Why Investigate Accidents?
• Find the cause
• Prevent similar accidents
• Protect company interests
Video
http://www.youtube.com/watch?v=7pBKrJL
YcDc&feature=related
Investigation is 5 Step Process
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Arrive to the scene safely
Control the scene
Gather data
Analyze data
Write report
Control the Scene
• Provide medical care for injured
– First aid
– On scene evaluation
– Transport for medical care
• Control existing hazards
– Prevent further injuries
– Get more help if needed
• Preserve evidence
Preserving Evidence
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Limit personnel access
Remove witnesses and isolate
Record names and numbers
Secure (barricade) area
Protect high-value/critical equipment
Avoid adverse exposure to scene
Collecting Evidence
• Methods for collection
• The four Ps of evidence collection:
People
Positions
Parts
Papers
Gather Data
• Photos of accident scene
• Drawings, sketches and measurements
(call in the surveyors)
• Data
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Persons involved
Date, time, location
Activities at time of accident
Equipment involved
List of witnesses
Information Interviews
• Gather just the facts …
make no judgments or
statements
• Conduct interviews one
on one
• Be friendly but
professional
• Conduct interviews near
the scene in private
• Interview all supervisors
Four Traits of the Best Interviewer:
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Good listener
Organized
Good listener
Good listener
Initiating an Interview
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Explain who you are (if not already known)
Explain why accident is being investigated
Discuss the purpose of the investigation
Ensure witness he/she is not a target
Let them know who will see report
Let them know they can review their comments
Remain objective
Beginning the Interview
• Put witness at ease
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Make them comfortable
Offer refreshments
Call them by their first name
Shake their hand
• Communicate at their level
– Never speak down to a witness
– Don’t be arrogant or superficial
– Explain that the investigation is a “FACT” finding
and not a “FAULT” finding.
Locating Witnesses
• Primary sources
– Those involved may lead to others
– Time cards, work schedules, sign
in logs
– Area supervisors
– People working in adjacent areas
– Emergency first responders
• Other sources
– Police reports, hospital records, news reports
Witness Interviews and Statements
• Types of witnesses
– “Eye witness” and “ear witness”
– Peoples’ perceptions and opinions
change
Ensuring Unbiased Testimony
• Witness description may differ from one person
to the next
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No two people see things the same way
Points of observation vary
Technical and personal differences between people
Personal interest of witnesses (self preservation)
Difference in rationalization and articulation
The Interview Location
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Ensure a comfortable, relaxed atmosphere
Use on-scene interviews when beneficial
Ensure privacy and prevent interference
Use a non-threatening location
– Small conference room, break area
• Group interviews - use caution
12 Elements of an Effective Interview
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Establish Rapport
Don’t Interrupt
Listen actively
Tell eyewitnesses to actively generate information and not
wait passively for questions from the interviewer
Ask open-ended questions
Pause after each response before asking another question
Explicitly request detailed descriptions
Encourage the eyewitness to concentrate intensely
Encourage the eyewitness to use imagery / sketches
Adopt the eyewitness’s perspective
Ask eyewitness compatible questions
Don’t interrupt
Concluding the Interview
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Ask about accident prevention
Foster attitude of accident prevention
Look for ideas of improvement
Remind witness their help was valuable
Accident Investigation/Accident Causes
An accident investigation is used to
identify the cause(s) of an accident and
determine the proper corrective actions.
Virtually all accidents are caused by a
combination of unsafe acts (about 80%)
and/or unsafe conditions (about 20%).
Immediate (direct) Causes
• UNSAFE ACTS
– Operating w/o
authority
– Failure to secure
– Failure to warn
– Improper speed
• UNSAFE CONDITIONS
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No guards
Defective
tools/equipment
Existing fire hazard
Excessive noise
Inadequate lighting
Accident Investigation/Accident
Causes/Unsafe Conditions
A. Unsafe conditions relate to such physical and /or
environmental conditions as:
1. Improper or missing guards
2. Equipment malfunctions or defects
3. Improper tool for the task
4. Improper illumination (too bright or too dim)
5. Improper ventilation
6. Poor housekeeping
Accident Investigation/Accident
Causes/Unsafe Conditions
7.
