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Accident Investigation Slide 2
Professional Disclaimer
By no means am I a professional accident investigator…
But I did stay at a Holiday Inn Express last night!
Introduction
Accident Investigation Slide 3
Why do we need Accident Investigations?
To prevent future accidents.
To avoid spending money on accidents in the future.
To comply with the law and determine the total cost of an accident
Introduction
Accident Investigation Slide 5
PRE-ACCIDENT PLANNING
Formal written accident investigation policy
Emergency response plan and training
Accident investigation training
Accident investigation kit
Program Evaluation
Accident Investigation Slide 6
Typical Accident Investigation Kit
Barricade Tape Cones Tape Measure Flashlight Evidence Tags Evidence Bags Tweezers Gloves (latex and work) PPE Binoculars
Camera Graph Paper Witness statement forms Notepad and clipboard Analytical technique
forms Copy of the accident
investigation policy
Program Evaluation
Accident Investigation Slide 7
Decisions to be made before an Accident Investigation
Determine the level of accident
Decide who will investigate
How much time will be allotted to investigate
Determine if outside resources will be needed
Program Evaluation
Accident Investigation Slide 8
WHAT IS ACCIDENT INVESTIGATION?
4 step Process to determine the underlying causes of accidents 1. Analyzing the facts 2. Developing an accident sequence 3. Finding the causes 4. Recommending corrective actions
Causal information used to identify and take preventive action
Introduction
Accident Investigation Slide 9
INVESTIGATIVE TECHNIQUES
Preservation of evidence
Types of evidence
Gathering evidence
When to stop collecting evidence
Gathering Evidence
Accident Investigation Slide 10
Preservation of Evidence
Cordon off the area Photograph the scene Interview emergency response personnel as
soon as possible Assess the evidence Draw a picture or diagram of the scene
Gathering Evidence
Accident Investigation Slide 11
Types of Evidence
Photographic
People
Physical
Paper
Gathering Evidence
Accident Investigation Slide 12
Gathering EvidencePhotographic Evidence
Take photos of the “Big Picture”
Include a reference object
Keep a photo log Keep back-up copies in
safe place
Gathering Evidence
Accident Investigation Slide 13
INTERVIEWING TIPSPeople Evidence
Choose site carefully. Put the person at ease, explain purpose. Fact-finding process, don’t assess blame. Ask open-ended questions. Take notes. Ask for their opinion. Get contact information.
Gathering Evidence
Accident Investigation Slide 14
Gathering EvidencePhysical Evidence
Take universal precautions
Examine equipment, tools, debris, etc…
Note defects
Gathering Evidence
Accident Investigation Slide 15
Gathering EvidencePaper Evidence
Policies Procedures Training records Equipment maintenance records Accident records
Gathering Evidence
Accident Investigation Slide 16
Charting
Sequence of events: Establishment of
timelines and or charts provides:
The recording of events and conditions in a visual manor.
Validation and verification of facts.
Identification of multiple causes.
Elimination of memorization.
Analyzing Data & Determining Causes
Accident Investigation Slide 17
Charting Tips
Fill the chart with information
Make room for your chart
Keep the notes sticky Leave some expansion
room Use computer charts
Analyzing Data & Determining Causes
Accident Investigation Slide 18
DETERMINING CAUSES
The root cause is the most fundamental and direct cause of an accident or incident
There may be one or more contributory causes, in addition to the root cause
Accident Investigation is ineffective unless all causes are determined and corrected
Analyzing Data & Determining Causes
Accident Investigation Slide 19
CATEGORIES OF ROOT CAUSES
Can be classified as:
Workplace Factors - Largely a function of Management Practices
Employee Factors - Largely a function of Employee Behavior
Analyzing Data & Determining Causes
Accident Investigation Slide 20
The Analytical Process
The five whys?
The why staircase
Analyzing Data & Determining Causes
Accident Investigation Slide 21
The Five Whys?
Investigator: John, why did the pipe fall on your foot?
John: I dropped it. Investigator: Why did you drop it? John: It slipped out of my hand. Investigator: Why did it slip? John: It was wet. Investigator: Why was it wet? John: It rained earlier today.
Analyzing Data & Determining Causes
Accident Investigation Slide 22
The Why Staircase?
“Accident” Why? WHY? WHY? WHY? WHY? “Solution”
Analyzing Data & Determining Causes
Accident Investigation Slide 23
Analytical Techniques
Event and Causal Factor Analysis
Root Cause Analysis
Change Analysis
Analytical Trees
Barrier Analysis
Analyzing Data & Determining Causes
Accident Investigation Slide 24
CORRECTIVE ACTIONS
Once the cause(s) are determined, corrective actions must be developed and implemented.
Must directly address each cause identified. Consider short term CA’s if permanent CA’s
are not readily available. Reference the “Control Hit List” to make sure
that the “best” corrective actions are used.
Corrective Actions & Reporting
Accident Investigation Slide 25
THE CONTROL HIT LIST
1. Eliminate the Hazard
2. Substitute a less hazardous material
3. Use Engineering Controls
4. Use Administrative Controls
5. Personal Protective Equipment (PPE)
6. Training of Employees
Corrective Actions & Reporting
Accident Investigation Slide 26
Accident Reports
Method of communicating A/I results to others.
Severity and scope of accident dictates which report to use. Accident Logs
Accident Form
Accident Report
Corrective Actions & Reporting
Accident Investigation Slide 27
Accident Reports
Should include but not limited to: IntroductionMethodologySequence of EventsFacts and AnalysisCausal FactorsCorrective ActionsConclusion and Summary
Corrective Actions & Reporting
Accident Investigation Slide 28
Review of a Detailed Accident Investigation Report
GROUP DISCUSSION
&
BREAK OUT SESSION
Accident Investigation Slide 29
References
Oakley, Jeffrey S. Accident Investigation Techniques. The American Society of Safety Engineers: Des Plaines, Illinois, 2003.
Cianbro The Constructors. Yankee Rowe Decommissioning Project. 1997
Rooney, James J., and Vanden Heuvel, Lee N. Root Cause Analysis For Beginners. Quality Progress, July 2004.