Chapter Accident Investigation

8/4/2019 Chapter Accident Investigation

1/46

ACCIDENT INVESTIGATION


2/46

What Is An Incident?

Unplanned and unwanted event whichdisrupts the work process and has thepotential of resulting in injury, harm, ordamage to persons or property.

An incident disrupts the work process, does not result in injury or damage, butshould be looked as a wake up call. It can be thought of as the first of a series of

events which could lead to a situation in which harm or damage occurs. Employers

should investigate an incident to determine the root cause and use the informationto stop process and behaviors that could just as easily have resulted in an accident.

Example of an incident:: A 50 lb carton falls off the top shelf of a 12 high rack and

lands near a worker. This event is unplanned, unwanted, and has the potential forinjury.


3/46

What Is An Accident?

Unplanned, unwanted, but controllableevent which disrupts the work processand 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. Anaccident stops the normal course of events and causes property damage, orpersonal injury, minor or serious and occasionally results in a fatality.


4/46

What Is An Accident?

An accident is not just one of those things. Accidents are predictable and preventable

events.

They dont have to happen.Most workplace injuries and illness are not due to accidents. The term accident

is defined as an unexpected or unintentional event, that it was just bad luck.

More often than not it is a predictable or foreseeable eventuality.By accidents we mean events where employees are killed, injured, or become ill

from exposure to toxic chemicals or microorganisms (TB, Hepatitis, HIV, etc).A systematic plan and follow through of investigating incidents or disasters andaltering behaviors can help stop a future accident.Lets take the 50 lb carton falling 12, for the 2nd time, only this time it hits a

worker, causing injury. Predictable? Yes. Preventable? Yes. Investigating whythe carton fell will usually lead to solution to prevent it from falling in the future.


5/46

The Tip of the Iceberg

Dont just investigate accidents. Incidents should also be reported and investigated. Criteria for investigating

an incident: What is reasonably the worst outcome, equipment damage, or injury to the worker? Whatmight the severity of the worst outcome have been? If it would have resulted in significant property loss or aserious injury, then the incident should be investigated with the same thoroughness as an actual accidentinvestigation.The 50 pound carton falls off the top shelf of a 12 high rack and lands near a worker. The outcome of an

investigation might include correction of sloppy storage at several locations in the warehouse,unstable/heavy items will be stored at floor level if possible, refresher training of stockers on proper methodsis done, supervisor begins doing daily checks.

Accidents or injuries are the tip ofthe iceberg of hazards

Investigate incidents since they are

potential accidents in progress

Accidents

Incidents


6/46

What is an Accident?

By dictionary definition: an unforeseen event, .chance..,unexpected happening..,

Hazardous conditions

Close calls

Minor injuries

Severe Injuries

Fatalities

From experience andanalysis: they are

caused occurrencesPredictable - the logical

outcome of hazards

Preventable andavoidable - hazards do nothave to exist. They arecaused by things people do-- or fail to do.


7/46

Why Investigate?

Prevent future incidents (leading toaccidents).

Identify and eliminate hazards.

Expose deficiencies in process and/orequipment.

You lose money when regular work stops.

Maintain worker morale.

The rule requires you to investigate seriousaccidents.


8/46

How To Investigate

Develop a

plan

The time to develop your companys Accident Investigation Plan is before you have anincident or an accident. The who, when, where, what and how should be developedbefore the incident.

Accident Investigation Training, investigation tools and policies and procedures should bedeveloped before the incident or accident.


9/46

How To Investigate

Assemble an investigation kit

Investigate all incidents

and accidents immediately

Collect facts

It is important to begin your investigation immediately. Evidence disappears, the 50 lb cartonof material was cleaned up and memory fadesthe employee was not encouraged to report

the near-miss incident and forgot about the whole thing.When investigating incidents or accidents be thorough in your capture of all available facts.

