accident investigation what is an accident? what is an accident? o any unexpected event o some may...

Accident Investigation

WHAT IS AN ACCIDENT?

• What is an accident?o Any unexpected evento Some may even be good

• Does an accident always involve an injury?

• Does an injury always involve an accident?

What Is An Accident?

Accidents

• Accidento Any unplanned event that results in

Personal injury Property damage

Accidents

• Usual causeso Failure of people, equipment, supplies, or

surroundings to behave or react as expected

WHY INVESTIGATE?

• Why investigate?o To PREVENT injuries

• Investigations should not be witch huntso If results show need for discipline, fine But.....o That is not the purpose

INVESTIGATIONS

• Include non injury accidents incidentso Proactiveo Preventative

• Investigating only injurieso Reactive

INJURY PYRAMID

Non-injury Accidents

1st Aid Cases

Recordable

Serious Recordable

Fatality

Incident Investigation Plan

• Establish parameters• Be aware of other requirements

o ADA, EEO, Union, etc.• Establish procedures• Develop forms• Train employees

First Report

The “First Report of Injury” sent to Workers’

Compensation Company is NEITHER an accident report

NOR an investigation.

Incident Report

• Write an incident reporto As soon as possible

• Start with a supervisor’s report based on information provided by employeeso “Employee said......”

Injury Potential

• Investigate based on POTENTIAL FOR INJURY

• The greater the potential, the more thorough the investigation

The Investigation

Avoid a “cold trail”

The Investigation

• Be methodical• Gather as much information as

possibleo Throw out irrelevant information during the

analysis step

The Investigation

• Beware of preconceived conclusions• Beware of “jumping the gun”

o Do not offer solutions before you find the basic cause

The Investigation

• ASK QUESTIONS• When you get an answer, ask “WHY”• Then ask “WHY” again• And AGAIN• And “who?”, “what?”, and ...”why?”

Basic Causes

Management Safety Policies & Decisions Personal Factors Environmental Factors

Indirect Causes Unsafe Act Unsafe Condition

Direct Causes Unplanned Release of Energy

and/or Hazardous Material

Incident

The Investigation

• Investigate the sceneo Take measurementso Take pictureso Evaluate equipmento Be imaginative

The Investigation

• Look foro Guards offo Lack of PPEo Housekeeping issueso Poor work practiceso Faulty equipmento Inadequate trainingo Poorly written procedureso Etc.

The 4 “Ps”

• People • Position• Parts• Paper

Interviews

• Interview employee involved• Interview witnesses• Interview other employees in area• Look for similar incidents

Interviews• Explain the purpose of the investigation

o Accident prevention• Put at ease• Let speak freely• Take notes without distracting • Only use a tape recorder with the

person’s knowledge and consent.• Interview as soon as possible

Analysis Techniques

• Change analysis• Job Safety Analysis (JSA)• Event and Causal Factors Analysis• Multi linear Events Sequencing (MES)• Project Evaluation Tree (PET)• Combination

Report of Investigation

• 1. Background information

• 2. Detailed account of the incident

• 3. Resolution• 4. Corrective actions

RESOLUTION

• Discuss ways of preventing future incidents

• Solicit ideas from employees & others• Be creative• Make recommendations

Corrective Actions

• Corrective actions o Recommendations that are adopted

• Inform and train employees and supervisors

Follow-Up

• Involve supervisors & employees• Are solutions:

o Used?o Effective?

• Solicit feedback

Trend Analysis

• Evaluate for incident, accident and injury trends in order to focus efforts

• Use 300 forms, incident & accident reports, first aid logs, inspection reports, etc.

• Analyze by entity, facility, time, job, etc.

• Do at least a 3 year comparison

Resource

• Ask for help from your workers’ compensation carrier

Sandra A. Mihalik, WSO-CSTSafety & Health Specialist

Montana Safety & Health BureauPhone: 406.444.6418

E-mail: smihalik@mt.gov