Risk Management Services
Accident Investigation Basics
Department of Administrative Services
Loss Control Services
March, 2013
1
Risk Management Services
Why Investigate?
• Prevent future incidents, injuries, accidents, etc.
• Identify and eliminate hazards.
• Expose deficiencies in process and/or equipment.
• Reduce injury and workers’ compensation costs.
• Maintain worker morale.
2
Risk Management Services
What Is An Accident?
An unplanned, unwanted, but controllable event
which disrupts the work process and causes injury
to people.
Most everyone would agree that an accident is unplanned and unwanted.
The idea that an accident is controllable might be a new concept. An
accident stops the normal course of events and causes property damage or
personal injury, minor or serious, and occasionally results in a fatality.
3
Risk Management Services
What Is An Incident?
An unplanned and unwanted event which disrupts the work process
and has the potential of resulting in injury, harm, or damage to
persons or property.
An incident may disrupt the work
process, but does not result in injury or
damage. It should be looked at as a
“wake up call”. It can be thought of as
the first of a series of events which could
lead to a situation in which harm or
damage does occur.
Example of an incident: A 50 lb carton falls off the
top shelf of a 12’ high rack and lands near a
worker. This event is unplanned, unwanted, and
has the potential for injury.
4
Risk Management Services
“The Tip of the Iceberg”
Accidents
Accidents or injuries are the tip of
the iceberg of hazards.
Investigate incidents since they are
potential “accidents in progress”.
Incidents
Don’t investigate only accidents. Incidents should also be reported and investigated. They
were in a sense, “aborted accidents”.
Criteria for investigating an incident: What is reasonably the worst outcome, equipment
damage, or injury to the worker? What might the severity of the worst outcome have been? If
it would have resulted in significant property loss or a serious injury, then the incident should
be investigated with the same thoroughness as an accident investigation.
5
Risk Management Services
Major Injury
or Death
10
Injury
The
Incident
Pyramid
1
30
First Aid or
Property Damage
600
Near Misses
Management Systems
Interventions
Training
Feedback
Sampling
Rewards
Safe
Practices
Goals
Enforcement
Involvement
6
Risk Management Services
Investigate All Incidents and Accidents
• Conduct and document an investigation that
answers:
▪ Who was present?
▪ What activities were occurring?
▪ What happened?
▪ Where and what time?
▪ Why did it happen?
Root causes should be determined. Example: An employee gets cut. What is the cause?
It is not just the saw or knife or the sharp nail. Was it a broken tool and no one reported it?
Did someone ignore a hazard because of lack of training, or a policy that discourages
reporting? What are other examples of root causes? Enforcement failure, defective PPE,
horseplay, no recognition plan, inadequate labeling?
7
Risk Management Services
Accident
investigation
is “fact-finding”
not
fault-finding.
The six-step process
Gather
information
Analyze the
facts
Implement
Solutions
Step 1: Secure the accident scene
Step 2: Collect facts about what happened
Step 3: Develop the sequence of events
Step 4: Determine the causes
Step 5: Recommend corrective actions & improvements
Step 6: Write the report
8
Risk Management Services
Actions At The Accident Scene
• Check for danger
• Help the injured
• Secure the scene
• Identify and separate witnesses
• Gather the facts
First, make sure you and others don’t become victims! Always check for stillpresent dangerous situations. Then, help the injured as necessary. Secure the
scene and initiate chains of custody for physical evidence. Identify witnesses and
physical evidence. Separate witnesses from one another If physical evidence is
stabilized, then begin as quickly as possible with interviews.
9
Risk Management Services
Begin Investigation Immediately
• Investigation should be conducted by
supervisor/manager.
• It’s crucial to collect evidence and interview
witnesses as soon as possible because evidence
will disappear and people will forget.
10
Risk Management Services
Fact Finding
•
•
•
•
•
•
•
•
•
Take notes on environmental conditions, air quality, witnesses
and physical evidence
Employees/other witnesses
Position of tools and equipment
Equipment operation logs, charts, records
Equipment identification numbers
Take samples
Note housekeeping and general working environment
Note floor or working surface condition
Take lots of pictures. Draw the scene if applicable.
