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Accident InvestigationsPart I

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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

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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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What is an Accident ?

“An accident is an undesired event that results

in physical harm to a person or damage to

property.”

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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 .

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Effective Accident Investigations

What to Look for:

Policies/Procedures Equipment Materials

Environment Task People/Operators

Accidents generally have more than one cause

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Critical Injury Defined

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. 714/82 s.1

For the purpose of the Act and Regulations, “critically injured” means an injury of serious nature that,

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Who Investigates Accidents?

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.

Supervisors

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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

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Who Investigates Accidents?

Government and Business

Ministry of Labour

Ministry of the Environment

Workplace Safety & Insurance Board

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Before an Accident Occurs…

Create an accident “action plan”

Create an Accident Investigation Policy

Develop Investigation Procedures

Practice

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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.

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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.

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At the Accident Scene

Contributing Factors:Housekeeping

Floor/surface conditions

Noise

Air quality/temperature

Equipment malfunction

Supervision

Employee morale/attitude/health

Alcohol/drug abuse

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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 NumbersAccident Investigation FormsOptional - tape recorder, photo log, flares, etc.

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Immediate Causes

Struck ByStruck AgainstCaught In, On, Between, or UnderFall On, In, or FromScraped / Rubbed AgainstOverexertion or Body Strain

Contact with

- Electricity

- Heat or Cold

- Radiation

- Noise

- Caustics

- Toxic

Substances

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Basic Causes

Lack of 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

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Root Causes

Personal Factors

Poor Motivation

Labour Relations

Lack of Skill or Knowledge

Physical and/or

Psychological Problems

Job FactorsPoor Purchasing Standards

Poor Work Standards

Poor Maintenance or Design

Abnormal Usage

Excessive Wear and Tear

Lack of Programs and Procedures

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Equipment or Conditions Involved

EquipmentMetal Lab cartSpecimen BlenderMetal work counterelectrical applianceplug-ins (cart & counter)metal sinkleather shoeseyeglasses

Conditionswater on floor

damaged equipment

running water

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Accident Scene

• Click here to view accident scene

• What happened?

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Flip Chart Layout

Who was injured?

What happened?

How to prevent a recurrence?

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Accident InvestigationPart II

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Effective Accident Investigations

What to Look for:

Policies/Procedures Equipment Materials

Environment Task People/Operators

Accidents generally have more than one cause

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Accident Investigation Process

Response

Assess Scene /

Identify Witnesses

Preserve Evidence

Notification

Interview Witnesses

Analysis and

Conclusions

Recommendations

Follow up

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Accident Investigation Forms

Internal Accident Report

Investigator’s Checklist

Witness Interview Form

JHSC Accident Investigation Report

Accident Findings Recommendation Form

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At the Accident Scene

Contributing Factors:Housekeeping

Floor / surface conditions

Noise

Air quality / temperature

Equipment malfunction

Supervision

Employee morale / attitude / health

Alcohol / drug abuse

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Basic Causes

Preventative MaintenanceServicing Moving or Live EquipmentFailure To Warn or SecureTampering or Removing Safety DevicesUnsafe Working or Travelling Speed

Unsafe Working Posture or Position

Incorrect Equipment or Body Use

Poor or Improper Work Practices

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Root Causes

Personal Factors

Poor motivation and/or labour relationship

Lack of skill or knowledge

Physical and/or psychological problems

Job FactorsPoor purchasing StandardsPoor work standardsPoor maintenance or designAbnormal usageExcessive wear and tear

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Who Are The Witnesses ?

Eye Witness

First Person (s) at the scene Witness

Surrounding Events Witness

Person Having Knowledge

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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

advisable)

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Effective Interview Technique

Put person at ease

Explain purpose of accident investigation

Listen to the individual’s version

Ask the right questions at the right time

Repeat the information given back to the individual

Always thank person for their cooperation

Immediately document critical information

Provide drawings and photos where useful

Probe for Basic Causes

Keep the door open for further information

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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”

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Typical Investigation

• Who was injured?

We should clean up spills right away or put sign up saying wet floor.

• How to prevent a recurrence?

Slipped on spill on floor and struck their head.

John Doe

• What happened?

Hot link to poster 2

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At the Accident Scene

• Contributing Factors: Housekeeping

Floor/surface conditions

Noise

Air quality/temperature

Equipment malfunction

Supervision

Employee morale/attitude/health

Alcohol/drug abuse

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Investigation Begins

• Individual shots of accident scene

• Click link(s) • Lab cart - first view

• Lab cart - second view

• Plug

• Water

• Feet

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Effective Investigation

Examples…

Immediate Causes?

Basic Causes?

Root Causes?

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Effective Investigation

Poor maintenance / housekeeping

Poor labour relations

Poor health

Tampering / removal of safety device (3 prong & insulating rubber feetWater on floor

Contact with live equipmentFall to the floorStruck head

Examples…

Immediate Causes?

Basic Causes?

Root Causes?

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Accident SceneRe-visited

• Click here to view accident scene

• What really happened?

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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

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Thank You

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OPTIONAL SCENARIO:OFFICE ACCIDENT

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OPTIONAL SCENARIO:OFFICE ACCIDENT

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OFFICE ACCIDENT

Contributing Factors:

Policies/Procedures Equipment Materials

Environment Task People/Operators

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Office Accident Investigation

Immediate Causes?

Basic Causes?

Root Causes?

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Office Accident Investigation

Working alone

Training

Using improper procedure / equipmentStanding on cabinet

Fall to the floorStruck back

Immediate Causes?

Basic Causes?

Root Causes?

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OFFICE ACCIDENTCONCLUSION

Accidents generally have more than one

cause Keep asking WHY until you determine the root cause

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Thank You