8.
9.
10.
Unsafe storage
Inadequate clearance
Hazardous arrangement
Improper personal protective equipment for
task or hazard
11. Abnormal temperature
12. Uneven/slippery surfaces
Accident Investigation/Accident
Causes/Unsafe Acts
B. Unsafe acts relate to individual employee
actions such as:
1. Operating equipment or machinery without
authority
2. Removing, misadjusting or disconnecting
safety devices
3. Operating unsafe or defective equipment
4. Using improper tool for the task
Accident Investigation/Accident
Causes/Unsafe Acts
5. Disobeying established rules, procedures
and practices
6. Taking an unsafe posture or position
7. Failure to lockout equipment
8. Crawling under/over/on machinery, equipment
and conveyors
9. Distracting, teasing, abusing, startling, quarreling,
horseplay, etc.
10. Improper care and use of personal protective
equipment
Accident Investigation/Accident
Causes/Contributing Causes
C. Contributing causes relate to these items that attribute
to or allow the primary condition to exist, such as:
1. Disregard for instruction or warning
2. Failure to understand instructions
3. Poor vision
4. Diminished hearing
5. Fatigue
6. Intoxication/drug abuse
7. Deficiency of job knowledge or required skills
Accident Investigation/Accident
Causes/Contributing Causes
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New employee on the job
Transferred to new job/department/plant
Improperly trained
Not physically suited to job or task
Pre-existing injury
Emotional/mental distraction
Improper attire for task
Improper personal hygiene practices
Improper or no inspection of job, machinery,
equipment or department
Accident Investigation/Common Errors
D. Common errors encountered in accident investigation:
1. When an accident occurs, there was either an unsafe act
or condition present or a combination thereof. If neither is
found to be existing, “Why?” must continually be asked.
2. Stopping at the primary unsafe act(s) or condition(s)
rather than seeking the contributing causes. If an injury
or accident were to occur as a result of an employee
slipping on oil left by a leaking lift truck, the corrective
action is not using additional absorbent. This would
remedy the unsafe condition whereas repairing the lift
truck would eliminate the hazard entirely.
Accident Investigation/Common Errors
3. Assigning causes to accidents that are too general or
vague fail to yield corrective action.
4. Determining cause of an accident without the agreement
of the employee involved. The employee involved and
the investigator must arrive at similar conclusions as to
cause of loss, for the investigation to be useful.
Employees must be able to understand the cause or
they will not make, or accept, corrective actions.
Contribution of Safety Controls such as:
• Hazard Elimination
• Engineering Controls - machine guards, safety controls,
isolation of hazardous areas, monitoring devices, etc.
• Administrative Controls - procedures, assessments,
inspection, records to monitor and ensure safe practices
and environments are maintained.
• Personal Protective Equipment (PPE) – respirator, hard
hat, safety glasses
• Training Controls - initial new hire safety orientation, job
specific safety training and periodic refresher training.
Unsafe Acts
• List all unsafe acts involved in the accident
• Examples of unsafe acts
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Unauthorized operation of equipment
Running - Horse Play
Not following procedures
By-passing safety devices
Not using protective equipment
Under influence of drugs or alcohol
Taking short-cuts
REVIEW / EXAM QUESTIONS
These questions are common questions
on the STS exam.
Review Questions
After an accident, the first thing you want to
do is take care of any injured person. What
should be the next thing that you do?
A)
B)
C)
D)
Secure the area
Preserve the evidence
Start interviewing people
Start your accident report
Answer
After an accident, the first thing you want to
do is take care of any injured person. What
should be the next thing that you do?
A)
B)
C)
D)
Secure the area
Preserve the evidence
Start interviewing people
Start your accident report
Review Questions
When interviewing a witness during an
accident investigation, what is the best
approach?
