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Representatives
Guide to Accident
Investigation
By
Jim Howe
Assistant Director
UAW Health and Safety Department
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INTRODUCTION
Acknowledgments
Most of the material in this manual is the result of personal experiences
investigating serious injuries and fatalities. Unfortunately most of this
experience was possible because of tragic events, most of which were completely
avoidable, which resulted in life long disability and or death for the victims. I owe
a great deal to the other accident investigators that I have had the opportunity to
work with.
Ludwig Benner, one of the most notable experts in the field of accident
investigation, has provided many important ideas and suggestions in this effort.
Introduction
***
Definition of Accident
***
Accident Investigation
Systems
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Introduction
The job of investigating accidents has typically been delegated to supervisors and other
management personnel that have little formal training if any. The result is incomplete
accident reports filled with inaccurate information. Hazardous remain, making future
injuries and illnesses a certainty.
To break this cycle and prevent workers from becoming sick and injured on the job,
union representatives will have to learn and practice the techniques of effective accident
investigation. In doing so, underlying causes of past injuries and illness can be
understood and corrected; preventing future tragedies from taking place.
Once an accident has occurred, for the victim(s), it's too late. As much as we regret the
incident and feel sorry for the victim(s) and their families nothing can be done that will
change what happened. It is a sad reality. The only way to give meaning and make
something positive from the tragedy is to investigate the incident, identify causes and
implement recommendations to prevent future suffering.
The term "accident" can be misleading. It is sometimes used to describe a tragic event
that could not be anticipated, that was the result of chance. Almost all industrial
"accidents" do not fall into this category. Almost every industrial "accident" has a
cause(s) and is predictable, avoidable and preventable.
When an accident occurs at a plant the individual(s) injured are not the only victim. Coworkers, first responders and many others are psychologically injured, some for a short
period of time and others for life. The Critical Incident Response program advocated in
this manual provides assistance to these victims.
This manual is intended to provide the user with a practical step by step approach to
accident investigation. It begins with planning and preparation and ends with report
development, writing recommendations and implementation.
Preparation
Initial Notification
On-site Investigation
Development of a Report
Implementation and Follow-up
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Preparation
Preparation
1.
2.
Notification System
3.
4.
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The planning and preparation process must include the establishment of training
and communication, a notification system, identification of critical incident
response resources and the procurement of the necessary materials and
equipment.
1)
Ludwig Benner
2) Notification System
A communication system must be developed to insure the prompt
notification of appropriate union and management personnel in the event of
an accident. Often unions have found that it is helpful to negotiate contract
language that requires management to notify union representative(s) when
a serious accident occurs. The union and management should agree on the
criteria for a serious accident so that the language can be properly
9
During the course of the accident investigation, a Critical Incident Response Form
should be completed listing each individual that was involved/affected by the incident
and a short description of the nature of their involvement.
In some companies it has been a common practice to allow those involved in the
incident to leave the plant and go home. This is often not the best course of action
because it hampers the accident investigation process and is psychologically dangerous
to allow an employee that has been emotionally injured to leave the plant without the
assurance that proper emotional support systems are in place. Some of these
individuals may even feel that something that they did or did not do contributed to the
incident. In the vast majority of cases, it is best to keep those involved in the incident in
the plant, in a comfortable environment, separated from others that were involved,
available to investigators and offered/provided critical incident counseling.
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JOB TITLE
SHIFT
INVOLVEMENT IN INCIDENT
1)
Bill Evans
Press Operator
2)
Tom Rolland
Inspector
3)
Ann Jones
Press Operator
4)
Kathy Oliver
Nurse
5)
Ron Spalding
Supervisor
DEBRIEF
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
6)
YES
NO
7)
YES
NO
8)
YES
NO
9)
YES
NO
10)
YES
NO
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Date
Incident
The Health and Safety Investigation Team should complete the name, job title, shift and involvement in Incident columns.
NAME
JOB TITLE
SHIFT
INVOLVEMENT IN INCIDENT
DEBRIEF
1)
YES
NO
2)
YES
NO
3)
YES
NO
4)
YES
NO
5)
YES
NO
6)
YES
NO
7)
YES
NO
8)
YES
NO
9)
YES
NO
10)
YES
NO
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11)
YES
NO
12)
YES
NO
13)
YES
NO
14)
YES
NO
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4)
Materials Needed
1. Photographic Equipment
2. Forms and Checklists
3. Personal Protective Equipment
4. Miscellaneous Supplies
5.
6.
7.
8.
9.
