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Accident/Incident Investigation - Supervisor Training

Accident/Incident Investigation - Supervisor Training. N.C. Department of Labor Mine and Quarry Bureau. What is the root cause?. Responsibilities under the ACT. You are already aware of your responsibility as a supervisor You understand “having reason to know”

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Accident/Incident Investigation - Supervisor Training

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  1. Accident/Incident Investigation - Supervisor Training N.C. Department of Labor Mine and Quarry Bureau

  2. What is the root cause?

  3. Responsibilities under the ACT • You are already aware of your responsibility as a supervisor • You understand “having reason to know” • You are familiar with the levels of “negligence”

  4. Accident Prevention is paramount • Company safety culture - the atmosphere within the company that influences safe behavior • Accomplished by shared beliefs, practices, and attitudes from management down to the newest hired worker • A break-down of the culture leads to loss

  5. How is the safety culture created? • Positive attitudes by management and employee • Developing policy and procedures • Supervisors taking responsibility and accountability • Safety planning and goals • Properly addressing unsafe behavior • Motivate and train employees • Employee involvement or “buy-in”

  6. Accidents do occur • Any loss costs everybody • Direct cost is only a small percentage of the actual cost of an accident – medical expenses, worker’s compensation • Indirect cost can be 4 to 7 times the direct cost – wages of the injured, decreased productivity, emergency response cost, investigation cost, remediation cost to prevent recurrence, replacement cost of property and personnel, plus others

  7. The Three Basic Causes Poor Management Safety Policy & Decisions Personal Factors Environmental Factors Basic Causes Unsafe Condition Unsafe Act Indirect Causes ACCIDENT Personal Injury Property Damage Unplanned release of energy and/or Hazardous material Direct Causes

  8. Minimize loss • Promote an active accident prevention program • Perform task analysis • Train employees in hazard recognition • Front line supervisor must understand NEGLIGENCE

  9. When loss occurs • Root causes of accidents are identified through recognition and investigation of unsafe behavior • As supervisors you must recognize and investigate all unsafe acts, unsafe conditions, and correct root cause • Example – An accident involving a fall from a ladder; the broken rung on the ladder is easily recognized as a hazard and causation of the fall, however the root cause could be, improper maintenance, poor inspection technique, or inadequate training on recognizing the hazard • Document the occurrence and train employees on recognizing and preventing future occurrence

  10. What is The Aim of the Investigation? • EXONERATE INDIVIDUALS OR MANAGEMENT • SATISFY INSURANCE REQUIREMENTS • DEFEND A POSITION FOR LEGAL ARGUEMENT • OR, TO ASSIGN BLAME

  11. The aim of any accident/incident investigation THE KEY RESULT SHOULD BE TO PREVENT A RECURRENCE OF THE SAME ACCIDENT

  12. THE ACCIDENT WHAT IS AN ACCIDENT?

  13. THE ACCIDENT AN UNPLANNED AND UNWELCOMED EVENT WHICH INTERRUPTS NORMAL ACTIVITY.

  14. THE ACCIDENT THREE BASIC TYPES OF ACCIDENTS

  15. THE ACCIDENT MINOR ACCIDENTS: SUCH AS PAPER CUTS TO FINGERS OR DROPPING A BOX OF MATERIALS

  16. THE ACCIDENT MORE SERIOUS ACCIDENTS THAT CAUSE INJURY OR DAMAGE TO EQUIPMENT OR PROPERTY: SUCH AS A FORKLIFT DROPPING A LOAD OR SOMEONE FALLING OFF A LADDER

  17. THE ACCIDENT ACCIDENTS THAT OCCUR OVER AN EXTENDED TIME FRAME: SUCH AS HEARING LOSS OR AN ILLNESS RESULTING FROM EXPOSURE TO CHEMICALS

  18. THE ACCIDENT ACCIDENTS HAVE TWO THINGS IN COMMON

  19. THE ACCIDENT THEY ALL HAVE OUTCOMES FROM THE ACCIDENT

  20. THE ACCIDENT THEY ALL HAVE CONTRIBUTORY FACTORS THAT CAUSE THE ACCIDENT

  21. OUTCOMES OF ACCIDENTS • NEGATIVE ASPECTS • DEATH & INJURY • DISEASE • DAMAGE TO EQUIPMENT & PROPERTY • LITIGATION COSTS • LOST PRODUCTIVITY

