Mastering Accident Investigation: Key Elements and Techniques

1. Accident Investigation: Getting to the Root of the Matter PestSure Loss Control Training Series Fall 2005

2. Outline I. Fundamentals of Accident Investigation II. Case Study: “Routine Duties” III. Getting Started in Your Location

3. I. Fundamentals of Accident Investigation

4. Accident Investigation is ‘More’ • More than an assigned ‘safety activity’ • More than proper documentation • More than a way to ‘cover’ yourself • More than just a training tool • More than some college theory • More than simply the ‘right thing to do’ Accident Investigation is a way for you to control your own destiny

5. Key Elements of aSafety Management System • Management Commitment • Written Policies and Procedures • Supervisory Accountability • Employee Participation • Hazard Identification & Control • Safety Education & Training • Accident Investigation • Program Review & Improvement

6. Why Perform an Accident Investigation? • Gain basic information about the incident • Inform stakeholders about the incident • Injured worker/family • Business owner(s) • Regulatory agencies • Injured third parties • Determine causes of the incident • Implement corrective actions Main reason for performing an accident investigation is to prevent recurrence!

7. Building a Chain • Gain basic information about the incident • ‘Who,’ ‘What,’ ‘Where,’ and ‘When’ • Dig down into methods and mechanisms • ‘How’ did it happen? • Unsafe acts & conditions • Determine motivations • ‘Why’ did this happen? • Organize info into a logical flow • Chain represents progression • Events = “links” in the chain • Link events together • Show relationship between events • Why go to the trouble to do this?!?

8. Breaking a Chain • If we can ‘see’ the chain, we can find its weak points • If we can break the chain in any place, we can disrupt the relationships between events that lead to the undesirable event • Reconstruct events in proper order* • Show cause and effect • What actions led to reactions • What combinations had to occur • Deconstruct chain in proper place • Point of greatest impact Build it so we can BREAK it!

9. Root Cause “the most basic reason for an accident… elimination of the root cause leads to the elimination of the accident” “real cause or origin of a problem” “the ultimate source of an effect” “The underlying reason for the occurrence of a problem” “most fundamental reason for the failure or inefficiency of a process”

10. Unsafe act Unsafe condition Accident Investigation • More than simple listing of ‘facts’ • Goal is to prevent recurrence • Recreate the incident step-by-step • Identify Root Cause • Taking specific, directed action to eliminate Root Cause OR • Breaking the links between cause/effect Which of these is the Root Cause of the accident?

11. Unsafe condition Ask the ‘5 Whys’ • Why was this bear trap left here? • “To catch bears.” • Why was it necessary to catch bears? • “They were terrorizing the lunchroom.” • Why were bears in the lunchroom? • “Because they were hungry?” • Why were they hungry? • “Because they missed their morning break.” • Why did they miss their morning break? • “The Production Supervisor on Line 3 said they had too much work to do...” • Corrective Actions: • Develop hiring criteria • Candidate pre-screening • Background checks • Employee orientation Inadequate HR Policies

12. Unsafe act Ask the ‘5 Whys’ • Why did you step in the trap? • “I didn’t see it.” • Why didn’t you see it? • “I was rushing to deliver a message.” • Why were you rushing? • “The Supervisor was yelling at me.” • Why was the Supervisor yelling at you? • “I suppose because he was angry.” • Why was the Supervisor angry? • “Because the bears from Production Line 3 were late coming back from lunch!” • Corrective Actions: • Counseling • Sensitivity Training • Anger Management • Supervising Safety • Reassignment Improper Management Practices

13. Root Causes Accident Event Fault Tree Analysis Bear trap left in floor Bears terrorizing lunch room b/c hungry Bears missed break Work inappropriate for BEARS! Bill steps in bear trap Causedby Bill didn’t see bear trap Bill was rushing Supervisor was yelling at Bill

14. II. Case Study:Routine Duties

15. “Routine Duties” “On Tuesday, December 23, 2003 the Chief Engineer (Robert) of a well-known Massachusetts hotel entered the first floor “pump room” for the property’s indoor swimming pool. His intention was to add chlorine tablets to the pool system – a routine duty in which dry tablets were dropped into a small cylindrical canister attached to the pool’s pump.

16. “Routine Duties” As he was doing this, Robert noticed (not for the first time) the old chlorine canister which had recently been removed from service by the 3rd party (contract) pool technician (Jim). Two weeks prior, Jim had made his usual visit as a representative of the pool chemicals company. He normally tested the water, made any necessary adjustments, restocked pool chemicals in the storage room, etc. During this trip, Jim had also replaced the old chlorine cylinder with a new one as instructed by his work order; but instead of taking the old cylinder with him, Jim had left it sitting in one corner of this 12’x12’ cinder block ‘bunker.’

17. Non-Routine Incident Now, two weeks later, Robert - thinking to reclaim those unused chlorine tablets in the old cylinder - moved to open the cylinder as he had done hundreds of times before…” • Canister rapidly depressurized! • Projectile fired across the room, narrowly missing head • Sustained a chemical burn to the eyes and face • No eye wash present in the room • Co-worker heard screams, found him outside building • Washed eyes with water hose • Transported via ambulance • No sustained respiratory injury • No permanent loss of vision • Hospitalization limited to 2 days

18. What Happened?!

19. Additional Information • Inspection • Interviews • Inference

20. Pool Chemicals Contractor Supervisor • Chlorine tabs + water = chlorine gas • Enclosed space, increased pressure • “I told the Tech that when I hired him” • Instructed him “never leave out of service equipment behind”

21. Pool Chemicals Contractor Technician (Jim) • Pool technician introduced water to the cylinder • Completed steps in wrong order; new employee • Training was all verbal; no written instructions; • No OTJ training • “It was a 2 hour class – I can’t remember everything” • “Hands were full goin to the truck - figured I’d get it next time”

22. Hotel Staff Chief Engineer (Robert) • Chief states that “something told him this wasn’t right” • “Didn’t think it through” • “Didn’t do anything wrong” • “Wouldn’t have known what to do anyway” • “Just wanted to save the company a few bucks” • No PPE worn “…it was a routine job; none was required”

23. Root Cause Fault Tree Analysis Procedure not defined Pool Tech didn’t follow isolation/ removal procedure Inadequate training Cylinder with wet chlorine tabs was present Cylinder abandoned by pool technician Procedure known, not followed Chief Engineer injured by chlorine gas from cylinder Chief not wearing PPE Procedure not defined Procedure not defined Chief didn’t assess non-routine situation Chief opened cylinder after two weeks had passed Inadequate training Chief wanted to recover tabs, save $$

24. III. Getting Started

25. Written Policy and Procedures • Accident investigation mandatory for all • Reportable Accidents (OSHA) • WC and GL Claims • First Aid cases? • Near Misses • List specific expectations • Who will participate? Lead? • What is the goal? • How will the results be reported? By when? • Who will review and approve? • Outline hazard control process • An acceptable corrective action prevents recurrence • ID a responsible party • Follow-up to completion

26. Education and Training • Formulate your message • Why are we doing this? • Be consistent • How are we going to do this? • Employ interactive training • Move past awareness to expectation • Share your findings!

27. You have a resource…