(add additional items)
Photographic Equipment
1. 35mm or Digital Camera
2. External Flash Unit (mandatory)
3. Tripod
4. Battery charger
5. Extra film, batteries, memory cards
6. Video Camera
7. Extra batteries, tape
8. Power supply
9.
10.
11.
(add additional items)
Forms, Checklists and Documents
1. Investigation form
2. Interview form
3. Document checklist
4. Phone listing
5. Photo log
6. Critical incident form
7. Relevant standards and regulations
8. Graph paper for sketches
9. Post-It pads
10.
11.
12.
(add additional items)
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15
Initial Steps of an
Investigation
When a serious incident occurs, focus on the following three tasks in
this order.
1. Provide Medical Treatment for Victim(s)
2. Notification of family members if appropriate
3. Secure and preserve the accident site
After the above tasks have been completed investigators can begin the
investigation.
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Family Support
1. Initial communication
2. Support at the hospital
3. Assistance with travel and housing for out-of-town
family members
4. Counseling assistance
5. Medical treatment support
6. One union representative and one management
representative available to the family 24 hours a day
7. Arrange for family members to visit the accident site
when requested. This should be done when the plant
is not operating.
8. On-going support and benefit assistance
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Mentally Preparing
for an Accident
Investigation
Before you arrive at the accident site, think about the accident investigation process.
You may want to review this manual. It is important to remember that as a trained
accident investigator you have the ability to:
1)
transform the chaos of the investigation to an orderly effective
investigation
2)
keep an open mind, control your biases and not jump to conclusions.
3)
recognize that the first step is to document;
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19
On Site
Investigation
On Site Investigation
conduct interviews
photograph/video scene
collect documents
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On Site Investigation
photograph/video scene
collect documents
conduct interviews
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21
2)
corrective action can be taken a this facility and at other facilities within the
company.
2)
3)
Explain that the investigation will be most effective and efficient if it is conducted
jointly.
4)
Review the four laws of accident investigation and the mental movie concept.
b)
Do not ask witnesses or those involved to write out and sign a statement. This method of
collecting information is ineffective and inadequate because many people will be inhibited
by having to write a statement because they; have poor handwriting, spelling or grammar.
5)
During the investigation process complete the Critical Incident Response Form.
(see attached) Provide a copy of the competed form to the Critical Incident
Response Team or the local EAP (Employee Assistance Program) Committee.
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25
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Received
________
________
1)
Photographs
________
________
2)
Witness Statements
________
________
3)
________
________
4)
________
________
5)
________
________
6)
Maintenance records
________
________
7)
________
________
8)
________
________
9)
________
________
10)
________
________
11)
________
________
12)
________
________
13)
Death Certificate
________
________
14)
________
________
15)
Autopsy Results
________
________
16)
Contractor Contracts
________
________
17)
________
________
18)
________
________
19)
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Mental
Movie
Concept
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Interview
*
*
*
*
*
*
*
*
*
*
*
Victim(s)
Co-workers
Supervisors
Workers that perform similar jobs in other
departments or on different shifts
Engineers
Maintenance Personnel
Witnesses
Emergency Personnel
Medical Personnel
Equipment Suppliers
Coroner
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Interview Reminders
1. Prioritize interviews based upon importance of information, emotional
condition and availability.
2. Select a comfortable, private, non-threatening place
3. Explain who you are and what you are doing
4. Explain that you need his/her help to understand, as accurately as possible,
what happened
5. Ask for help
6. Be sensitive to the emotional state of the individual
7. Ask the individual to tell you what he/she saw, heard or did - start at the
beginning
8. The most important question "and then what happened?"
9. Remember the mental movie
10. When possible "walk through" the actions of the individual (people recall
things best in order of occurrence)
11. Take your time
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DO NOT
1.
2.
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INTERVIEW FORM
Interviewee:
Accident:
Accident Location:
Interviewed by:
_______________________________________ on _____/_____/_____
Direction: Write out a description of what the interviewee saw, hear, or did. Ask the
interviewee to describe the accident setting and what they saw, heard, or did, or
what they observed other people or things doing during the incident. The objective
is to transfer the mental movie of the incident as seen through the eyes of the
interviewee in chronological order. You should ask questions to fill in the missing
frames of the mental movie.
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LEGAL
ISSUES
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2.
Begin the video tape with a wide outside shot of the plant complex, including the
plant sign. Next, shoot a wide shot of the area where the accident occurred.
3.
Using the widest angle adjustment on the zoom lens, video tape the operation from
the place where the victim was located immediately prior to the accident.
