Accident Investigation You Did What Again?

Accident Investigation
You Did What…Again?
Presented by:
John Dietrich,
Atkinson, Andelson, Loya, Rudd & Romo
LaFaye Platter, Hemet USD
Lucy Rebuck, Hemet USD
Suzanne Trowbridge, Keenan & Associates
Why Investigate?
Prevent future incidents (leading to accidents).
Identify and eliminate hazards.
Expose deficiencies in process and/or equipment.
Reduce injury and worker compensation costs.
Maintain employee morale.
Meet DOSH rule requirement that you investigate
serious accidents.
“You can’t manage risk and change
culture from behind a desk”
John Dietrich
“Common sense is not so
Lucy Rebuck
Investigate All Incidents and
Conduct and document an investigation that answers:
Who was present?
What activities were occurring?
What happened?
Where and what time?
Why did it happen?
How Do You Investigate??
How To Investigate – Main Steps
• Develop a plan
• Assemble an
investigation kit
• Investigate all incidents
and accidents
• Collect facts
• Interview witnesses
• Write a report
Tips for Developing An Accident
Investigation Plan
Develop your action plan ahead of time.
Your plan might include:
Who to notify in the workplace?
How to notify outside agencies?
Who will conduct the internal
Tips for Developing a Plan (continued)
• What level of training is needed?
• Who receives report?
• Who decides what corrections will be taken and
• Who writes report and performs follow up?
What Should Be in The “Investigation Kit”
Tape recorder
Tape measure
Large envelopes
High visibility tape
Personal protective equipment
First aid kit
Report Forms
Root Cause Analysis
• Direct Cause
– Unplanned release of energy or hazardous materials
• Indirect Cause
– Unsafe acts and/or unsafe conditions
• Root Cause
– Policies and decisions, personal factors, environmental factors
The Five Whys
Basic Question - Keeping asking
“What caused or allowed this condition/practice to occur?”
The “five whys” is one of the simplest of the
root cause analysis methods.
5 Whys In Action
Suzy had an unwitnessed trip and fall accident:
She wasn’t looking where she was going
She was carrying a box
She was wearing inappropriate shoes
There was water on the ground
Begin Investigation Immediately
• It’s crucial to collect evidence and interview
witnesses as soon as possible because evidence will
disappear and people will forget.
Fact Finding
Witnesses and physical evidence
Employees/other witnesses
Position of tools and equipment
Equipment operation logs, charts, records
Equipment identification numbers
Take notes on environmental conditions, air quality
Take samples
Note housekeeping and general working environment
Note floor or working surface condition
Take many pictures
Draw the scene
Interview Witnesses
Interview promptly after the incident
Choose a private place to talk
Keep conversations informal
Talk to witnesses as equals
Ask open ended questions
Listen. Don’t blame, just get facts
Ask some questions you know the answers to
Write The Report
Why – Root Cause
Prevention & Action Steps
Follow through
Case Study #1
• Handout to be provided
Case Study #1 - Findings
• Morale a result of poor supervision &
Case Study #2
• Eye Injury
• Investigation results: wasn’t following safety
protocol; training provided on correct
chemical handling
• Action steps:
– Disciplined employee for failing to follow safety
Case Study #3
• Bus Driver Crashes Bus While Texting
• Investigation:
– Employee trained not to text
– Employee observed texting on run in the am
– Letter of reprimand at end of am shift for texting
– Accident in pm while texting
• Root Cause Analysis
• Close Loop On Accident Investigation Findings
• Hold Everyone Accountable for Safety