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Accident / Incident Investigation Process. OSHA / AMI Alliance Spring Meeting May 7, 2014. Accident / Incident Investigation. Accident – An unplanned event that actually results in damage, injury, or upset of some kind
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Accident / Incident Investigation Process OSHA / AMI Alliance Spring Meeting May 7, 2014
Accident / Incident Investigation Accident – An unplanned event that actually results in damage, injury, or upset of some kind Incident – An unplanned event that has potentially serious consequences “All accidents are incidents; however, not all incidents are accidents.”
Accident / Incident Investigation Purpose: • Prevent Reoccurrence– Identify Causes and Implement Corrective Actions “Fact-finding …… Not …… Fault-Finding”
Accident / Incident Investigation “Insanity: doing the same thing over and over again and expecting different results.” Albert Einstein
Death or Serious Injury 1 Minor Injury The Accident Pyramid Minor Accidents 30 Near Miss Near Misses (NM) 600 This is why it is so important to investigate not only the serious accidents, but the minor accidents and NMs as well. Sooner or later the NMs could result in a serious accident.
ACCIDENT INVESTIGATION STEPS • Interview Employee • Interview Witnesses • Examine the Scene • Identify Immediate and Basic Causes • Identify and Implement Corrective Actions • Evaluate and Follow Up on Effectiveness of Corrective Actions
Accident / Incident Investigation KMF Cause Analysis Process (CAP) Type of Event • Struck Against • Struck By • Fall from Elevation to Lower Level • Fall on Same Level (Slip/Trip/Fall) • Caught In (Pinch Point) • Caught Under / Between (Crush) • Contact With (Electricity/Heat/Cold/Chemical) • Overstress (Overexertion/Strain/Ergonomics)
Accident / Incident Investigation Immediate Causes Unsafe Acts by Worker • Operating Equipment without Authority • Failure to Warn • Failure to Secure • Operating at Improper Speed • Using Defective Equipment • Failing to Use PPE Properly • Improper Loading • Improper Lifting • Improper Placement • Improper Position for Task • Using Equipment Improperly • Failure to Follow Procedures
Accident / Incident Investigation Immediate Causes • Unsafe Work Conditions • Inadequate Guards • Improper Protective Equipment / Materials • Defective Tools / Equipment • Congestion • Poor Housekeeping • Noise Exposure • Inadequate / Excess Lighting • Inadequate Ventilation
Accident / Incident Investigation Basic Causes Personal Factors • Inadequate Physical Capability - (restricted range of motion, vision, or hearing) • Inadequate Mental Capability - (poor judgment, inability to understand) • Physical Stress - (fatigue due to task load) • Mental Stress - (emotional overload, routine task, frustration) • Lack of Knowledge - (lack of experience, inadequate training) • Lack of Skill – (inadequate instruction, inadequate practice) • Improper Motivation – (improper performance is rewarded, lack of incentives)
Accident / Incident Investigation Job Factors • Inadequate Leadership / Supervision • Inadequate Engineering • Inadequate Purchasing • Inadequate Maintenance • Inadequate Tools / Equipment • Inadequate Procedures / Standards
Accident / Incident Investigation System Needs • Management Leadership / Commitment • Employee Involvement (Hazard ID & Control) • Hazard ID, Prevention, & Control (Inspections, Engineering Changes, PPE, Ergonomics) • Occupational Hygiene (Hazard Comminications) • Safety Training • Emergency Response Planning • Incident Investigation Process
Any material on the floor? Type of floor/condition? Any activities causing slick condition (cleaning, etc.)? Type of shoes EE was wearing? Anyone see the slip or the floor condition? Is this somewhere the EE should have been? Was the EE doing something that contributed to the slip (carrying boxes, not paying attention, hurrying) An Employee Slips On the Floor and Hurts Their BackWhat do we look for or ask?
Analyze Problems & Causes Don't Just Look At The Surface.... Identify the Root Cause! Go Deep
Fall Employee Hurrying No 3-point used Slick Boots Wet Floor Accidents are like dominoes! Remove 1 Domino (factor) and you may stop the accident!
Accident / Incident Investigation Summary • Investigate accidents immediately • Determine who was involved and who witnessed it • Ascertain what items or equipment were involved • Record detailed description • Determine causal factors • Conduct corrective actions
Accident / Incident Investigation • Role Playing – Conduct Investigation • Identify Basic Causes and System Deficiencies