  22. OUTCOMES OF ACCIDENTS • POSITIVE ASPECTS • ACCIDENT INVESTIGATION • CHANGE TO SAFETY PROGRAMS

  23. CONTRIBUTING FACTORS • ENVIRONMENTAL • DESIGN • SYSTEMS & PROCEDURES • HUMAN BEHAVIOR

  24. CONTRIBUTING FACTORS • ENVIRONMENTAL • NOISE • VAPORS, FUMES, DUST • LIGHT • HEAT • CRITTERS

  25. CONTRIBUTING FACTORS • DESIGN • WORKPLACE LAYOUT • DESIGN OF TOOLS & EQUIPMENT

  26. CONTRIBUTING FACTORS • SYSTEMS & PROCEDURES • LACK OF SYSTEMS & PROCEDURES • INAPPROPRIATE SYSTEMS & PROCEDURES

  27. CONTRIBUTING FACTORS • HUMAN BEHAVIOR • COMMON TO ALL ACCIDENTS • NOT LIMITED TO THE PERSON INVOLVED IN THE ACCIDENT

  28. WHO SHOULD INVESTIGATE • DEPENDENT ON SEVERITY OF THE ACCIDENT • INVESTIGATION TEAM • INDIVIDUALS INVOLVED • SUPERVISOR • SAFETY SUPERVISOR • UPPER MANAGEMENT • OUTSIDE CONSULTANTS

  29. INVESTIGATION STRATEGY • GATHER INFORMATION & ESTABLISH FACTS • ISOLATE ESSENTIAL CONTRIBUTORY FACTORS • DETERMINE CORRECTIVE ACTIONS • IMPLEMENT CORRECTIVE ACTIONS

  30. INVESTIGATION STRATEGY • FACT GATHERING • BE IMPARTIAL & OBJECTIVE • COMPILE PROCEDURES & RULES FOR THE AREA • GATHER MAINTENANCE RECORDS ON EQUIPMENT INVOLVED

  31. INVESTIGATION STRATEGY • FACT GATHERING (CONTINUED) • ISOLATE ACCIDENT SCENE • PHOTOS & DIAGRAMS • DO NOT DISCARD OR DESTROY ANYTHING

  32. INVESTIGATION STRATEGY • FACT GATHERING (CONTINUED) • TIME IS OF THE ESSENCE • OBTAIN INFORMATION • INJURED • WITNESSES • SUPERVISORS • OTHER PERSONNEL

  33. INVESTIGATION STRATEGY • FACT GATHERING (CONTINUED) • INTERVIEWS (SEPARATELY) • WHAT WERE YOU DOING? • HOW DO YOU THINK THE ACCIDENT OCCURRED? • HOW WERE YOU TRAINED FOR THE JOB? • WHAT IS THE SAFETY PROCEDURE FOR THIS JOB?

  34. INVESTIGATION STRATEGY • FACT GATHERING (CONTINUED) • OBTAIN FACTS NOT OPINIONS • MAKE IT CLEAR THE OBJECT OF THE INVESTIGATION IS TO AVOID RECURRENCE, NOT TO APPORTION BLAME

  35. INVESTIGATION STRATEGY • ISOLATE ESSENTIAL CONTRIBUTORY FACTORS • INVESTIGATION TEAM • EVALUATES ALL FACTORS CONCERNED

  36. INVESTIGATION STRATEGY • ISOLATE ESSENTIAL CONTRIBUTORY FACTORS • INVESTIGATION TEAM • ISOLATES THE KEY FACTOR(S) BY ASKING THE FOLLOWING QUESTION....

  37. INVESTIGATION STRATEGY WOULD THE ACCIDENT HAVE HAPPENED IF THIS PARTICULAR FACTOR WAS NOT PRESENT?

  38. INVESTIGATION STRATEGY • DETERMINE CORRECTIVE ACTIONS • INVESTIGATION TEAM • INTERPRETS & DRAWS CONCLUSION • DISTINCTION BETWEEN INTERMEDIATE & UNDERLYING CAUSES

  39. INVESTIGATION STRATEGY • DETERMINE CORRECTIVE ACTIONS • INVESTIGATION TEAM • RECOMMENDATIONS BASED ON KEY CONTRIBUTORY FACTORS AND UNDERLYING CAUSES

  40. INVESTIGATION STRATEGY • IMPLEMENT CORRECTIVE ACTIONS • INVESTIGATION TEAM • RECOMMENDATION(S) MUST BE COMMUNICATED CLEARLY • STRICT TIME TABLE ESTABLISHED • FOLLOW UP CONDUCTED

  41. BENEFITS OF ACCIDENT INVESTIGATION • PREVENTING RECURRENCE • IDENTIFYING OUT-MODED PROCEDURES • IMPROVEMENTS TO WORK ENVIRONMENT

  42. BENEFITS OF ACCIDENT INVESTIGATION • INCREASED PRODUCTIVITY • IMPROVEMENT OF OPERATIONAL & SAFETY PROCEDURES • RAISES SAFETY AWARENESS LEVEL

  43. BENEFITS OF ACCIDENT INVESTIGATION WHEN AN ORGANIZATION REACTS SWIFTLY AND POSTIVELY TO ACCIDENTS AND INJURIES, ITS ACTIONS REAFFIRM ITS COMMITMENT TO THE SAFETY AND WELL-BEING OF ITS EMPLOYEES

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