Some scenes are more delicate then others. If items of physical evidence are time sensitive
address those first. If items of evidence are numerous then you may need additional assistance.
Some scenes will return to normal very quickly. Are you prepared to be able to recreate the scene
from your documentation?
Consider creating a photo log. The log should describe the date, time, give a description of what is
captured in the photo and directionality. Link to sketch of accident scene.
11
Risk Management Services
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
Your method and outcome of interview should include: who is to be interviewed first, who
is credible, who can corroborate information you know is accurate, how to ascertain the
truth based on a limitation of the number of witnesses. Be respectful. Are you the best
person to conduct the interview?
If the issue is highly technical, consider an internal or external specialist for assistance.
12
Risk Management Services
Analysis – Injury
• Reconstruct the specific events prior to, during, and after
the accident.
• Analyze the injury event to identify and describe the
direct cause of injury.
▪ Describe the injury and its cause.
▪ Identify the accident type.
Strains
Burns
Cuts
13
Risk Management Services
“Accident”
Weed
Strains
Burns
Cuts
Un
gu
ard
ed
ma
ch
se p
H or
ine
ken
Chem
Defe
too
ls
Ignore
ical sp
ill
ctive
Untrained
No accountability policy
Lack of vision No mission statement
Inadequate training plan
y
Secondary
Surface
Causes
Fails to tr
ain
work
To much
No orientation process
jur
rt in
Fails to enforce
Lack of time
No discipline procedures
d
Fails to inspect
worker
Inadequate training
rd
r
a haza
po
to re
Fails
PPE
Primary
Surface
Causes
lay
aza
te a h
Crea
Bro
Root Causes
System Design
Direct
Cause
No recognition
Inadequate labeling
Outdated hazcom program
Root Causes
System
Implementation
No recognition plan
No inspection policy
14
Risk Management Services
Analysis – Events
• Analyze at least two events occurring just prior to
the injury event to identify surface causes for the
accident.
▪ Determine the primary surface causes. Look for
specific hazardous conditions and employee behaviors
that caused the injury.
▪ Determine secondary surface causes. These are also
specific conditions and behaviors.
5 Simple Questions
WHY? x5
Lack of time
Fails to enforce
15
Risk Management Services
The Five Whys
• Basic Question – Keep asking, “What caused or allowed this
condition/practice to occur?” until you get to the root causes.
• The “five whys” is one of the simplest of the root cause analysis
methods. It is a question-asking method used to explore the
cause/effect relationships underlying a particular problem.
Ultimately, the goal of applying the 5 Whys method is to
determine a root cause of a defect or problem.
The following example demonstrates the basic process:
My car will not start. (the problem)
1) Why? - The battery is dead. (first why)
2) Why? - The alternator is not functioning. (second why)
3) Why? - The alternator belt has broken. (third why)
4) Why? - The alternator belt was well beyond its useful service life and has never been
replaced. (fourth why)
5) Why? - I have not been maintaining my car according to the recommended service schedule.
(fifth why and the root cause)
16
•
Risk Management Services
Benefit of Asking the Five Whys
Simplicity. It is easy to use and requires no advanced mathematics or tools.
Effectiveness. It truly helps to quickly separate symptoms from causes and identify
the root case of a problem.
Comprehensiveness. It aids in determining the relationships between various
problem causes.
Flexibility. It works well alone and when combined with other quality improvement
and trouble shooting techniques.
Engaging. By its very nature, it fosters and produces teamwork and teaming within
and without the organization.
Inexpensive. It is a guided, team focused exercise. There are no additional costs.
Often the answer to the one “why” uncovers another reason and generates another
“why.” It often takes “five whys” to arrive at the root-cause of the problem. You will
probably find that you ask more or less than “five whys” in practice.
