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Presented by Joe Angyus, CSPOctober 7, 2009
Easy Incident & Accident Investigations
Three Common Myths
1. Accidents, by definition, “just happen”
2. Many accidents are caused by “stupidity”
3. No accidents = safe workplace
Establish an investigation process
Determine what to investigate;
Who will investigate; and
Write policy on investigation procedure
“Those designated simply have to take the time, understanding that, in the long run, inadequate investigations will cost them even more time” – Frank Bird, Jr., Practical Loss Control Leadership
Reporting incidents
Employees who:
Fear
Have concern
Want to avoid
Misunderstand
Won’t report!
But when employees:
Buy in
Perceive importance
See the value
Believe in end goal
They’re more likely to report!
Phases of Investigation
1. Initial actions at the scene
2. Gather information (Four P’s)
3. Analyze all significant causes
4. Develop and take corrective actions
5. Write the report
6. Review the findings and recommendations
7. Follow up to verify effectiveness of the actions
Initial actions at the scene
Take control
Ensure first aid, call emergency services
Control secondary incidents
Identify sources of evidence
Preserve evidence
Determine loss potential
Notify personnel
Gathering Information
Interviewing witnesses (people)
Photos, sketches, or maps (positions)
Equipment exam (parts)–Material failure analysis
Records check (paper)
Write a good description
Description should contain:
1. What was the injured attempting to do?2. What went wrong?3. What was the outcome (loss)?
Be thorough, but keep it simple!
Writing a good description
1. What was the injured attempting to do?
The injured was attempting to replace a defective air valve by using a 12 ft. step ladder.
Writing a good description
2. What went wrong?
Since it was leaning unsecured against the air receiver tank, the ladder slipped outward as the injured climbed to access the valve.
Writing a good description
3. What was the outcome (loss)?
The injured fell 7 ft. to the floor beneath the tank, striking against hydraulic lines causing a fractured left collarbone and significant bruising to his right arm and shoulder.
Analyze significant causes
Start with the event (loss)
Work backwards by asking “why”
Identify the unsafe acts/conditions
Don’t stop at “symptoms”
Determine system failures
Take immediate corrective actions
At the scene
With the people involved
By the frontline leader
Examples:– Re-instruct the injured
– Replace the tool
Take long-term corrective actions
Identify and correct system deficiencies
Types of system deficiencies could include:– Standards for tools and equipment selection,
use and inspection
– Training program
– Employee observation
– Management controls
Review the findings and recommendations
Management’s role in investigation process: –Demonstrates importance
–Verify problems solved
–Determine who else needs to know
–Identify why the safety program didn’t adequately control the hazard
Follow up to verify action effectiveness
Evaluate how systems are working after actions taken
Circle back with injured employee
Questions?
? ? ? If you have further questions, please
contact:
–Joe Angyus ~ [email protected]
–800-733-8621
