Accident /Incident

Investigation

Overview
Purpose of Investigation

Managing the Accident Scene

Steps in Conducting Investigation
Investigations are conducted to:
.Prevent recurrence
.Comply with policies and regulatory
requirements
.Maintain employee awareness
ACCIDENT
An undesired event that results
in harm to people, damage to
property, or loss to process
ILO Accident Report
Accidents - 250 M/year or 685 T/day or
475/minute or 8/second
Working children - 12 M (recorded),
12,000 are fatal
Working Adults - 3,000/day = 2/min.

Types of Accident
1. Personal injury or illness
2. Property damage
3. Combination of items 1 & 2
4. Near-miss (actually an
incident)
INCIDENT
An undesired event which,
under slightly different
circumstances, could have
resulted in harm to people,
damage to property, or loss to
process
Accidents are the result of: :
Unsafe Acts
Unsafe Conditions
UNSAFE ACTS
Behaviors which could permit
the occurrence of an accident or
incident
Deviation from standard
procedures or practices
UNSAFE CONDITIONS
Circumstances which could
permit the occurrence of an
accident or incident
Deviation from
standard conditions
(equipment, materials,
or environment)
Unless the unsafe acts/conditions are:

Prevention is the reason for
conducting an Accident
Investigation

4 Identified and
4 Eliminated or controlled
similar mishaps will occur
+ LTI
+ Non-LTI
+ Near Miss
+ Chemical Spill
+ Property Damage
+ Fire and Explosion
All accidents must be
investigated:

Accident Investigations are
usually considered a
Supervisors responsibility
7 More familiar with the people
involved
7 Better understanding of the
operations
7 Personal interest in investigations
Advantages of Supervisors
over other investigators:
Team Effort
All employees should
understand :
C What to report
C How to report
+ LTI
+ Non-LTI
+ Near Misses
+ Property Damage
+ Chemical Spill
+ Fire or Explosion
What to Report

Medical
Safety
Environmental Control
Management
Whom to Report to:
Managing the Accident Scene
Two Priorities:
e Care & treatment of the injured
e Elimination or control of
remaining hazards

Training in First Aid
Drills under normal and abnormal
conditions
Liaison with hospitals
Care & Treatment of Injured
Supervisors can increase their
ability to respond to Medical
Emergencies by:
+ Notify necessary personnel
+ Provide PPE to potentially
exposed
+ Refer to MSDS
Controlling Remaining Hazards
If a hazardous environment or toxic
materials exist:

Isolate the site
q To protect people from further
injury
q To preserve evidence and
valuable clues
Successful investigation is
done ...
7 Immediately
7 Completely
7 Thoroughly


Investigate immediately,
because:
Operations are disrupted
Memories fade
Employees are at risk
Conducting the Investigation
O Gather information
O Analyze the facts
O Make recommendations

ACCIDENT INVESTIGATION
Guidelines:
1. Investigate immediately
2. Ensure immediate treatment
3. Secure the area
4. Record details of event (photo, sketch, etc.)
5. Collect physical evidence
6. Review other sources (victims record, friends, etc.)
7. Interview witnesses (5Ws + 1H)
8. Write causal factors (man, machine, material, method)
9. Make recommendations (effective/reliable results)
Gathering Information

4 NOI, POI, DOI, TOI
4 personnel involved
4 property damage
4 environmental harm
Preliminary Facts:
Accident Investigation
Equipment
Report form
Notebook or pad of
paper
Tape recorder
Camera (instant or
digital)
Measuring equipment
E Witnesses
E Physical evidence at the
scene
E Existing records
Victim and onlookers
Those who heard what happened
Saw area prior to incident
Others with info about involved
individuals, equipment or
circumstances
Witnesses
Interviewing Witnesses
1. Reassure the witness
2. Let the witness tell the story
3. Begin with open-ended questions
4. Dont ask leading questions
Interviewing Witnesses
5. Summarize
6. Ask for recommendations
7. Get written statements
8. Close on a positive note
ACCIDENT INVESTIGATION
Questions for reporting: WHO
- was injured?
- saw the accident?
- was working with the injured?
- had instructed/assigned the job to the injured?
- else was involved?
- has the information of events prior to the accidents?
ACCIDENT INVESTIGATION
Questions for reporting: WHAT
- is the injury?
- is the damage or loss?
- was the injured doing?
- had the injured been
instructed to do?
- tools/equipment/machinery
were being used?
- did the injured & any
witnesses saw?
- training had been given?
- were the contributory causes
of the accident?
- communication system was
used?
- is the state of health of the
injured?
- safety rules were violated?
- safety system and procedures
were there?
ACCIDENT INVESTIGATION
Questions for reporting: WHEN
- did the accident occur?
- did the damage become evident?
- did the injured start the job?
- was the explanation of hazard given?
- did the supervisor last see the injured?
- did the persons involved last have food & rest?
ACCIDENT INVESTIGATION
Questions for reporting: WHY
- did the injury occur?
- did the communication fail?
- was the training not given?
- were the unsafe condition
permitted?
- was the hazard not spotted at
previous inspection?
- was PPE not provided?
- was PPE not used?
- was there no safe system of
work?
- was there no safety
instruction given?
- was the supervisor not
consulted when things
started go wrong?
- was the supervisor not there
at the time?
ACCIDENT INVESTIGATION
Questions for reporting: WHERE
- did the accident occur?
- did the damage occur?
- was the supervisor at that time?
- was the witnesses at that time?
ACCIDENT INVESTIGATION
Questions for reporting: HOW
- did the injury occur?
- could the accident have been avoided?
- could have been the injury avoided?
- could the supervisor have prevented the
accident?
- could better design help?
Physical Evidence
Provides information about an
accident that witnesses may
overlook or take for granted
Sketches
To record important details at the
accident site for later study
Electrocution
victim
Comfort
Room