17
Risk Management Services
Direct Cause of
Incident
Burn
s
Strain
s
Cuts
Strains
Burns
Hazardous Condition
Contributing conditions
Unsafe Behaviors
Contributing Behaviors
Cuts
Un
gu
ard
ed
ma
ch
Bro
ken
sep
H or
ine
rd
Crea
too
ls
Chem
ctive
Fails
PPE
Inadequate training plan
No accountability policy
Lack of vision No mission statement
Implementation
Root Causes
ry
Fails to tra
in
work
To much
Design
Root Causes
ju
rt in
Fails to enforce
Lack of time
No orientation process
po
to re
Fails to inspect
ined work
er
No discipline procedures
rd
a haza
Fails to enforce
Lack
of time
Untra
Inadequate training
aza
te a h
Ignore
ical sp
ill
Defe
lay
No recognition
Inadequate labeling
Outdated hazcom program
No recognition plan
No inspection policy
18
Risk Management Services
Sequence of Events
• An accident is not “just one of those things”.
• Accidents are predictable and preventable events.
• They don’t have to happen.
• Look for the chain of events leading up to the Incident.
Most workplace injuries and illness are not due to “accidents”. More often than not it
is a predictable or foreseeable eventuality.
By “accidents” we mean events where employees are killed, maimed, injured, or
become ill from exposure to toxic chemicals or microorganisms (TB, hepatitis, HIV).
A systematic plan and follow through of investigating incidents or mishaps and
altering behaviors can help stop a future accident.
Let’s take the 50 lb carton falling 12 feet for the second time, only this time it hits a
worker, causing injury. Predictable? Yes. Preventable? Yes. Investigating why the
carton fell will usually lead to solution to prevent it from falling in the future.
19
Risk Management Services
Recommend Corrective Actions
Hierarchy of Hazard Controls
1.
Elimination of Hazard Remove or reduce
2.
Substitution less hazardous material or reduce energy –
lower speed, force, amperage, pressure, temperature, and
noise.
3.
Engineering Controls
4.
Warnings
5.
Administrative Controls & Procedures – Remove or reduce
the exposure
6.
Personal protective equipment (PPE) – Put up a barrier
INTERIM MEASURES
Should also be taken if the risk cannot be engineered or
20
managed right away.
Risk Management Services
Corrective Actions: The main reason for Incident Investigations
Here’s the key. Do you give…
(0) Advice:
Stay out of trouble when you are out tonight.
(1) Action:
Come home by 11:00.
(2) Plan:
I’ll be staying up. See you at home by 11:00.
Levels of Actions
• Direct action taken by worker or assistant
• Single Use Plan – Get supervision at the workplace to get someone to do it.
• Multiple Use Plan – Build the plan in writing, directing someone to do it. Plans
should be pre-arranged, scheduled, and lead to an objective.
Decide which of these 4
root causes applies
Decide who didn’t:
1. Know
2. Understand
3. Believe
4. Observe
Start with these clues to
find a corrective action
Devise a Plan to:
1. Teach
2. Educate
3. Persuade
4. Assign
21
Risk Management Services
Conclusions of Report
Report conclusions should answer the following:
▪ What should happen to prevent future accidents?
▪ What resources are needed?
▪ Who is responsible for making changes?
▪ Who will follow up and insure changes are implemented?
▪ What will be the future long-term procedures?
If additional resources are needed during the implementation of recommendations,
then provide options. Having a comprehensive plan in place will allow for the
success of your investigation. Success of an investigation is the implementation of
viable corrections and their ongoing use.
The outcome of an investigation of the 50 lb. carton falling off the top shelf of the 12 ft. high rack
might include correction of sloppy storage at several locations in the warehouse, moving
unstable/heavy items to floor level, conducting refresher training for stockers on proper storage
methods, and supervisors doing daily checks.
22
Risk Management Services
Write a Report
The report should include:
 An accurate narrative of “what happened”?
 How and Why the Accident Happened?
 Who was involved?
 What injuries occurred or what equipment was damaged?
 How were the employees injured?
 Clear description of unsafe act or condition.
 Sequence of events.
 Recommended immediate corrective action.
 Recommended long-term corrective action.
 Recommended follow up to assure fix is in place.
 Recommended review to assure correction is effective.
23
Risk Management Services
Questions?
Contact Information
C. G. Lawrence, III, MS, CSP, REM, ARM-P
Chief Loss Control & Safety Officer
(404) 657-4457
Charles.Lawrence@doas.ga.gov
Hiram Lagroon, BS
Chief Loss Control & Safety Officer
(404) 463-6309
Hiram.lagroon@doas.ga.gov
24