You might discover that many other items were also improperly stored and that whenemployees were questioned there had been several other near misses


10/46

How To Investigate

Interview witnesses

Interview witnesses and victims in a timely manner. LISTENDont blame, dont point out poor judgment, be sympatheticLISTEN

If you know for a fact that someone broke a rule it is not important to point that out to them atthis time. Verify with them the training they have received and ask them if they know whathappened to cause the accident. Again, it doesnt do anyone any good at this stage to be told

it was your fault or you knew better

As an investigator, you will often come to the conclusion that someone engaged in an unsafeact. It is most important to determine why they engaged in an unsafe act as well as verify that

they did or did not know better.


11/46

How To Investigate

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.


12/46

Tips for Developing A Plan

Develop your action plan ahead oftime.

Your plan might include:

Who to notify in the workplace?How to notify outside agencies?

Who will conduct the internal

investigation?

Preplanning will help you address situations timely, reducing the chance forevidence to be lost and witnesses to forget. All procedures, forms, notifications,etc. need to be listed out as step-by-step procedures. You might wish to develop

a flow chart to quickly show the major components of program.


13/46

Develop a Plan Tips (continued)

What level of training is needed?Who receives report?

Who decides what corrections will be takenand when?

Who writes report and performs follow up?

Some expansion questions on the above points are:

Who will be trained to investigate? Who is responsible for the finished report and what is the time frame? Who receives copies of the report? Who determines which of the recommendations will be implemented? Who is responsible for implementing the recommendations? Who goes back and assures that fixes are in place?

Who assures that fixes are effective?


14/46

What Should Be In The Investigation Kit

Camera equipment First aid kitTape recorder Gloves

Tape measure Large envelopes

High visibility tape Report forms

Scissors Graph paper

Scotch tape

Sample containers with labels

Personal protective equipment

These are some common items for a kit. What else might be useful?

Anything for specific business or workplace that might be needed?


15/46

Investigate All Incidents/Accidents

Conduct and document an investigationthat 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?Did someone ignore a hazard because of lack of training, or a policy that discouragesreporting? What are other examples of root causes? Enforcement failure, defective PPE,

horseplay, no recognition plan, inadequate labeling.


16/46

Investigate All Incidents/Accidents

Also answer:

Is this a company or industry-recognizedhazard?

Has the company taken previous action tocontrol this hazard?

What are those actions?

Is this a training issue?


17/46

Begin Investigations Immediately

Its important to collect evidence andinterview witnesses as soon aspossible because evidence will

disappear and people will forget.


18/46

How Do You Investigate?

Notify individuals according to your plan

You must involve an employee

representative, the immediate supervisor,and other people with knowledge

Grab your investigation kit

Approach the scene


19/46

Actions At The Accident Scene

Check for danger

Help the injured

Secure the scene

Identify and separate witnesses

Gather the facts

First, make sure you and others dont become victims! Always check for still-present dangerous situations. Then, help the injured as necessary.

Secure the scene and initiate chains of custody for physical evidence. Identify witnesses and physical evidence. Separate witnesses from one another If physical evidence is stabilized, then begin as quickly as possible with interviews.

REMEMBER, BE A GOOD LISTENER


20/46

Fact Finding

Witnesses and physicalevidence

Employees/other witnesses

Position of tools and equipment

Equipment operation record,charts,

Equipment identification numbers


21/46

Fact Finding

Take notes on environmental conditions,

air quality Take samples

Note housekeeping and general workingenvironment

Note floor or surface condition

Take many pictures

Draw the scene

Some scenes are more delicate then others. If items of physical evidence are timesensitive address those first. If items of evidence are numerous then you mayneed additional assistance. Some scenes will return to normal very quickly. Are youprepared to be able to recreate the scene from your documentation?Consider creating a photo log. The plot should describe the date, time, give adescription of what is captured in the photo and directionality. Link to sketch of

accident scene.


22/46

Interview Witnesses

LISTEN

Dont blame, just get facts

Talk to witnesses as equals

Keep conversations informal


23/46

Interview Witnesses

Choose a private place to talk

Ask open ended questions

Interview promptly after the incident Ask some questions you know the

answers to

Your method and outcome of interview should include: who is to be interviewedfirst; who is credible; who can corroborate information you know is accurate; how todetermine the truth bases on a limitation of numbers of witnesses. Be respectful,are you the best person to conduct the interview?If the issue is highly technical consider a specialist, this may be an internalresource or it may be an outside resource.


