Accident Investigations
Part I
1
Accident Investigation Objectives
By the end of this session the participants will:
Understand the importance of the need for
effective and thorough investigation of an
accident
Demonstrate practical skills required to
respond and investigate an incident/accident in
a consistent manner
Make meaningful recommendations for
preventive actions to reduce potential risks that
may contribute to accidents
2
Effective Accident
Investigations - Objectives
(cont.)
By the end of this session the participants will:
Understand their critical role in the accident
investigation and the accident reporting
process
Determine the cause(s) of this accident and
make recommendations to help prevent a
recurrence of this type of incident
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4
What is an Accident ?
“An accident is an undesired event that results
in physical harm to a person or damage to
property.”
5
Purpose of an Accident
Investigation
The purpose of an accident investigation is to
prevent the recurrence of the accident. The focus
should be on the accident , not the injury .
6
Effective Accident
Investigations
What to Look for:
Policies/Procedures Equipment
Environment
Task
Materials
People/Operators
Accidents generally have more than one cause
7
Critical Injury Defined
For the purpose of the Act and Regulations, “critically
injured” means an injury of serious nature that,
a) places life in jeopardy;
b) produces
unconsciousness;
c) results in substantial
loss of blood;
d) involves the fracture of a
leg or arm but not a
finger or toe;
e) involves the amputation
of a leg, arm, hand or
foot but not a finger or
toe;
f) consists of burns to a
major portion of the
body; or
g) causes the loss of sight
in an eye. O. Reg. 8
714/82 s.1
Who Investigates
Accidents?
Supervisors
They have a personal interest to protect.
They know their people, the conditions and the
job.
They know how to get the information needed.
They will take action in any case.
9
Who Investigates
Accidents?
JHSC Representative
They are familiar with the people and
workplace.
They have a legal requirement in Critical
Injuries
They have been trained in Accident
Investigation
10
Who Investigates
Accidents?
Government and Business
Ministry of Labour
Ministry of the Environment
Workplace Safety & Insurance Board
11
Before an Accident Occurs…
Create an accident “action plan”
Create an Accident Investigation Policy
Develop Investigation Procedures
Practice
12
When To Investigate An
Accident
Immediately or ASAP
( If a Critical Injury or Immediately Reportable
Accident, secure the scene and advise the MOL
)
Accident Investigation Procedures should be in
writing to ensure a consistent response to all
accidents.
13
At the Accident Scene
Control the Scene
People are the first priority; send for help;
make sure area is safe; administer first aid
Stop Ongoing Hazards
Get personal protective equipment; provide
emergency lighting, power, air, etc.
Collect Evidence
Take notes, pictures, sketches of tools,
equipment, layout, etc.
14
At the Accident Scene
Contributing Factors:
Housekeeping
Floor/surface conditions
Noise
Air quality/temperature
Equipment malfunction
Supervision
Employee morale/attitude/health
Alcohol/drug abuse
15
What Equipment Is Required?
Personal Protective
Equipment
Caution Tape
Measuring Tape
Graph Paper
Pencils
Lockout / Tagout
Clipboard
Camera (battery and
film)
Flashlight (with
batteries)
Emergency Phone
Numbers
Accident Investigation
Forms
Optional - tape recorder,
photo log, flares, etc. 16
Immediate Causes
Struck By
Struck Against
Caught In, On,
Between, or Under
Fall On, In, or From
Scraped / Rubbed
Against
Overexertion or Body
Strain
Contact with
- Electricity
- Heat or Cold
- Radiation
- Noise
- Caustics
- Toxic Substances
17
Basic Causes
Lack of preventative
maintenance
Unsafe Working or
Travelling Speed
Servicing, Moving or
Live Equipment
Unsafe Working
Posture or Position
Failure To Warn or
Secure
Incorrect Equipment or
Body Use
Tampering or
Removing Safety
Devices
Poor or Improper Work
Practices
18
Root Causes
Personal Factors
Poor Motivation
Labour Relations
Lack of Skill or Knowledge
Job Factors
Poor Purchasing
Standards
Poor Work Standards
Physical and/or
Poor Maintenance or
Design
Psychological Problems
Abnormal Usage
Excessive Wear and Tear
Lack of Programs and
Procedures
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Equipment or Conditions
Involved
Equipment
Metal Lab cart
Specimen Blender
Metal work counter
electrical appliance
plug-ins (cart &
counter)
metal sink
leather shoes
eyeglasses
Conditions
water on floor
damaged equipment
running water
20
Accident Scene
• Click here to view accident
scene
• What happened?
21
Flip Chart Layout
Who was injured?
What happened?
How to prevent a recurrence?