A)
B)
C)
D)
Interview witnesses one at a time
Interviews should be conducted at the site
Take notes or record the interview
Interview witnesses together for a “big
picture”
Answer
When interviewing a witness during an
accident investigation, what is the best
approach?
A)
B)
C)
D)
Interview witnesses one at a time
Interviews should be conducted at the site
Take notes or record the interview
Interview witnesses together for a “big
picture”
Review Questions
A)
B)
C)
D)
Prior to an accident occurring which requires
first aid or medical attention, what should your
course of action be?
Phone 911
Have personnel trained in first aid and CPR
procedures on your crew
Take the injured personnel to the hospital
Have an emergency response plan prior to
beginning work
Review Questions
A)
B)
C)
D)
Prior to an accident occurring which requires
first aid or medical attention, what should your
course of action be?
Phone 911
Have personnel trained in first aid and CPR
procedures on your crew
Take the injured personnel to the hospital
Have an emergency response plan prior to
beginning work
Review Questions
What is the primary reason for conducting a
safety inspection?
A) To ensure compliance with governmental
codes and regulations
B) To ensure that safety rules are being followed
C) To identify unsafe conditions and practices
D) To discover and correct hazards
Answer
What is the primary reason for conducting a
safety inspection?
A) To ensure compliance with governmental
codes and regulations
B) To ensure that safety rules are being followed
C) To identify unsafe conditions and practices
D) To discover and correct hazards
Review Questions
Which of the following would be the most
likely to produce severe injuries or a high
probability of accidents?
A)
B)
C)
D)
Routine task
Volunteer activities
Closely supervised actions
Unusual and non-routine task
Answer
Which of the following would be the most
likely to produce severe injuries or a high
probability of accidents?
A)
B)
C)
D)
Routine task
Volunteer activities
Closely supervised actions
Unusual and non-routine task
Review Questions
Which of the following is not an example of an
indirect accident cost?
A)
B)
C)
D)
Cost of accident investigation
Cost of training replacement workers
Cost of lost days
Lost production
Answer
Which of the following is not an example of an
indirect accident cost?
A)
B)
C)
D)
Cost of accident investigation
Cost of training replacement workers
Cost of lost days
Lost production
Review Questions
Occupational accidents/injuries usually
result from:
A)
B)
C)
D)
Physical limitations
Personality differences
Combination of factors
Environmental conditions
Answer
Occupational accidents/injuries usually
result from:
A)
B)
C)
D)
Physical limitations
Personality differences
Combination of factors
Environmental conditions
Review Questions
What is the best way to control or eliminate
a hazard?
A)
B)
C)
D)
PPE
Administrative controls
Engineering controls
Stop working
Answer
What is the best way to control or eliminate
a hazard?
A)
B)
C)
D)
PPE
Administrative controls
Engineering controls
Stop working
Review Questions
The cost of accidents includes direct and
indirect costs. What do experts normally use
as the approximate ratio of direct to indirect
costs?
A)
B)
C)
D)
1 to 2
1 to 5
1 to 85
1 to 100
Answer
The cost of accidents includes direct and
indirect costs. What do experts normally use
as the approximate ratio of direct to indirect
costs?
A)
B)
C)
D)
1 to 2
1 to 5
1 to 85
1 to 100
Review Questions
It is generally accepted that accidents:
A) Are all preventable
B) Are only 50% preventable
C) Are unexpected events that cannot be
controlled
D) Can be prevented, but where absolute
prevention is not possible, take steps to
reduce severity
Answer
It is generally accepted that accidents:
A) Are all preventable
B) Are only 50% preventable
C) Are unexpected events that cannot be
controlled
D) Can be prevented, but where absolute
prevention is not possible, take steps to
reduce severity
Review Questions
What is the primary purpose of accident
investigations?
A) To establish fault
B) To prevent recurrence based on similar
causes
C) To find the root cause
D) To report accidents and near misses
Answer
What is the primary purpose of accident
investigations?
A) To establish fault
B) To prevent recurrence based on similar
causes
C) To find the root cause
D) To report accidents and near misses
END
MODULE #2