24/46

Write The Report

How and why did the accidenthappen?

A list of suspected causes and humanactions

Use information gathered fromsketches, photographs, physicalevidence, witness statements

Remember that your report needs to be based on facts. All recommendationsshould be based on accurate documented findings of facts and all findings andrecommendations should be from verifiable sources.


25/46

Write The Report

When and where did the accidenthappen?

What was the sequence of events?

Who was involved?

What injuries occurred or whatequipment was damaged?

How were the employees injured?

Answer the following in the report:


26/46

Report Conclusions

What should happen to prevent futureaccidents?

What resources are needed?

Who is responsible for making changes?

Who will follow up and insureimplementation of corrections?

What will be future long-termprocedures?

Conclusions must always be based upon facts found during your investigation. If additionalresources are needed during the implementation of recommendations then provide options.Having a comprehensive plan in place will allow for the success of your investigation. Successof an investigation is the implementation of viable corrections and their ongoing use.

R t A D th H it li ti


27/46

Report A Death or Hospitalization(Catastrophe)

Report the death, probable death, orthe in-patient hospitalization of 2 ormore employees within 8 hours.

The required information that must be provided1- Name of the work place2- Location of the incident

3- Time and date of the incident4- Number of fatalities or hospitalized employees5- Contact person6- Phone number7- Brief description of the incident


28/46

The ultimate purpose of incidentinvestigation and analysis activities is toprevent future incidents. As such, theinvestigation or analysis must producefactual information leading to corrective

actions that prevent or reduce the numberof incidents.

The more complete the information, theeasier it will be for management to takeeffective corrective actions. All incidentsshould be investigated, regardless ofseverity of injury or amount of propertydamage.


29/46

The minimum data set that investigatorsshould record includes the following:

If data will be used to compare one company with another, record

data about employer characteristics. This includes the type ofindustry and the size of the company (number of full-timeequivalent employees).

Record employee characteristics. The victim's age and sex, thedepartment and occupation in which he or she worked, andwhether a full-time, part-time, or seasonal employee. Questions

about the victim's experience are also asked.

How long has the victim been with the company? How long in current occupation? How often had the employee repeated the activity engaged in when

the incident occurred?

Employee training records may be examined and assessed duringthis part of the investigation.

Record the characteristics of the injury. Describe exactly theinjury or injuries and the part or parts of the body affected by theincident.

P ti d i ti d id t


30/46

Prepare a narrative description and accident sequencethat provides the exact location of the incident (attach anymaps or diagrams to the report);

a complete, specific breakdown of the sequence of events leadingto the injury or near-miss;

what objects or substances were involved in the incident; conditions such as temperature, light, noise, and weather

pertaining to the incident; whether any preventive measures had been in place; and The investigators should include only the facts obtained during the

investigation; they should not record opinions or place blame.

Record the characteristics of the equipment associatedwith the incident. These data should be incorporated intothe narrative description on the report form. Include thetype, brand, size, and any distinguishing features of theequipment, its condition, and the specific part involved.

Record the characteristics of the task being performedwhen the incident happened: the general task (such asrepairing a conveyor) and the specific activity (such asusing a wrench).


31/46

Record the time factors. The investigation should record the time

of day and whether it was the victim's first hour of the shift,second hour, or later.

Record the task and activity factors. First, describe the generaltype of task the employee was performing at the time the injuryoccurred. Second, record the specific activity in which theemployee was engaged.

Record supervision information. Indicate in the appropriate placeon the form whether the employee was being supervised directly,indirectly, or not at all at the time of the incident.

Record the causal factors. Record the events and conditions thatcontributed to the incident. Be as specific and complete aspossible.

Describe the corrective actions taken immediately after theincident to prevent a recurrence, including temporary actions.


32/46

ESTIMATING INCIDENT COSTS

Although most executives want to make their company a safe

place to work, they also have a responsibility to run their businessprofitably.

Definition of Work Incidents for Cost Analysis

Work incidents, for the purpose of cost analysis, are unintendedoccurrences arising in the work environment. These incidents fallinto two general categories:

(1) incidents resulting in work injuries or illnesses(2) incidents causing property damage or interfering with

production.

