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ACCIDENT /INCIDENT

INVESTIGATION AND
REPORTING

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)

Prevention is the reason for


conducting an Accident
Investigation
Unless the unsafe acts/conditions are:

Identified and
Eliminated or
controlled

similar mishaps will occur

Accident Investigations are


usually considered a
Supervisors responsibility

Advantages of Supervisors
over other investigators:

More familiar with the people involved


Better understanding of the operations
Personal interest in investigations

Team Effort
All employees should understand :

What to report
How to report

What to Report:

LTI
Non-LTI
Near Misses
Property Damage
Chemical Spill
Fire or Explosion

Whom to Report to:

Medical
Safety
Environmental Control
Management

Managing the Accident Scene


Two Priorities:

Care & treatment of the injured

Elimination or control of
remaining hazards

Care & Treatment of Injured


Supervisors can increase their
ability to respond to Medical
Emergencies by:

Training in First Aid


Drills under normal and abnormal
conditions
Liaison with hospitals

Controlling Remaining
Hazards
If a hazardous environment or
toxic materials exist:

Notify necessary personnel


Provide PPE to potentially
exposed
Refer to MSDS

Isolate the site

To protect people from further


injury
To preserve evidence and
valuable clues

Successful investigation is
done ...
Immediately
Completely
Thoroughly

Investigate immediately,
because:

Operations are disrupted


Memories fade
Employees are at risk

Conducting the Investigation

Gather information
Analyze the facts
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
Preliminary Facts:
personnel involved
property damage
environmental harm

Accident Investigation
Equipment

Report form
Notebook or pad of paper
Tape recorder
Camera (instant or digital)
Measuring equipment

Sources of Information

Witnesses
Physical evidence at the
scene
Existing records

Witnesses

Victim and onlookers


Those who heard what happened
Saw area prior to incident

Interviewing
Witnesses:
1.
2.
3.
4.

Reassure the witness


Let the witness tell the story
Begin with open-ended questions
Dont ask leading questions

Interviewing Witnesses

5.
6.
7.
8.

Summarize
Ask for recommendations
Get written statements
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?

ACCIDENT INVESTIGATION
Questions for reporting: WHAT
- is the injury?

- training had been given?

- is the damage or loss?

- is the state of health of the


injured?

- was the injured doing?


- had the injured been
instructed to do?
- tools/equipment/machinery
were being used?
-

- safety rules were violated?


- safety system and procedures
were there?

ACCIDENT INVESTIGATION
Questions for reporting: WHEN
- did the accident occur?
- 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?

- was PPE not used?

- did the communication fail?

- was there no safety


instruction given?

- was the training not given?


- was PPE not provided?

- 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?

Sketches

To record important details at the


accident site for later study

Comfort Room

Electrocution
victim

Include everything that could


be important:

Floor plan from overhead view


Location of involved man,
machine, tool
Size and location of transient
evidences (spills, dust, footprints,
skid marks)

AHU

Photographs

detail
color differences
complex shapes
difficult to recall

Photographs
General area
Detailed shots
Show scale on small objects
Better to take too many than
too few

Examining Physical Evidence

Machines

EXAMINING

Tools

Materials

Machines & Tools

Physical condition
Position of switches/levers
Reading of gauges
Safeguards
Warning devices

Material

Position and condition can indicat

Misuse
Abuse
Disuse
Improper handling
Damage

Material - Chemical
If chemicals are involved:
correct item used
correct concentration
expired
contaminated
MSDS availability
(Materials Safety Data Sheet)

If items have to be
removed from the scene
for detailed examination:

Log and label


Secure storage & transport
Avoid contamination
Guard against tampering and loss
Appropriate warnings

Existing Records

Employee records
Equipment records
Job or Task records
Previous Accident Investigation
reports

Analyzing the Facts

Cause Analysis (root)


Change analysis

Immediate and Basic


Causes
A C C ID E N T / IL L N E S S

H A ZA R D O U S
A C TS

H A ZA R D O U S
C O N D IT IO N S

U N A W A R E
U N A B LE
U N M O T IV A T E D

U N N O T IC E D
U N C O R R E C TE D

Direct
Causes

Basic
(root)Cause
s

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

Recommending Corrective
Actions

Specific
Measurable
Attainable
Realistic
Time-bound

Report forms require four


basic types of information

General information
A Summary
An Analysis
Recommendations

Reports should be

Clear
Detailed
Neat
Legible

Management Approach

Training
Inspections
Hazard analysis
Safety Meetings

Accident Investigation...

Not just for incidents involving


serious injury, its for ANY
occurrence
that
has
the
POTENTIAL of causing harm

ACCIDENT INVESTIGATION
(General Process Flow)
Ensure
immediate
medical
treatment

Followup

Corrective
action

Secure
the area

Identify
the root
cause
(causal
factors)

Gather
facts
about the
accident:
witnesses

Document
the facts:
hard
evidence,
witness

Quote of the
day:

It is better to be careful
100 times than to get
killed once
Mark Twain

The End
Thank You and
Good Morning

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