ACCIDENT INVESTIGATION 101ACCIDENT INVESTIGATION 101

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Course ObjectivesCourse Objectives Understand the need to investigateUnderstand the need to investigate Know what to investigateKnow what to investigate Determine the cause(s) of accidentsDetermine the cause(s) of accidents Identify the methods of Identify the methods of

investigationsinvestigations Understand the need to be Understand the need to be

thorough and comprehensivethorough and comprehensive Identify prevention methodsIdentify prevention methods Identify sources of assistance Identify sources of assistance

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What is your What is your definition of an definition of an

“Accident”?“Accident”?

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What is an AccidentWhat is an Accident

- an unplanned event- an unplanned event- an unplanned incident - an unplanned incident involving injury or fatalityinvolving injury or fatality- a series of events - a series of events culminating in an culminating in an unplanned and unforeseen unplanned and unforeseen eventevent

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How do Accidents How do Accidents occur?occur?

- - Accidents (with or without injuries) Accidents (with or without injuries) occur when a series of unrelated occur when a series of unrelated events coincide at a certain time and events coincide at a certain time and space.space.

-This can be from a few events to a -This can be from a few events to a series of a dozen or moreseries of a dozen or more(Because the coincidence of the (Because the coincidence of the series of events is a matter of luck, series of events is a matter of luck, actual accidents only happen actual accidents only happen infrequently)infrequently)

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Unsafe ActsUnsafe Acts

- An unsafe act occurs in approx 85%- - An unsafe act occurs in approx 85%- 95% of all analyzed accidents with 95% of all analyzed accidents with injuriesinjuries- An unsafe act is usually the last of a - An unsafe act is usually the last of a series of events before the accident series of events before the accident occurs (it could occur at any step of the occurs (it could occur at any step of the event)event)- By stopping or eliminating the unsafe - By stopping or eliminating the unsafe act, we can stop the accident from act, we can stop the accident from occurringoccurring

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Why Investigate Accidents?Why Investigate Accidents?

Prevent a recurrence with corrective Prevent a recurrence with corrective actionaction

Determine the causeDetermine the cause Document your Line Office’s version Document your Line Office’s version

of of the incidentthe incident

Complete OSHA-required reportingComplete OSHA-required reporting

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What is an Accident What is an Accident Investigation?Investigation?

A systematic approach to the A systematic approach to the identification of causal factors and identification of causal factors and implementation of corrective actions implementation of corrective actions without placing blamewithout placing blame on or on or finding personal fault. The finding personal fault. The information collected during an information collected during an investigation is essential to determine investigation is essential to determine trends and taking appropriate steps trends and taking appropriate steps to prevent future accidents.to prevent future accidents.

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Which Accidents should Which Accidents should be be

Recorded or Reported?Recorded or Reported?ALLALL accidents accidents (including illnesses) shall(including illnesses) shallbe recorded and reportedbe recorded and reportedthrough the established through the established procedures and guidance procedures and guidance as provided by as provided by NOAA Safety DivisionNOAA Safety Division

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Why Investigate Accidents?Why Investigate Accidents? Determine the causeDetermine the cause Develop and implement corrective Develop and implement corrective

actionsactions Document the eventsDocument the events Meet legal requirementsMeet legal requirements

Primary Focus:

PREVENT REOCCURENCE!!!PREVENT REOCCURENCE!!!PREVENT REOCCURENCE!!!

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Who Investigates?Who Investigates?

Minor accident/incidentMinor accident/incident— SupervisorSupervisor— Safety committee memberSafety committee member

Major accident/incidentMajor accident/incident— SupervisorSupervisor— Safety committee memberSafety committee member— Occupational Health & Safety Manager’s Occupational Health & Safety Manager’s

(OHS’s/IIC)(OHS’s/IIC)— Regional Environmental Compliance Regional Environmental Compliance

Officer’s (RECO’s)Officer’s (RECO’s)

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Investigator’s QualificationsInvestigator’s Qualifications

Accident investigation trainingAccident investigation training Understanding the importance Understanding the importance

of investigationof investigation Ability to communicate detailsAbility to communicate details

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When to Investigate?When to Investigate? Immediately after incidentImmediately after incident

— Witness memories fadeWitness memories fade— Equipment and clues Equipment and clues

are movedare moved

Finish investigation quicklyFinish investigation quickly

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Accident vs. Near-MissAccident vs. Near-Miss

Accident :

Any undesired, unplanned event arising out of a given work-related task which results in physical injury/ illness or damage to property.

Near-Miss :

Events which did not result in injury/illness or damage but had the potential to do so.