Method for Estimating

To be of maximum usefulness, cost figures should represent asaccurately as possible the specific experience of the company. Estimated costs of incidents in general do not take into account

differences in hazards from one industry to another. Because of the differences between direct and indirect costs are

difficult to maintain, instead they use more precise terms"insured" and "uninsured" costs. Using these data, a company canestimate its incident cost with reasonable accuracy.


33/46

Insured Costs

Every organization paying compensation insurance premiumsrecognizes such expense as part of the cost of incidents. Insome cases, medical expenses too, may be covered byinsurance. These costs are definite and known. They includethe insured element of the total incident cost.

In addition to these costs, many other costs arise in connectionwith incidents.

Although the expense of damaged equipment is easilyidentified, others, such as wages paid to the injured employeefor downtime on the day of the injury, are hidden. These itemsinclude the uninsured element of the total incident cost.

Uninsured Costs

While insured costs can be determined easily from accountingrecords, uninsured (also called "indirect") costs are moredifficult to assess. The method described here is one way tocalculate these added expenses associated with manyincidents.


34/46

The first step is to conduct a pilot study Determine approximate averages of uninsured costs for each of thefollowing four classes of incidents:

1. Class 1-Cases involving lost workdays

days away from work or days of restricted work activity

2.Class 2-Medical treatment cases requiring the attention of a physician outside the facility

3.Class 3-Medical treatment cases requiring only first aid

local dispensary treatment and resulting in property damage of lessthan $100 or loss of less than eight hours in work time

4.Class 4-Incidents that either cause no injury or cause minorinjury, not

requiring the attention of a physician, and that result in propertydamage of $100 or more, or loss of eight or more employee-hours.

Once average costs have been established for each incident class, theycan be used as multipliers to obtain total uninsured costs in subsequentperiods. These costs are then added to known insurance premium coststo determine the total cost of incidents.


35/46

Example of a Cost Estimate

An estimate of costs made by one company is given in thefollowing example. First, a pilot study was conducted toobtain the average cost of each class of incident.

Included in the study were 20 Class 1 incidents, 30 Class 2incidents, 50 Class 3 incidents, and 20 Class 4 incidents.Costs were determined and averages developed in Table 7-A.

During the entire year, the company had 34 Class 1incidents, 148 Class 2 incidents, and 4,000 Class 3 incidents.No record was kept of the Class 4 incidents after the pilotstudy was completed. Instead, the ratio of the number ofClass 4 to Class 1 incidents found in the pilot study was used.

This ratio was shown to be about 1 to 1, and since there were34 Class 1 incidents during the year, it was assumed therewere about 34 Class 4 incidents. (A separate record could bekept of the number of Class 4 incidents.)


36/46

TABLE 7-A Average Cost Determined by Pilot Study___________________________________________________

Class of Number of Average of

Accidents Accident Reported Uninsured cost______________________________________________Class 1 20 $251.10Class 2 30 80.80Class 3 50 15.70

Class 4 20 507.10

The average cost for each incident class was applied to thesetotals to secure the results shown in Table 7-B.

The estimate should be rounded to three significant digits-inthis case, to the nearest thousand dollars. As a result, in this

instance, the analyst reported to the plant manager, "Duringthe past year, incidents cost this company about $155,000in compensation, medical expense, lost time, and propertydamage."

The average costs determined in this pilot study representthe actual experience of this particular organization.


37/46

Table 7-B. Estimate of Yearly Accident Costs________________________________________________________Average Cost Total

Class of Number of per Accident UninsuredAccident Accidents (from pilot study) Cost

________________________________________________________

Class 1 34 $251.10 $ 8,537.40Class 2 148 80.80 11,958.40Class 3 4,000 15.70 62,800.00Class 4 34 507.10 17,241.40

Total Uninsured Cost $100,537.20Insurance Premiums 54,400.00Total Accident Cost for the Period $154,937.20

It f U i d C t


38/46

Items of Uninsured Cost Important to a pilot study is a careful investigation of each incident to

determine all the costs arising out of it.

