Accident Investigation

 

 

What you will learn

▪ What is an accident or incident?

▪ Why should you investigate both?

▪ How do you find the true cause?

▪ How should you investigate?

▪ What should be the results of the investigation?

▪ What are you required to do for L & I

What Is An Accident?

An unplanned, unwanted, but controllable event which disrupts the work process and causes injury to people.

What is an “Accident”?

By dictionary definition: “an unforeseen event”, “chance”, “unexpected happening”, formerly “Act of God”

• From experience and analysis: they are

“caused occurrences”

– Predictable - the logical outcome of hazards

– Preventable and avoidable - hazards do not have to exist. They are caused by things people do -- or fail to do.

What Is An Incident?

An unplanned and unwanted event which disrupts the work process and has the potential of resulting in injury, harm, or damage to persons or property.

An incident may disrupt the work process, but does not result in injury or damage. It should 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 does occur.

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 for injury.

Accidents Don’t Just Happen

▪ An accident is not “just one of those things”.

▪ Accidents are predictable and preventable events.

▪ They don’t have to happen.

“The Tip of the Iceberg”

Accidents or injuries are the tip of the iceberg of Accidents hazards.

Investigate incidents since

they are potential Incidents

“accidents in progress”.

 

Root Cause Analysis

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.

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

The Five Whys

▪ Basic Question - Keeping asking “What caused or allowed this condition/practice to occur?” until you get to root causes.

▪ The “five whys” is one of the simplest of the root cause analysis methods. It is a question-asking method used to explore the cause/effect relationships underlying a particular problem.

Ultimately, the goal of applying the 5 Whys method is to determine a root cause of a defect or problem.

Benefit of Asking the Five Whys

Simplicity. It is easy to use and requires no advanced mathematics or tools.

Effectiveness. It truly helps to quickly separate symptoms from causes and identify the root case of a problem.

Comprehensiveness. It aids in determining the relationships between various problem causes.

Flexibility. It works well alone and when combined with other quality improvement and trouble shooting techniques.

Engaging. By its very nature, it fosters and produces teamwork and teaming within and without the organization.

Inexpensive. It is a guided, team focused exercise. There are no additional costs.

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.

▪ Meet DOSH rule requirement that you investigate serious accidents.

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?

Investigate All Incidents and Accidents

▪Also answer:

– Is this a company or industry-recognized hazard?

– Has the company taken previous action to control this hazard?

– What are those actions?

– Is this a training issue?

Link to sample accident investigation form

How To Investigate – Main Steps

▪ Develop a plan

▪ Assemble an investigation kit

▪ Investigate all incidents and accidents immediately

▪ Collect facts

▪ Interview witnesses

▪ Write a report

How To Investigate 

Tips for Developing An Accident Investigation Plan

▪ Develop your action plan ahead of time.

▪ Your plan might include:

– Who to notify in the workplace?

– How to notify outside agencies?

– Who will conduct the internal investigation?

Tips for Developing a Plan (continued)

– What level of training is needed?

– Who receives report?

– Who decides what corrections will be taken and when?

– Who writes report and performs follow up?

What Should Be In The “Investigation Kit”

 Camera equipment First aid kit

 Tape recorder Gloves

 Tape measure Large envelopes

 High visibility tape Report forms

 Scissors Graph paper

Scotch tape

Sample containers with labels

Personal protective equipment Items specific to your worksite

Begin Investigation Immediately

▪ It’s crucial to collect evidence and interview witnesses as soon as possible because evidence will disappear and people will forget. 

How Do You Start the Investigation?

▪ 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

Actions At The Accident Scene

▪ Check for danger

▪ Help the injured

▪ Secure the scene

▪ Identify and separate witnesses

▪ Gather the facts

Fact Finding

Witnesses and physical evidence

▪ Employees/other witnesses

▪ Position of tools and equipment

▪ Equipment operation logs, charts, records

▪ Equipment identification numbers

Fact Finding

▪ Take notes on environmental conditions, air quality

▪ Take samples

▪ Note housekeeping and general working environment

▪ Note floor or working surface condition

▪ Take many pictures

▪ Draw the scene

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

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.

Write The Report

▪How and why did the accident happen?

– A list of suspected causes and human actions

– Use information gathered from sketches, photographs, physical evidence, witness statements

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

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?

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?

If additional resources are needed during the implementation of recommendations, then provide options. Having a comprehensive plan in place will allow for the success of your investigation. Success of an investigation is the implementation of viable corrections and their ongoing use.

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.

When Accidents Occur, What Is Required By L & I?

There are four specific requirements:

– WAC 296-800-320 – Accident Reporting & Investigating

– WAC 296-800-32010 – Do not move equipment

– WAC 296-800-32015 – Assign people to assist L & I investigators

– WAC 296-800-32020 – For all serious injuries, conduct a preliminary investigation

Report A Death or Hospitalization

WAC 296-800-32005

Report the death, probable death, or the in-patient hospitalization of 1 or more employees within 8 hours to Labor and Industries at 1-800-4BE-SAFE

The required information that must be provided to L&I:

1- Name of the work place

2- Location of the incident

3- Time and date of the incident

4- Number of fatalities or hospitalized employees

5- Contact person

6- Phone number

7- Brief description of the incident

Do Not Move Equipment

WAC 296-800-32010

▪ IF: A death or probable death happens or one or more employees are admitted to the hospital

▪ THEN: You must not move any equipment until L&I says you can

▪ UNLESS: You must move the equipment to remove victims or prevent further injury

Assign People to Assist L&I

WAC 296-800-32015

▪ The immediate supervisor of victim

▪ employees who witnessed the accident

▪ other employees L&I feels are necessary

Conduct a Preliminary Investigation

(Required for all serious injuries)

WAC 296-800-32020

▪ Evaluate facts relating to cause of accident by involving the following people:

– Person assigned by employer

– Immediate supervisor of injured employee

– Witnesses

– Employee representative

– Any other person who has the experience and skills

WAC 296-800-32025 – Document your findings

Link to Sample Accident Investigation form

Need further help?

DOSH Consultation Services offers…

▪ Safety & health program review and worksite evaluation

• By employer invitation only

• Free

• Confidential

• No citations

• No penalties

• Letter explains findings

• Follow-up all serious hazards

For additional assistance, you can call one of our consultants. Find local L&I office locations: