accident invsuptng

7/30/2019 Accident Invsuptng

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Accident/Incident Investigation -Supervisor Training

N.C. Department of LaborMine and Quarry Bureau


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What is the root cause?


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Responsibilities under the ACT

You are already aware of yourresponsibility as a supervisor

You understand having reason to knowYou are familiar with the levels ofnegligence


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Accident Prevention is

paramount

Company safety culture - the atmospherewithin the company that influences safe

behaviorAccomplished by shared beliefs, practices,

and attitudes from management down to

the newest hired workerA break-down of the culture leads to loss


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How is the safety culture

created?

Positive attitudes by management andemployee

Developing policy and proceduresSupervisors taking responsibility and

accountability

Safety planning and goalsProperly addressing unsafe behavior

Motivate and train employees

Employee involvement or buy-in


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Accidents do occur

Any loss costs everybody

Direct cost is only a small percentage of theactual cost of an accident medicalexpenses, workers compensation

Indirect cost can be 4 to 7 times the directcost wages of the injured, decreasedproductivity, emergency response cost,investigation cost, remediation cost toprevent recurrence, replacement cost of

property and personnel, plus others


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Leading Causes of Workplace Deaths

Motor Vehicles

32%

Struck by Moving,

Falling or Stationary

Objects

18%

Gunshot Wounds

8%

Miscellaneous

11%

Slips and Falls

8%

Heart Attacks/Strokes13%

Airplanes

5%

Caught Between

Object/Equipment

5%


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The Three Basic Causes

Poor Management Safety Policy & Decisions

Personal Factors

Environmental Factors

Unsafe Act

Unsafe

Condition

Unplanned release of energy

and/or

Hazardous material

Basic Causes

Indirect Causes

ACCIDENT

Personal Injury

Property Damage


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Minimize loss

Promote an active accident preventionprogram

Perform task analysisTrain employees in hazard recognition

Front line supervisor must understand

NEGLIGENCE


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When loss occurs

Root causes of accidents are identified throughrecognition and investigation of unsafe behaviorAs supervisors you must recognize and investigate

all unsafe acts, unsafe conditions, and correct root

causeExample An accident involving a fall from a ladder;

the broken rung on the ladder is easily recognizedas a hazard and causation of the fall, however the

root cause could be, improper maintenance, poorinspection technique, or inadequate training onrecognizing the hazardDocument the occurrence and train employees on

recognizing and preventing future occurrence


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What is The Aim of the

Investigation?

EXONERATE INDIVIDUALS ORMANAGEMENT

SATISFY INSURANCE REQUIREMENTS

DEFEND A POSITION FOR LEGAL

ARGUEMENT

OR, TO ASSIGN BLAME


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The aim of any accident/incident

investigation

THE KEY RESULT SHOULD BE TOPREVENT A RECURRENCE OF THE SAME

ACCIDENT


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THE ACCIDENT

WHAT IS AN ACCIDENT?


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THE ACCIDENT

AN UNPLANNED AND UNWELCOMED EVENTWHICH INTERRUPTS NORMAL ACTIVITY.


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THE ACCIDENT

THREE BASIC TYPES OF ACCIDENTS


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THE ACCIDENT

MINOR ACCIDENTS:

SUCH AS PAPER CUTS TO FINGERS ORDROPPING A BOX OF MATERIALS


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THE ACCIDENT

MORE SERIOUS ACCIDENTS THAT CAUSEINJURY OR DAMAGE TO EQUIPMENT OR

PROPERTY:

SUCH AS A FORKLIFT DROPPING A LOAD

OR SOMEONE FALLING OFF A LADDER


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THE ACCIDENT

ACCIDENTS THAT OCCUR OVER ANEXTENDED TIME FRAME:

SUCH AS HEARING LOSS OR AN ILLNESSRESULTING FROM EXPOSURE TO

CHEMICALS


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THE ACCIDENT

ACCIDENTS HAVE TWO THINGS INCOMMON


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THE ACCIDENT

THEY ALL HAVE OUTCOMES FROM THEACCIDENT


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THE ACCIDENT

THEY ALL HAVE CONTRIBUTORY

FACTORS THAT CAUSE THE ACCIDENT


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OUTCOMES OF

ACCIDENTS

NEGATIVE ASPECTS

DEATH & INJURY

DISEASE

DAMAGE TO EQUIPMENT & PROPERTY

LITIGATION COSTS

LOST PRODUCTIVITY


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OUTCOMES OF

ACCIDENTS

POSITIVE ASPECTS

ACCIDENT INVESTIGATION

CHANGE TO SAFETY PROGRAMS


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CONTRIBUTING FACTORS

ENVIRONMENTAL

DESIGN

SYSTEMS & PROCEDURES

HUMAN BEHAVIOR


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ENVIRONMENTAL

NOISEVAPORS, FUMES, DUST

LIGHT

HEATCRITTERS


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DESIGN

WORKPLACE LAYOUTDESIGN OF TOOLS & EQUIPMENT


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SYSTEMS & PROCEDURES

LACK OF SYSTEMS & PROCEDURESINAPPROPRIATE SYSTEMS & PROCEDURES


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HUMAN BEHAVIOR

COMMON TO ALL ACCIDENTSNOT LIMITED TO THE PERSON

INVOLVED IN THE ACCIDENT


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WHO SHOULD

INVESTIGATE

DEPENDENT ON SEVERITY OF THEACCIDENT

INVESTIGATION TEAM

INDIVIDUALS INVOLVED

SUPERVISORSAFETY SUPERVISOR

UPPER MANAGEMENT

OUTSIDE CONSULTANTS


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INVESTIGATION

STRATEGY

GATHER INFORMATION & ESTABLISHFACTS

ISOLATE ESSENTIAL CONTRIBUTORYFACTORS

DETERMINE CORRECTIVE ACTIONS

IMPLEMENT CORRECTIVE ACTIONS


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INVESTIGATION

STRATEGY

FACT GATHERING

BE IMPARTIAL & OBJECTIVECOMPILE PROCEDURES & RULES FOR THEAREA

GATHER MAINTENANCE RECORDS ONEQUIPMENT INVOLVED


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INVESTIGATION

STRATEGY

FACT GATHERING (CONTINUED)

ISOLATE ACCIDENT SCENEPHOTOS & DIAGRAMSDO NOT DISCARD OR DESTROY ANYTHING


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INVESTIGATION

STRATEGY


TIME IS OF THE ESSENCEOBTAIN INFORMATION

INJURED

WITNESSES

SUPERVISORS

OTHER PERSONNEL


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INVESTIGATION

STRATEGY


INTERVIEWS (SEPARATELY)

WHAT WERE YOU DOING?

HOW DO YOU THINK THE ACCIDENT

OCCURRED?HOW WERE YOU TRAINED FOR THE JOB?

WHAT IS THE SAFETY PROCEDURE FOR THISJOB?


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INVESTIGATION

STRATEGY


OBTAIN FACTS NOT OPINIONS

MAKE IT CLEAR THE OBJECT OF THE

INVESTIGATION IS TO AVOID RECURRENCE,NOT TO APPORTION BLAME


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INVESTIGATION

STRATEGY


INVESTIGATION TEAM

EVALUATES ALL FACTORS CONCERNED


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INVESTIGATION

STRATEGY


INVESTIGATION TEAM

ISOLATES THE KEY FACTOR(S) BY ASKING THE

FOLLOWING QUESTION....

INVESTIGATION


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INVESTIGATION

STRATEGY

WOULD THE ACCIDENT HAVE HAPPENED

IF THIS PARTICULAR FACTOR WAS NOTPRESENT?

INVESTIGATION


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INVESTIGATION

STRATEGY


INVESTIGATION TEAM

INTERPRETS & DRAWS CONCLUSION

DISTINCTION BETWEEN INTERMEDIATE &

UNDERLYING CAUSES

INVESTIGATION


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INVESTIGATION

STRATEGY


INVESTIGATION TEAM

RECOMMENDATIONS BASED ON KEYCONTRIBUTORY FACTORS AND UNDERLYING

CAUSES

INVESTIGATION


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INVESTIGATION

STRATEGY

IMPLEMENT CORRECTIVE ACTIONS

INVESTIGATION TEAM

RECOMMENDATION(S) MUST BECOMMUNICATED CLEARLY

STRICT TIME TABLE ESTABLISHED

FOLLOW UP CONDUCTED

BENEFITS OF ACCIDENT


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INVESTIGATION

PREVENTING RECURRENCE

IDENTIFYING OUT-MODED PROCEDURES

IMPROVEMENTS TO WORKENVIRONMENT



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INVESTIGATION

INCREASED PRODUCTIVITY

IMPROVEMENT OF OPERATIONAL &SAFETY PROCEDURES

RAISES SAFETY AWARENESS LEVEL



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INVESTIGATION

WHEN AN ORGANIZATION REACTSSWIFTLY AND POSTIVELY TO ACCIDENTS

AND INJURIES, ITS ACTIONS REAFFIRMITS COMMITMENT TO THE SAFETY ANDWELL-BEING OF ITS EMPLOYEES

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