesses can serve as primary sources of information in many investigations. • Accident scene tampering and evidence removal prior to the investigator arriving would make witnesses very important.

5. Classifying Causal Factors • Understand the importance of classifying causal factors in one of the following three categories. • Relates to operational factors • such as unsafe job processes, inadequate task supervision, lack of job training, and work area hazards. • Relates to human motivational factors • including risky behaviors, job-related stress, poor attitudes, drug use, and horseplay. • Relates to organizational factors • including inadequate hazard control policies and procedures, management deficiencies, poor organizational structure, or lack of senior leadership.

6. Unsafe materials, tools, and equipment • • Ineffective machine guarding • • Defective materials and tools • • Improper or poor equipment design • • Using wrong tool or using tool improperly • • Poor preventive maintenance procedures • Unsafe conditions • • Poor lighting or ventilation • • Crowded or poorly planned work areas • • Poor storage, piling, and housekeeping practices • • Lack of exit and egress routes • • Poor environmental conditions such as slippery floors Common Causal Factors Poor supervision • Lack of proper instructions • Job and/or safety rules not enforced • Inadequate PPE, incorrect tools, and improper equipment • Poor planning, improper job procedures, and rushing the worker Worker job practices • Use of shortcuts and/or working too fast • Incorrect use or failure to use protective equipment • Horseplay or disregard of established safety rules • Physical or mental impairment on the job • Using improper body motion or technique

7. Interviewing Witnesses • Interview witnesses individually and never in a group setting. • If possible, interview a witness at the scene of the accident. It also preferable to carry out interviews in a quiet location. • Seek to establish a rapport with the witness and document information using their words to describe the event. • Put the witness at ease and emphasize the reason for the investigation. • Let the witness talk and listen carefully and validate all statements. Record the interview. • Never intimidate, interrupt, or prompt the witness. • Use probing questions that require witnesses to provide detailed answers. • Never use leading questions. • Ensure that logic and not emotion directs the interview process. • Always close the interview on a positive note.

8. ACCIDENT ANALYSIS • Hazard evaluations and accident trend analysis help improve the effectiveness of established hazard controls. • Routine analysis - develop and implement appropriate controls in work procedures, hazardous processes, and unsafe operations. • Analyze to determine how and why an accident occurred. Use findings to develop and implement the appropriate controls. • Don’t overlook information sources such as technical data sheets, hazard control committee minutes, inspection reports etc. • When using accident investigation evidence, information can exist in a physical or documentary form & come from eyewitness accounts. The analysis must evaluate sequence of events, extent of damage, human injuries, surface causal factors, hazardous chemical agents, sources of energy, and unsafe behaviors. • A good accident analysis should create a complete accident picture of the entire event. • The final analysis report should include detailed recommendations for controlling hazards discovered during the investigation and analysis.

9. Root Cause Analysis • RCA processes can help connect the dots of accident causation by painting a picture that includes beneath the surface causes. • A root cause process must involve teams using systematic and systemic methods. • It focus on the identification of problems and causal factors that triggered the unwanted event not placing blame. • When analyzing a problem, understand what happened before discovering why it happened. • Don’t overlook causal factors related to procedures, training, quality processes, communications, safety, supervision, and management systems.

10. Continued… • An effective RCA process lays a foundation for designing and implementing appropriate hazard controls. • For simplicity reasons, system-related root causes fall into two major classifications. The first class concerns design flaws such as inadequate or missing policies, plans, processes, or procedures that impact conditions and behaviors. • The other category, known as operational weaknesses, refer to failures related to implementing or carrying out established policies, plans, processes, or procedures. • When discovered and validated, specific root causes can provide insight to an entire process or system. • The process can also help identify what fed the problem that impacted the system. • Finally, RCA provides insight for developing solutions or changes that will improve the organization.