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Accident Investigations Part I

Accident Investigations Part I. By the end of this session the participants will: Understand the importance of the need for effective and thorough investigation of an accident Demonstrate practical skills required to respond and investigate an incident/accident in a consistent manner

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Accident Investigations Part I

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  1. Accident InvestigationsPart I

  2. By the end of this session the participants will: Understand the importance of the need for effective and thorough investigation of an accident Demonstrate practical skills required to respond and investigate an incident/accident in a consistent manner Make meaningful recommendations for preventive actions to reduce potential risks that may contribute to accidents Accident Investigation - Objectives

  3. By the end of this session the participants will: Understand their critical role in the accident investigation and the accident reporting process Determine the cause(s) of this accident and make recommendations to help prevent a recurrence of this type of incident Effective Accident Investigations - Objectives(cont.)

  4. “An accident is an undesired event that results in physical harm to a person or damage to property.” What is an Accident ?

  5. The purpose of an accident investigation is to prevent the recurrence of the accident. The focus should be on the accident, not the injury . Purpose of an Accident Investigation

  6. What to Look for: Policies/Procedures Equipment Materials Environment Task People/Operators Accidents generally have more than one cause Effective Accident Investigations

  7. a) places life in jeopardy; b) produces unconsciousness; c) results in substantial loss of blood; d) involves the fracture of a leg or arm but not a finger or toe; e) involves the amputation of a leg, arm, hand or foot but not a finger or toe; f) consists of burns to a major portion of the body; or g) causes the loss of sight in an eye. O. Reg. 714/82 s.1 Critical Injury Defined • For the purpose of the Act and Regulations, “critically injured” means an injury of serious nature that,

  8. They have a personal interest to protect. They know their people, the conditions and the job. They know how to get the information needed. They will take action in any case. Who Investigates Accidents? • Supervisors

  9. JHSC Representative Who Investigates Accidents? • They are familiar with the people and workplace. • They have a legal requirement in Critical Injuries • They have been trained in Accident Investigation

  10. Government and Business Who Investigates Accidents? • Ministry of Labour • Ministry of the Environment • Workplace Safety & Insurance Board

  11. Create an accident “action plan” Create an Accident Investigation Policy Develop Investigation Procedures Practice Before an Accident Occurs…

  12. Immediately or ASAP ( If a Critical Injury or Immediately Reportable Accident, secure the scene and advise the MOL ) Accident Investigation Procedures should be in writing to ensure a consistent response to all accidents. When To Investigate An Accident

  13. Control the Scene People are the first priority; send for help; make sure area is safe; administer first aid Stop Ongoing Hazards Get personal protective equipment; provide emergency lighting, power, air, etc. Collect Evidence Take notes, pictures, sketches of tools, equipment, layout, etc. At the Accident Scene

  14. Contributing Factors: Housekeeping Floor/surface conditions Noise Air quality/temperature Equipment malfunction Supervision Employee morale/attitude/health Alcohol/drug abuse At the Accident Scene

  15. Personal Protective Equipment Caution Tape Measuring Tape Graph Paper Pencils Lockout / Tagout Clipboard Camera (battery and film) Flashlight (with batteries) Emergency Phone Numbers Accident Investigation Forms Optional - tape recorder, photo log, flares, etc. What Equipment Is Required?

  16. Struck By Struck Against Caught In, On, Between, or Under Fall On, In, or From Scraped / Rubbed Against Overexertion or Body Strain Contact with - Electricity - Heat or Cold - Radiation - Noise - Caustics - Toxic Substances Immediate Causes

  17. Lack of preventative maintenance Servicing, Moving or Live Equipment Failure To Warn or Secure Tampering or Removing Safety Devices Unsafe Working or Travelling Speed Unsafe Working Posture or Position Incorrect Equipment or Body Use Poor or Improper Work Practices Basic Causes

  18. Personal Factors Poor Motivation Labour Relations Lack of Skill or Knowledge Physical and/or Psychological Problems Job Factors Poor Purchasing Standards Poor Work Standards Poor Maintenance or Design Abnormal Usage Excessive Wear and Tear Lack of Programs and Procedures Root Causes

  19. Equipment Metal Lab cart Specimen Blender Metal work counter electrical appliance plug-ins (cart & counter) metal sink leather shoes eyeglasses Conditions water on floor damaged equipment running water Equipment or Conditions Involved

