PestSure Loss Control Training Series

Fall 2005

Accident Investigation:Getting to the Root of the Matter

Outline

I. Fundamentals of Accident Investigation

II. Case Study: “Routine Duties”

III. Getting Started in Your Location

I. Fundamentals of Accident Investigation

Accident Investigation is ‘More’

• More than an assigned ‘safety activity’• More than proper documentation• More than a way to ‘cover’ yourself• More than just a training tool• More than some college theory• More than simply the ‘right thing to do’

Accident Investigation is a way for you to control your own destiny

Key Elements of aSafety Management System

• Management Commitment• Written Policies and Procedures• Supervisory Accountability• Employee Participation• Hazard Identification & Control• Safety Education & Training• Accident Investigation• Program Review & Improvement

Why Perform an Accident Investigation?

• Gain basic information about the incident• Inform stakeholders about the incident

– Injured worker/family– Business owner(s)– Regulatory agencies– Injured third parties

• Determine causes of the incident• Implement corrective actions

Main reason for performing an accident investigation is to prevent recurrence!

Building a Chain

• Gain basic information about the incident– ‘Who,’ ‘What,’ ‘Where,’ and ‘When’

• Dig down into methods and mechanisms– ‘How’ did it happen?– Unsafe acts & conditions

• Determine motivations– ‘Why’ did this happen?

• Organize info into a logical flow– Chain represents progression – Events = “links” in the chain– Link events together– Show relationship between events– Why go to the trouble to do this?!?

Breaking a Chain

If we can ‘see’ the chain, we can find its weak points

If we can break the chain in any place, we can disrupt the relationships between events that lead to the undesirable event

Build it so we can BREAK it!

1. Reconstruct events in proper order*

– Show cause and effect– What actions led to reactions– What combinations had to occur

2. Deconstruct chain in proper place– Point of greatest impact

Root Cause

““the most basic reason for an accident… elimination of the most basic reason for an accident… elimination of the the root causeroot cause leads to the elimination of the accident” leads to the elimination of the accident”

“real cause or origin of a problem”

“the ultimate source of an effect”

“The underlying reason for the

occurrence of a problem”

“most fundamental reason for the failure or inefficiency of a process”

Accident Investigation

Unsafe act

Unsafe condition

• More than simple listing of ‘facts’

Which of these is the Root Cause of the accident?

• Goal is to prevent recurrence• Recreate the incident step-by-step

Identify Root Cause Taking specific, directed action to eliminate Root Cause OR Breaking the links between cause/effect

Ask the ‘5 Whys’

• Why was this bear trap left here?“To catch bears.”

• Why was it necessary to catch bears?“They were terrorizing the lunchroom.”

• Why were bears in the lunchroom?“Because they were hungry?”

• Why were they hungry?“Because they missed their morning break.”

• Why did they miss their morning break?“The Production Supervisor on Line 3 said

they had too much work to do...”

Inadequate HR Policies

Unsafe condition

Corrective Actions: Develop hiring criteria Candidate pre-screening Background checks Employee orientation

Ask the ‘5 Whys’

• Why did you step in the trap?“I didn’t see it.”

• Why didn’t you see it?“I was rushing to deliver a message.”

• Why were you rushing?“The Supervisor was yelling at me.”

•Why was the Supervisor yelling at you?“I suppose because he was angry.”

•Why was the Supervisor angry?“Because the bears from Production

Line 3 were late coming back from lunch!”

Unsafe act

Improper Management Practices

Corrective Actions:• Counseling

Sensitivity Training Anger Management Supervising Safety

• Reassignment

Fault Tree Analysis

Bill steps in bear trap

Bear trap left in floor

Bill didn’t see bear trap

Bill was rushing

Bears terrorizing lunch room b/c hungry

Supervisor was yelling at

Bill

Bears missed break

Work inappropriate for BEARS!

Root Causes

Accident Event

Causedby

II. Case Study: Routine Duties

“Routine Duties”

“On Tuesday, December 23, 2003 the Chief Engineer (Robert) of a well-known Massachusetts hotel entered the first floor “pump room” for the property’s indoor swimming pool. His intention was to add chlorine tablets to the pool system – a routine duty in which dry tablets were dropped into a small cylindrical canister attached to the pool’s pump.

“Routine Duties”

As he was doing this, Robert noticed (not for the first time) the old chlorine canister which had recently been removed from service by the 3rd party (contract) pool technician (Jim). Two weeks prior, Jim had made his usual visit as a representative of the pool chemicals company. He normally tested the water, made any necessary adjustments, restocked pool chemicals in the storage room, etc.

During this trip, Jim had also replaced the old chlorine cylinder with a new one as instructed by his work order; but instead of taking the old cylinder with him, Jim had left it sitting in one corner of this 12’x12’ cinder block ‘bunker.’

Non-Routine Incident

Canister rapidly depressurized! Projectile fired across the room, narrowly missing head Sustained a chemical burn to the eyes and face No eye wash present in the room Co-worker heard screams, found him outside building Washed eyes with water hose Transported via ambulance

No sustained respiratory injury No permanent loss of vision Hospitalization limited to 2 days

Now, two weeks later, Robert - thinking to reclaim those unused chlorine tablets in the old cylinder - moved to open the cylinder as he had done hundreds of times before…”

What Happened?!

Additional Information

• Inspection

• Interviews

• Inference

Pool Chemicals Contractor

• Chlorine tabs + water = chlorine gas

• Enclosed space, increased pressure

• “I told the Tech that when I hired him”

• Instructed him “never leave out of service equipment behind”

Supervisor

• Pool technician introduced water to the cylinder

• Completed steps in wrong order; new employee

• Training was all verbal; no written instructions;

• No OTJ training

• “It was a 2 hour class – I can’t remember everything”

• “Hands were full goin to the truck - figured I’d get it next time”

Technician (Jim)

Pool Chemicals Contractor

Hotel Staff

• Chief states that “something told him this wasn’t right”

• “Didn’t think it through”

•“Didn’t do anything wrong”

•“Wouldn’t have known what to do anyway”

• “Just wanted to save the company a few bucks”

• No PPE worn “…it was a routine job; none was required”

Chief Engineer (Robert)

Fault Tree Analysis

Chief Engineer injured by

chlorine gas from cylinder

Cylinder with wet chlorine

tabs was present

Chief opened cylinder after

two weeks had passed

Chief didn’t assess non-

routine situation

Chief wanted to recover

tabs, save $$

Pool Tech didn’t follow isolation/

removal procedure

Cylinder abandoned by

pool technician

Chief not wearing PPE

Root Cause

Procedure not defined

Inadequate training

Procedure known,not followed

Procedure not defined

Procedure not defined

Inadequate training

III. Getting Started

Written Policy and Procedures

• Accident investigation mandatory for all– Reportable Accidents (OSHA)– WC and GL Claims– First Aid cases?– Near Misses

Accident Pyramid

Lost Time Injury

First Aid Cases

Near Misses

At-Risk Behaviors

Severity

Frequency

Accident

Potential

Situations

Major Accident

30

1

300

3,000

30,000

• List specific expectations– Who will participate? Lead?– What is the goal?– How will the results be reported? By

when?– Who will review and approve?

• Outline hazard control process– An acceptable corrective action prevents recurrence– ID a responsible party– Follow-up to completion

Education and Training

• Formulate your message– Why are we doing this?

• Be consistent– How are we going to do this?

• Employ interactive training

• Move past awareness to expectation

• Share your findings!

You have a resource…You have a resource…