The following items of uninsured or indirect costs are clearly the result ofwork incidents and are subject to reasonably reliable measurement.

1. Cost of Wages Paid for Time Lost by Workers Who were not Injured. These are employees who stopped work to watch or assist after the incident or

who lost time because they needed the equipment damaged in the incident orbecause they needed the output or the aid of the injured worker.

2.Nature and Cost of Damage to Material or Equipment. The validity of property damage as a cost can hardly be questioned.

Occasionally, there is no property damage, but a substantial cost is incurred inreorganizing material or equipment.

3.Cost of Wages Paid for Time Lost by the Injured Worker, other thanWorkers' Compensation Payments.

Payments made under workers' compensation laws for time lost after thewaiting period are not included in this element of cost.

4.Extra Cost of Overtime Work Necessitated by the Incident. The charge against an incident for overtime work is the difference between

normal wages and overtime wages for the time needed to make up lostproduction, and the cost of extra supervision, and other extra services.

5 Cost of Wages Paid to Supervisors for Time Spent on Activities Concerning


39/46

5.Cost of Wages Paid to Supervisors for Time Spent on Activities Concerningthe Incident. The most satisfactory way of estimating this cost is to charge the wagespaid to the supervisor for the time spent away from normal activities as a result of theincident.

6.Wage Cost Caused by Decreased Output of Injured Worker after Return to Work.

If the injured worker's previous wage payments are continued despite a 40% reductionin output, the incident should be charged with 40% of the worker's wages during theperiod of low output.

7. Cost of Learning Period of New Worker.If a replacement worker produces only half as much in the first two weeks as the injuredworker would have produced in the same time for the same pay, then half of the newworker's wages for the two weeks' period should be considered part of the cost of the

incident.

8.Uninsured Medical Cost Borne by the Company.This cost is usually that of medical services provided at the plant dispensary. There is nogreat difficulty in estimating an average cost per visit for this medical attention.

9.Cost of Time Spent by Management and Clerical Workers on Investigations or in theProcessing of Compensation Application Forms.

Time spent by management or supervision and by clerical employees in investigating anincident, or settling claims arising from it, is chargeable to the incident.

10.Miscellaneous Costs.Among such possible costs are public liability claims, equipment rental, losses due tocancelled contracts or lost orders if the incident causes an overall reduction in total sales,loss of company bonuses, cost of hiring new employees if this expense is significant, cost

of above-normal spoilage by new employees.


40/46

Conducting a Pilot Study

The purpose of the pilot study is to develop average uninsuredcosts for different classes of incidents that can be applied to future

incident totals.

Therefore, it is desirable not to include the costs of deaths andpermanent total disabilities. Such incidents occur so seldom thatthe costs should be calculated individually and not estimated onthe basis of averages.

OFF - THE - JOB DISABLING INJURY COST

When incidents take place off the job, a major portion of the costsare borne by employers. Some of the costs are obvious, such asinsurance premiums and wages paid to absent employees.

Some of the costs are hidden, such as training for new or

transferred workers and medical staff time demanded for workersreturning to work after an incident.

For example, a new worker does not produce at the same level asan experienced worker; thus, the decreased productivity of thenew worker indirectly increases the manufacturing overhead.


41/46

Categorizing OTJ Disabling Injury Cost

The cost of off the job disabling injuries (O T J DI) to anorganization falls into the following two categories: insuredand uninsured.

Most uninsured costs are hidden. Aside from wage costs, mostorganizations do not keep records of uninsured costs.However, these costs are associated with all O T J D I incidentsand, therefore, affect profit margins.

Insured Costs

worker productivity cost, product loss, andequipment damage. directly associated with the employeewho sustained the O T J D I injury are included in this expensesubcategory.

Uninsured Costs worker productivity cost, product loss,equipment damage, and administrative cost. incurred bypersonnel other than the employee who sustained the OTJ DI

injury are included in this subcategory. Miscellaneous costs This subcategory includes loss of profitfor cancelled contracts or orders and the costs of demurrage(compensation), telephone calls, transportation, or othermiscellaneous expenses.

E i i O T J D C


42/46

Estimating O T J D Costs

Some experts say the ratio of insured cost touninsured cost is 3:2. In order to estimate acompany's losses from employee OTJ D I s,management must first determine the insuredcost.

