Accident Investigation

1. Accident Investigation How to conduct workplace accident investigations

2. Why Investigate? • Prevent future incidents (leading to accidents). • Identify and eliminate hazards. • Expose deficiencies in process and/or equipment. • Reduce injury and worker compensation costs. • Maintain worker morale.

3. What Is An Accident? An unplanned, unwanted, but controllable event which disrupts the work process and causes injury to people. Most everyone would agree that an accident is unplanned and unwanted. The idea that an accident is controllable might be a new concept. An accident stops the normal course of events and causes property damage or personal injury, minor or serious, and occasionally results in a fatality.

4. 10 30 600 Major 1 The Incident Pyramid Minor Property Damage Near Misses Management Systems Interventions Training Sampling Rewards Enforcement Feedback Safe Practices Goals Involvement Handout p. 14

5. Multiple Causation and the Accident Weed 3 Levels • Injury Analysis-Direct Causes • Event Analysis-Indirect Causes • System Analysis-Root Causes

6. Strains Burns Cuts Direct Cause of Injury Horseplay Create a hazard Broken tools Ignore a hazard Chemical spill Hazardous Condition Contributing conditions Unsafe Behaviors Contributing Behaviors Fails to report injury Defective PPE Fails to inspect Untrained worker Fails to enforce Lack of time Too much work Fails to train Unguarded machine Design Root Causes Implementation Root Causes

7. The “Accident Weed” Hazardous Hazardous Practices Conditions Missing guard Horseplay Poor housekeeping Ignored safety rules Defective tools Didn’t follow procedures Equipment failure Did not report hazard No MSDS’s Don’t know how Purchasing unsafe equipment Poor work procedures Lack of supervision No follow-up/feedback Rules not enforced Lack of Training Lack of safety leadership Poor safetymanagement Poor safety leadership Root Causes

8. Strains Burns Cuts Injury Analysis • Reconstruct the specific events prior to, during, and after the accident. • Analyze the injury event to identify and describe the direct cause of injury. • Describe the injury and its cause. • Identify the accident type.

9. System Analysis • Analyze each surface cause to identify potential root cause(s): • Determine system implementation weaknesses. • Determine system design weaknesses.

10. Root Cause Analysis • Direct Cause – Unplanned release of energy or hazardous materials. • Indirect Cause – Unsafe acts and/or unsafe conditions. • Root Cause – policies and decisions, personal factors, environmental factors. Root cause analysis is a systematic technique that focuses on finding the real cause of a problem and dealing with that, rather than just dealing with its symptoms. A root cause is the cause that, if corrected, would prevent recurrence of this and similar occurrences. A root cause of a consequence is any basic underlying cause that was not in turn caused by more important underlying causes.

11. Accident Causes • Unsafe Act • an act by the injured person or another person (or both) which caused the accident; and/or • Unsafe Condition • some environmental or hazardous situation which caused the accident independent of the employee(s).

12. Accident investigation is “fact-finding” not fault-finding. The basics Accident Investigation • What two key conditions must exist before an accident occurs? • What causes the most accidents? • Hazardous conditions account for 3-5 % of all workplace accidents. • Unsafe/inappropriate behaviors account for >95 % of all workplace accidents. • Uncontrollable acts account for <2 % of all workplace accidents • Management is able to control factors that produce 98 % of all workplace accidents. EXPOSURE HAZARD Don’t play the blame game Common Sense is not a valid cause, since common sense is individualized. Accident investigation primarily determines Cause to support Preventive/Corrective Actions. Accident analysis primarily determines SYSTEM WEAKNESSES.

13. Investigate All Incidents and Accidents • Conduct and document an investigation that answers: • Who was present? • What activities were occurring? • What happened? • Where and what time? • Why did it happen? Root causes should be determined. Example: An employee gets cut. What is the cause? It is not just the saw or knife or the sharp nail. Was it a broken tool and no one reported it? Did someone ignore a hazard because of lack of training, or a policy that discourages reporting? What are other examples of root causes? Enforcement failure, defective PPE, horseplay, no recognition plan, inadequate labeling.

14. Investigate All Incidents and Accidents • Also answers: • Is this a recognized hazard? • Has the previous action been taken to control this hazard? • What are those actions? • Is this a training issue?

15. Accident investigation is “fact-finding” not fault-finding. Step 1: Secure the accident scene Gather information Implement Solutions Analyze the facts Step 2: Collect facts about what happened Step 3: Develop the sequence of events Step 4: Determine the causes Step 5: Recommend corrective actions & Improvements Step 6: Write the report The six-step process Handout p. 38-42

16. Begin Investigation Immediately • It’s crucial to collect evidence and interview witnesses as soon as possible because evidence will disappear and people will forget. May have to modify for extremely traumatic situations.

17. Actions At The Accident Scene • Check for danger • Help the injured • Secure the scene • Identify & separate witnesses • Gather the facts

18. Interview Witnesses • Interview promptly after the incident. • Choose a private place to talk. • Keep conversations informal. • Talk to witnesses as equals. • Ask open ended questions. • Listen. Don’t blame, just get facts. • Ask some questions you know the answers to.

19. Write a Report The report should include: - An accurate narrative of “what happened” - Clear description of unsafe act or condition - Recommended immediate corrective action - Recommended long-term corrective action - Recommended follow up to assure fix is in place - Recommended review to assure correction is effective.

20. Write The Report Answer the following in the report: • When and where did the accident happen? • What was the sequence of events? • Who was involved? • What injuries occurred or what equipment was damaged? • How were the employees injured?

21. Conclusions of Report Report conclusions should answer the following: • What should happen to prevent future accidents? • What resources are needed? • Who is responsible for making changes? • Who will follow up and insure changes are implemented? • What will be the future long-term procedures? Example: The outcome of an investigation of the 50 lb. carton falling off the top shelf of the 12 ft. high rack might include correction of sloppy storage at several locations in the warehouse, moving unstable/heavy items to floor level, conducting refresher training for stockers on proper storage methods, and supervisors doing daily checks.

22. Recommend Corrective Actions • Hierarchy of Hazard Controls • Elimination of Hazard - Remove or reduce • Substitution of less hazardous material or method • Engineering Controls • Warnings • Administrative Controls & Procedures - Remove or reduce the exposure • Personal protective equipment (PPE) - Put up a barrier Handout p. 26

23. Your Safety Coordinator Check with your center director Darlene Mallory Safety Committee Chair 770-339-5090 dmallory@grncsb.com Joshua Elzy Assistant HR Director 770-339-2287 jelzy@grncsb.com Kathy Martin Worker’s Comp Coordinator 770-339-5017 kmartin@grncsb.com Questions?