22
Accident Investigation
Part II
23
Effective Accident
Investigations
What to Look for:
Policies/Procedures Equipment
Environment
Task
Materials
People/Operators
Accidents generally have more than one cause
24
Accident Investigation
Process
Response
Interview Witnesses
Assess Scene /
Analysis and
Identify Witnesses
Conclusions
Preserve Evidence
Notification
Recommendations
Follow up
25
Accident Investigation
Forms
Internal Accident Report
Investigator’s Checklist
Witness Interview Form
JHSC Accident Investigation Report
Accident Findings Recommendation Form
26
At the Accident Scene
Contributing Factors:
Housekeeping
Floor / surface conditions
Noise
Air quality / temperature
Equipment malfunction
Supervision
Employee morale / attitude / health
Alcohol / drug abuse
27
Basic Causes
Preventative
Maintenance
Servicing Moving or
Live Equipment
Failure To Warn or
Secure
Tampering or Removing
Safety Devices
Unsafe Working or
Travelling Speed
Unsafe Working
Posture or Position
Incorrect Equipment
or Body Use
Poor or Improper
Work Practices
28
Root Causes
Job Factors
Personal Factors
Poor purchasing
Poor motivation and/or
Standards
labour relationship
Poor
work
standards
Lack of skill or
Poor maintenance or
knowledge
design
Physical and/or
Abnormal usage
psychological problems
Excessive wear and
tear
29
Who Are The Witnesses ?
Eye Witness
First Person (s) at the scene Witness
Surrounding Events Witness
Person Having Knowledge
30
Interview Process
 First - Get The Big Picture
 Separate All Witnesses
 Interview Each Witness Alone and In
Private
 Interview Eye Witnesses First
 Interview At Accident Scene (when
31
advisable)
Effective
Interview Technique
 Put person at ease
 Always thank person for
their cooperation
 Explain purpose of accident
 Immediately document
investigation
critical information
 Listen to the individual’s
 Provide drawings and
version
photos where useful
 Ask the right questions at
the right time
 Probe for Basic Causes
 Keep the door open for
 Repeat the information given further information
back to the individual
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Interviewing
Questions To Ask
• Where were you at the time of the accident ?
• What were you doing at the time ?
• What did you see, hear ?
• What were the environmental conditions ?
• What was the injured worker doing at the time ?
• In your opinion, what caused the accident ?
• How might similar accidents be prevented in the future ?
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Interviewing
Questions to Ask
• Ask “WHY” 5 times
“He was lying on the floor” - Why?
“Because there was water on the floor” - Why?
“Because there was a leak in the sink” - Why?
“Because maintenance hadn’t fixed it” - Why?
“Because they’re short-staffed” - Why?
“Because of the hiring freeze”
34
Typical Investigation
• Who was injured?
John Doe
• What happened?
Slipped on spill on floor
and struck their head.
• How to prevent a
recurrence?
We should clean up spills
right away or put sign up
saying wet floor.
Hot link to poster 2
35
At the Accident Scene
• Contributing Factors:
 Housekeeping
 Floor/surface conditions
 Noise
 Air quality/temperature
 Equipment malfunction
 Supervision
 Employee morale/attitude/health
 Alcohol/drug abuse
36
Investigation Begins
• Individual shots of accident scene
• Click link(s)
•
•
•
•
•
Lab cart - first view
Lab cart - second view
Plug
Water
Feet
37
Effective Investigation
Examples…
Immediate Causes?
Basic
Causes?
Root Causes?
38
Effective Investigation
Examples…
with live equipment
Immediate Causes? Contact
Fall to the floor
Struck head
Basic
Causes?
Root Causes?
Tampering / removal of safety device
(3 prong & insulating rubber feet
Water on floor
Poor maintenance / housekeeping
Poor labour relations
Poor health
39
Accident Scene
Re-visited
• Click here to view accident
scene
• What really happened?
40
Recommendations
& Follow - Up
 Have intermediate control
measures been
implemented prior to
final corrective measure ?
 Have the intermediate or
final corrective measures
resulted in further
hazards?
 How adequate are the
control measures ?
 How effective are the
control measures ?
 Has there been follow-up
and an analysis of the
corrective measures to
ensure they have been
implemented and are
effective ?
•Click to advance to optional Accident Scene
41
Thank You
42
OPTIONAL SCENARIO:
OFFICE ACCIDENT
43
OPTIONAL SCENARIO:
OFFICE ACCIDENT
44
OFFICE ACCIDENT
Contributing Factors:
Policies/Procedures Equipment Materials
Environment
Task
People/Operators
45
Office Accident Investigation
Immediate Causes?
Basic
Causes?
Root Causes?
46
Office Accident Investigation
Immediate Causes? Fall to the floor
Struck back
Basic
Causes?
Root Causes?
Using improper procedure / equipment
Standing on cabinet
Working alone
Training
47
OFFICE ACCIDENT
CONCLUSION
Accidents generally have more than one
cause
Keep asking WHY until you determine the
root cause
48
Thank You
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