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AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

DEFINITIONS A INCIDENT An undesired and unplanned event or chain of event, which under slightly different circumstances, could resulted in harm (injury or illness) to people, damage (loss) to property (assets) or loss to process. Eg ; near miss, accident, fire, spillage etc

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

DEFINITIONS B ACCIDENT An undesired event that results in harm to people, damage to property or loss to process. Usually as a results of contact with a substances or a source of energy above the threshold limit of the body or structure

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

DEFINITIONS C NEAR MISS An event which did not result in injuries or illness to people and/or damage (loss) to assets and the environment.

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

PICTURES

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

PURPOSE OF INCIDENT INVESTIGATION Law (OSHA 1994) and Company requirements. Prevent recurrence Essential element in OSH Management Contribute to good morale and overall OSH awareness.

Geared towards continuous OSH improvement thus increased productivity and improved work environment.

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

REQUIREMENT UNDER OSHA 1994 Occupational Safety & Health (Safety & Health Officer) Regulation 1997

Part IV, Duties of an employer

An employer shall direct one supervisor or who has direct control on person or activity of the place of work to assist the safety & health officer in any investigation of accident, near-miss accident, dangerous occurrence, occupational poisoning or occupational diseases.

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

REQUIREMENT UNDER OSHA 1994

Occupational Safety & Health (Safety & Health Committee) Regulation 1996 ; Section 31 (b) Function of SHC Shall investigate any matter at the place of work :(i) Which a member of the committee or a person employed thereat consider is not safe or is a risk to health; (ii) Which has been brought to the attention of the employer

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

REQUIREMENT UNDER OSHA 1994

Occupational Safety & Health Committee) Regulation 1996 Part III, Function of SHC Section 13. (1) A safety and health committee shall inspect the place of work, as soon as it is safe to do so, after any accident, near-miss accident, dangerous occurrence, occupational poisoning or occupational disease has occurred at the place of work. (Safety & Health

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

INVESTIGATION INTO ANY ACCIDENT

According to SHC Regulation :

To inspect the place of work as soon as it is safe to do so

SHO shall furnish the chairman of committee with a report of his findings.

Chairman shall as soon as possible (ASAP) convene a meeting of the committee to discuss the report.
If no SHO, employer or authorised manager shall inform the chairman or the secretary.

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

ACCIDENT THE CONSEQUENCES (LOSSES)

Immediate
Death Injury

Short Term
Medical Treatment Repairs

Long Term
Suffering Disability

Pain
Disease

Replacement
Lost Production

Lost Income
Insurance

Damage
Loss Fear

Increased Cost
Discipline Low Morale

Compensation
Mistrust Profitability

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

OUTCOMES OF ACCIDENTS

Negative results death injuries damage to equipment Positives results changes to safety procedure rehabilitation

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

ACCIDENT INVESTIGATION

A methodological effort to collect and interpret the facts

of the accident

An inquiry as to how and why the accident occurred in

order to explore actions that should be taken to prevent or minimise recurrence of the accident.

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

AIM OF ACCIDENT INVESTIGATION

To find the root cause and to prevent recurrence. Not to apportion or assign blame, satisfy insurance claims
or defend against liabilities.

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

ACCIDENT COST ICEBERG

INJURY & ILLNESS COSTS
LEDGER COST OF PROPERTY DAMAGE (UNINSURED COSTS)

RM 1

RM 5-50

RM 1-3

UNINSURED MISCELLANEOUS COST

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

HIDDEN UNINSURED COST Product & material damage Plant & building damage Tool and equipment damage Legal costs Expenditure on emergency supplies Clearing site Production delays Overtime working

Temporary labour
Investigation time Supervisors time diverted Clerical Effort Loss of expertise / experience

Fines

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

INVESTIGATING AN ACCIDENT Chairman/secretary shall as soon as possible after the committee has inspected the place of work convene a meeting to investigate into such incident. In the meeting, the committee shall discuss the cause of accident. And make recommendations to the employer to prevent the reoccurrence of such incident.

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

INVESTIGATING AN ACCIDENT SHO or Chairman ( if no SHO ) shall furnish the employer or his authorised manager on the recommendations. Employer or authorised manager shall ASAP discuss the report or recommendations with SHO or Chairman. SHO or Chairman shall record the decision of the employer or his authorised manager.

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

INVESTIGATING AN ACCIDENT Employer or authorised manager shall direct any person employed to take such action. Employer shall keep a copy of the report for a minimum period of SEVEN years.

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

AN ACCIDENT INVESTIGATION
ACCIDENT OCCURED INITIAL INSPECTION INFORM CHAIRMAN URGENT MEETING DISCUSS THE FINDINGS COMMITTEE INSPECTION MAKE RECOMMENDATION INFORM EMPLOYER EMPLOYER DISCUSS WITH SHO/CHAIRMAN RECORD THE DECISION EMPLOYER TO TAKE ACTION

KEEP RECORD FOR SEVEN YEARS

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

WHO SHOULD BE INVOLVED IN ACCIDENT INVESTIGATION?

Witnesses

Supervisor
Manager Safety Specialists and Safety & Health Officer (SHO) Safety Representatives

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

STAGES OF INVESTIGATIONS Managing the accident scene Gather information Isolate the essential contributory factors

Determine corrective actions

Carry out corrective actions.

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

MANAGING THE ACCIDENT SCENE Treat the injured

Control remaining hazards

Isolate the site to protect people

Preserve the evidence.

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

SOURCES OF EVIDENCE People evidence Position evidence Parts evidence Paper evidence.

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

CONDUCTING AN ACCIDENT INVESTIGATIONS Must answer the following questions : WHO was injured?

WHAT happened?
WHERE did accident occur? WHEN did the accident occur? WHY did the accident occur? HOW can similar accident be prevented?

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

FINDING THE WITNESS Essential for individual to arrive at the scene PROMPTLY. Question supervisor to identify employees present at the accident. Workers in adjacent areas may have information, sight, sound, weather condition, lightings, noise and other factors related to accident.

Limit contact between witness.

Assure the witness will have opportunity to tell the whole story. the

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

THE INTERVIEW PROCESS In Private Get written statement

Reassure the witness

Let the witness tell the story Begin with open-ended question

Dont ask leading question

Summarize Ask for recommendation Close on a positive note.

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

ACCIDENT CAUSATION MODEL

HEINRICH 1930s

ANCESTRY / SOCIAL ENVIRONMENT

FAULT OF A PERSON

UNSAFE ACTS AND CONDITION

ACCIDENT

INJURY

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

ACCIDENT CAUSATION MODEL

LACK OF CONTROL
INADEQUATE PROGRAM PROGRAM STANDARD COMPLIANCE TO STANDARD

BASIC CAUSES
PERSONAL FACTOR

IMMEDIATE CAUSES

INCIDENT

LOSS

JOB FACTOR

SUBSTANDARD ACTS AND CONDITIONS

CONTACT WITH ENERGY OR SUBSTANCE

PEOPLE PROPERT Y PROCESS

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

DOMINOES THEORY

IMMEDIATE CAUSES

LACK OF CONTROL

BASIC CAUSES

INCIDENT

LOSS

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

DOMINOES THEORY

IMMEDIATE CAUSES

BASIC CAUSES

INCIDENT

LOSS

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

DOMINOES THEORY

AC C I D E NT IN V E STI GATI ON & R E PO RTI N G

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