Next, using the 3:2 factor, it must rise theinsured cost to determine the total (insuredand uninsured) employee costs. The insured

cost for injuries to dependents of employeesis then added to the total employee cost todetermine total losses. The followingexamples illustrate calculation procedures.


43/46

Example 1

Company A is insured by an outside carrier. Twenty percent or$225,000 of its annual premium charge was required to pay for

its previous calendar year OTJ DI incident experience. Of thattotal, $75,000 was required for 11 employee injuries and theremaining $150,000 was required for 22 employee-dependentinjuries. These figures include the administrative fee paid by thecompany to the carrier.

The total cost for employee-dependent injuries is a conservativefigure, since it does not include the administrative cost incurred

by the company's insurance office staff to process claims. If thiscost is known, it should be added to the employee dependentinjury expense category.

When the $75,000 insured cost category is escalated to includethe uninsured cost category, the total expense for employeeinjuries becomes $125,000.

Company A Estimated OTJ DI Costs

Insured cost for employee injuries = $75,000Uninsured cost for employee injuries = 50,000Insured cost forEmployee dependent injuries = 150,000

Total annual estimated OTJ DI cost = $275,000


44/46

Example 2

Company B is insured by an outside carrier. Its carrier statedthat $850,000 was paid for 138 employee injuries and$1,800,000 was paid for 279 employee-dependent injuries forits previous calendar year OTJ DI incident experience.

Their administrative fee to the carrier was 6% of the total cost,resulting in a cost of approximately $900,000 for employeeinjuries and $1,900,000 for employee dependent injuries. Ifthe cost for insurance office staff claim-processing is known, itshould be added to the total employee-dependent cost.

Escalation of the insured cost category for employee injuriesinclude the uninsured cost category indicated a total of$1,500,000.

Company B Estimated OTJ DI Costs

Insured cost for employee injuries = $900,000Uninsured cost for employee injuries = 600,000Insured cost foremployee-dependent injuries = 1,900,000Total annual estimated OTJ DI cost = $ 3,400,000


45/46

Example 3

Company C is self-insured. Insurance office recordsindicated that for the previous calendar year, OTJ DI

incident experience for the amount of medical andhealth claims paid for 350 employee injuries was$2,280,000, and $4,700,000 was paid for 690employee-dependent injuries.

Insurance office staff administrative costs for claimprocessing should be added to the employee dependent cost category if that cost is known.

Thus, $2,280,000 escalated to include the uninsuredcost category for employee injuries resulted in a totalcost of approximately $3,800,000.

Company C Estimated OTJ DI Costs

Insured cost for employee injuries = $2,280,000Uninsured cost for employee injuries = 1,520,000Insured cost foremployee-dependent injuries = 4,700,000Total annual estimated OTJ DI cost = $ 8,500,000


46/46

Measuring the Effects of OTJ Safety Programs

Calculations of average costs are useful tools to support initiating or

accelerating off the job safety awareness programs. The calculationsalso can be used to measure the effects of safety programs. For example, 350 employees of Company C experienced OTJ injuries

during the previous year for a total of approximately $3,800,000 andan average cost per incident of approximately $10,860.

Based upon the OTJ DI loss experience, top management allocated$50,000 from the budget to initiate a safety awareness program.

At the end of the year, the $10,860 average cost figure will be

escalated to adjust for inflation and, in turn, the new figure will beused to calculate losses. For illustration purposes, it is assumed that the new average cost per

incident figure is $11,500 and that employee injuries were reducedfrom 350 to 300.

Calculations (300 x $11,500) indicate losses of $3,450,000, a savingsof approximately $350,000 from last year's total. The estimated netreturn is $300,000, which is a 600% return on investment.

To further support justification for operating funds, safety personnelcan add savings realized from reduced employee-dependent injuries tothe employee savings total.

This type of analysis provides a management tool to evaluate theimpact of off-the-job disabling injuries on profit margins; thus, it canbe used to gain management commitment to support operatingbudgets for safety awareness programs.

Documents

Chapter Accident Investigation