  20. Click here to view accident scene What happened? Accident Scene

  21. Who was injured? What happened? How to prevent a recurrence? Flip Chart Layout

  22. Accident InvestigationPart II

  23. What to Look for: Policies/Procedures Equipment Materials Environment Task People/Operators Accidents generally have more than one cause Effective Accident Investigations

  24. Response Assess Scene / Identify Witnesses Preserve Evidence Notification Interview Witnesses Analysis and Conclusions Recommendations Follow up Accident Investigation Process

  25. Internal Accident Report Investigator’s Checklist Witness Interview Form JHSC Accident Investigation Report Accident Findings Recommendation Form Accident Investigation Forms

  26. Contributing Factors: Housekeeping Floor / surface conditions Noise Air quality / temperature Equipment malfunction Supervision Employee morale / attitude / health Alcohol / drug abuse At the Accident Scene

  27. Preventative Maintenance Servicing Moving or Live Equipment Failure To Warn or Secure Tampering or Removing Safety Devices Unsafe Working or Travelling Speed Unsafe Working Posture or Position Incorrect Equipment or Body Use Poor or Improper Work Practices Basic Causes

  28. Personal Factors Poor motivation and/or labour relationship Lack of skill or knowledge Physical and/or psychological problems Job Factors Poor purchasing Standards Poor work standards Poor maintenance or design Abnormal usage Excessive wear and tear Root Causes

  29. Eye Witness First Person (s) at the scene Witness Surrounding Events Witness Person Having Knowledge Who Are The Witnesses ?

  30. First - Get The Big Picture Separate All Witnesses Interview Each Witness Alone and In Private Interview Eye Witnesses First Interview At Accident Scene (when advisable) Interview Process

  31. Put person at ease Explain purpose of accident investigation Listen to the individual’s version Ask the right questions at the right time Repeat the information given back to the individual Always thank person for their cooperation Immediately document critical information Provide drawings and photos where useful Probe for Basic Causes Keep the door open for further information Effective Interview Technique

  32. Where were you at the time of the accident ? What were you doing at the time ? What did you see, hear ? What were the environmental conditions ? What was the injured worker doing at the time ? In your opinion, what caused the accident ? How might similar accidents be prevented in the future ? Interviewing Questions To Ask

  33. Ask “WHY” 5 times “He was lying on the floor” - Why? “Because there was water on the floor” - Why? “Because there was a leak in the sink” - Why? “Because maintenance hadn’t fixed it” - Why? “Because they’re short-staffed” - Why? “Because of the hiring freeze” Interviewing Questions to Ask

  34. Who was injured? We should clean up spills right away or put sign up saying wet floor. Typical Investigation John Doe Slipped on spill on floor and struck their head. • What happened? How to prevent a recurrence? Hot link to poster 2

  35. Contributing Factors: Housekeeping Floor/surface conditions Noise Air quality/temperature Equipment malfunction Supervision Employee morale/attitude/health Alcohol/drug abuse At the Accident Scene

  36. Individual shots of accident scene Click link(s) Investigation Begins Lab cart - first view Lab cart - second view Plug Water Feet

  37. Effective Investigation Examples… Immediate Causes? Basic Causes? Root Causes?

  38. Poor maintenance / housekeeping Poor labour relations Poor health Effective Investigation Examples… Contact with live equipment Fall to the floor Struck head Immediate Causes? Tampering / removal of safety device (3 prong & insulating rubber feet Water on floor Basic Causes? Root Causes?

  39. Click here to view accident scene What really happened? Accident Scene Re-visited

  40. Have intermediate control measures been implemented prior to final corrective measure ? Have the intermediate or final corrective measures resulted in further hazards? How adequate are the control measures ? How effective are the control measures ? Has there been follow-up and an analysis of the corrective measures to ensure they have been implemented and are effective ? Recommendations & Follow - Up Click to advance to optional Accident Scene

  41. Thank You

  42. OPTIONAL SCENARIO:OFFICE ACCIDENT

  43. OPTIONAL SCENARIO:OFFICE ACCIDENT

  44. Contributing Factors: Policies/Procedures Equipment Materials Environment TaskPeople/Operators OFFICE ACCIDENT

  45. Office Accident Investigation Immediate Causes? Basic Causes? Root Causes?

  46. Working alone Training Office Accident Investigation Fall to the floor Struck back Immediate Causes? Using improper procedure / equipment Standing on cabinet Basic Causes? Root Causes?

  47. Accidents generally have more than one cause Keep asking WHY until you determine the root cause OFFICE ACCIDENTCONCLUSION

  48. Thank You

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