4.
5.
6.
Remember, when in doubt about taping a certain scene - tape it. Sometimes,
elements that may not seem relevant at the time, prove to be significant later. It is
better to have extra video tape than not enough.
7.
Video tape the route or movements that the victim followed prior to the accident.
Video tape scenes the victim would have seen (such as the view from a fork lift
driver).
8.
Often, it is useful to include rulers and tape measures laid out in the scene, so that
later precise measurements can be determined.
9.
Take shots from above the accident scene whenever possible to get a broad view of
the accident scene.
10.
Video tape similar operations to the one that the victim was performing when the
accident occurred.
Audio Track
1.
There should be no audio track editorializing or describing potential causes for the
accident.
39
2.
The audio track should include descriptions of the angle of the shot, machine
number, date, time, location, name of a part or operation, things moved or changed
since the accident occurred, direction of the shot (i.e. "facing North"), etc.
Whenever possible, use a tripod and additional lighting on the camera to improve
video quality.
2.
Most of the time it is probably better not to use the auto focus feature on the
camera. Instead, use the manual focus feature.
3.
When you are planning the video taping, think about explaining what you have found
and the circumstances that took place, then shoot the scenes accordingly. In other
words, tell a story with the video tape.
4.
5.
The purpose of the video tape is to gather visual information to be used during the
investigation.
Photographs
1.
2.
Create a log of all photographs taken listing the shot number, roll number,
description of shot, who took it, date, etc.
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Date ______________________________
Name of
Victim(s)____________________________________________________
Plant Name ________________________________ Local Union #_______
1.
_______________________________________________________
2.
_______________________________________________________
3.
_______________________________________________________
4.
_______________________________________________________
5.
_______________________________________________________
6.
_______________________________________________________
7.
_______________________________________________________
8.
_______________________________________________________
9.
_______________________________________________________
10.
_______________________________________________________
11.
_______________________________________________________
12.
_______________________________________________________
13.
_______________________________________________________
14.
_______________________________________________________
15.
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Developing a
Report
42
Recommendations
1. Specific Situation
2. Similar Situations, Conditions, Equipment
3. Management System Deficiencies
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1) Elimination or Substitution
2) Engineering Controls
3) Warnings
4) Training and Procedures
Administrative Controls
Least Effective
HS ID # 166C:\FILES\HIERARCH\HIERCHT.DOC
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ventilation systems
machine guarding
sound enclosures
circuit breakers
platforms and guard railing
interlocks
lift tables, conveyors, balancers
computer warnings
odor in natural gas
signs
backup alarms
beepers
horns
labels
safe job procedures
rotation of workers
safety equipment inspections
Hazard Communication Training
Lockout
Confined Space Entry
safety glasses
ear plugs
face shields
safety harnesses and lanyards
back belts
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IMPLEMENTATION
AND
FOLLOW UP
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Accident Investigation
BIBLIOGRAPHY
Benner, Ludwig, and Kingsley Hendrick. Investigating Accidents With STEP, Marcel Dekker1
Inc., New York and Basel, 1987.
Ferry, Ted S. Modern Accident Investigation and Analysls - Second Edition, John Wiley and
Sons, Inc., New York, 1988.
Kuhlman, Raymond. Professional Accident Investigation, Institute Press, Loganville,
1977.
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Who questions
1)
Who was injured
2)
Who saw the mishap?
3)
Who first responded?
4)
Who talked with the victim?
5)
Who has done the same job before?
6)
Who has trained the victim?
7)
Who supervised the victim?
8)
Who told the victim to do this work
9)
Who maintained this equipment
10)
Who inspected this equipment
11)
Who modified this equipment?
12)
Who installed this equipment?
b.
What questions
1)
What did the victim do prior to the accident?
2)
What was the victim doing at the time of the accident?
3)
What equipment was involved (serial number, model number, company
number, manufacturer's name)?
4)
What is the normal process?
5)
What was different this time?
6)
What were the instruction
7)
What was the training?
c.
Where questions
1)
Where was the victim at the time of the accident?
2)
Where was the equipment?
3)
Where was the witness?
4)
Where was the first aid/emergency equipment?
5)
Where was the supervisor?
d.
When questions
1)
What time did the accident take place? Was it at the end of the shift
2)
Was it at the end of the week?
3)
How long had the victim been working that day? That week?
e.
How questions
1)
How does the equipment normally operate?
2)
How did the equipment operate on this day?
3)
How does the victim normally perform this job?
4)
How did the victim perform this job this day?
5)
How did the mishap occur?
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