E Floor plan from overhead view
E Location of involved man,
machine, tool
E Size and location of transient
evidences (spills, dust,
footprints, skid marks)

Include everything that
could be important:
AHU
X
X
Photographs
6 detail
6 color differences
6 complex shapes
difficult to recall
Photographs
General area
Detailed shots
Show scale on small objects
Indicate reference point
Better to take too many than
too few
Materials
Tools
Machines
EXAMINING
Examining Physical Evidence
4 Physical condition
4 Position of switches/levers
4 Reading of gauges
4 Safeguards
4 Warning devices
Machines & Tools
6 Misuse
6 Abuse
6 Disuse
6 Improper handling
6 Damage
Material
Position and condition can indicate
If chemicals are involved:
correct item used
correct concentration
expired
contaminated
MSDS availability
Material - Chemical
Log and label
Secure storage & transport
Avoid contamination
Guard against tampering and loss
Appropriate HSE warnings
If items have to be
removed from the scene
for detailed examination:
Environment (Work)
p Weather condition
p Illumination
p Noise
p Housekeeping

Existing Records
+ Employee records
+ Equipment records
+ Job or Task records
+ Previous Accident Investigation
reports
Workshop I - Gathering of Facts
I. Actual Accident or Simulated Accident
- Nature of Accident
- Parties involved/responsible person(s)
- Place of Accident
- Time and Date of Accident

II. Interview witnesses/victims
- 5Ws and 1 H develop at least 20 questions

III. Collected evidences, photographs, records review
15 minutes

IV. Presentation: Dramatization
10 minutes
Analyzing the Facts
Cause Analysis (root)
Change analysis
UNAWARE
UNABLE
UNMOTIVATED
HAZARDOUS
ACTS
UNNOTICED
UNCORRECTED
HAZARDOUS
CONDITIONS
ACCIDENT / ILLNESS
Immediate and Basic Causes
Look beyond the direct causes of
the accident

Find out what can be done to
eliminate the underlying reason for
the hazardous behaviors and
conditions that led to the mishap
Direct
Causes
Basic
(root)Causes
Direct Causes

caught in, between, or under
struck against or struck by
fall from or fall on
overexertion or stress

Basic (Root) Causes
inadequate maintenance of equipment
inadequate codes and standards
insufficient employee safety training
safe work practices inadequately followed
faulty design of work area
supervisors not performing duties
Change Analysis
Compares how a job was
actually performed with the way
it should have been performed
Change Analysis
ACTUAL
BEHAVIORS or
CONDITIONS
STANDARD
BEHAVIORS or
CONDITIONS
SAFE
BEHAVIORS or
CONDITIONS
ACTUAL
BEHAVIORS or
CONDITIONS
STANDARD
BEHAVIORS or
CONDITIONS
UNSAFE
BEHAVIORS or
CONDITIONS
Recommending Corrective
Actions
Specific
Measurable
Attainable
Realistic
Time-bound
Follow-up
Its the best way to ensure that
recommendations are carried
out
_ General information
_ A Summary
_ An Analysis
_ Recommendations
Report forms require four
basic types of information
Reports should be
Clear
Detailed
Neat
Legible
Management Approach
[ Training
[ Inspections
[ Hazard analysis
[ Safety Meetings
Not just for incidents
involving serious injury, its
for ANY occurrence that has
the POTENTIAL of causing
harm
Accident Investigation...
Review
Purpose of Investigation

Managing the Accident Scene

Steps in Conducting Investigation
ACCIDENT INVESTIGATION
(General Process Flow)
Secure
the area
Document
the facts:
hard
evidence,
witness
Ensure
immediate
medical
treatment
Gather
facts
about the
accident:
witnesses
Identify
the root
cause
(causal
factors)
Corrective
action
Follow-
up