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Accident Ratio StudyAccident Ratio Study

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1

10

600

6000

Serious or Disabling

Minor Injuries

Property Damage

Accidents with no visible injury or damage

Unsafe Acts or Conditions

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Accident CausesAccident Causes

Unsafe ActUnsafe Act

- an act by the injured person or - an act by the injured person or another person (or both) which another person (or both) which caused the accident, caused the accident,

and/orand/or Unsafe ConditionUnsafe Condition

- some environmental or hazardous - some environmental or hazardous situation which caused the accident situation which caused the accident independent of the employeeindependent of the employee

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Accident Causation ModelAccident Causation Model

Results of the accidentResults of the accident- physical harm- physical harm- property damage- property damage

Incident OccurrenceIncident Occurrence- contact with- contact with- type- type

Immediate causesImmediate causes- practices- practices- conditions- conditions

Basic causesBasic causes- personal factors- personal factors- job factors- job factors- supervisory performance- supervisory performance- management policy and - management policy and decisionsdecisions

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Results of the AccidentResults of the Accident

Physical HarmPhysical Harm- catastrophic (multiple - catastrophic (multiple deaths)deaths)- single death- single death- disabling- disabling- serious- serious- minor- minor

Property DamageProperty Damage- catastrophic- catastrophic- major- major- serious- serious- minor- minor

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Incident OccurrenceIncident Occurrence TypeType

- struck by- struck by - struck against- struck against- slip, trip - slip, trip - fell from- fell from- caught on- caught on - fell on same level- fell on same level- caught in- caught in - overexertion- overexertion

Contact withContact with- electricity- electricity - equipment- equipment- noise- noise - vibration- vibration- hazmat- hazmat - heat/cold- heat/cold- radiation- radiation - - animals/insectsanimals/insects

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Immediate CausesImmediate Causes PracticesPractices

- operating without - operating without authorityauthority- use equipment - use equipment improperlyimproperly- not using PPE when - not using PPE when requiredrequired- correct lifting - correct lifting procedures not procedures not establishedestablished- drinking or drug use- drinking or drug use- horseplay- horseplay- equipment not - equipment not properly securedproperly secured

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Immediate Causes Immediate Causes (cont’d)(cont’d)

ConditionsConditions- ineffective guards- ineffective guards- unserviceable tools - unserviceable tools and equipmentand equipment- inadequate warning - inadequate warning systemssystems- bad housekeeping - bad housekeeping practicespractices- poor work space - poor work space illuminationillumination- unhealthy work - unhealthy work environmentenvironment

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Basic CausesBasic Causes

Personal FactorsPersonal Factors- lack of knowledge or skill- lack of knowledge or skill- improper motivation- improper motivation- physical or mental condition- physical or mental condition- literacy or ability- literacy or ability

Job FactorsJob Factors- Physical environment- Physical environment- sub-standard equipment- sub-standard equipment- abnormal usage- abnormal usage- wear and tear- wear and tear- inadequate standards- inadequate standards- design and maintenance- design and maintenance

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Basic Causes Basic Causes (cont’d)(cont’d) Supervisory PerformanceSupervisory Performance

- inadequate instructions- inadequate instructions- failure of SOPs- failure of SOPs- rules not enforced- rules not enforced- hazards not corrected- hazards not corrected- devices not provided- devices not provided

Management Policy and Management Policy and DecisionsDecisions- set measurable standards- set measurable standards- measure work in progress- measure work in progress- evaluate work vs. - evaluate work vs. standardsstandards- correct performance- correct performance

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Investigator’s QualificationsInvestigator’s Qualifications

Technical knowledgeTechnical knowledge ObjectivityObjectivity Analytical approachAnalytical approach Familiarity with the job, process or Familiarity with the job, process or

operationoperation Tact in communicatingTact in communicating Intellectual honestyIntellectual honesty Inquisitiveness and curiosityInquisitiveness and curiosity

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Beginning the InvestigationBeginning the Investigation Gather investigation Gather investigation

team and kitteam and kit Report to the sceneReport to the scene Look at the big Look at the big

picturepicture Record initial Record initial

observationsobservations Take picturesTake pictures

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What’s Involved?What’s Involved? Who was injured?Who was injured? Medication, drugs, Medication, drugs,

or alcohol?or alcohol? Was employee ill?Was employee ill? Double shift or Double shift or

rotating shifts?rotating shifts?

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WitnessesWitnesses

Who witnessed the Who witnessed the incident?incident?

Was a supervisor or Was a supervisor or lead person nearby?lead person nearby?

Where were other Where were other employees?employees?

Why didn’t anyone Why didn’t anyone witness the incident?witness the incident?

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Interviewing TipsInterviewing Tips

Discuss what happened leading Discuss what happened leading up to and after the accidentup to and after the accident

Encourage witnesses to describe Encourage witnesses to describe the accident in their own wordsthe accident in their own words

Don’t be defensive or judgmentalDon’t be defensive or judgmental Use open-ended questionsUse open-ended questions

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What Was Involved?What Was Involved?

Machine, tool, Machine, tool, or equipmentor equipment

ChemicalsChemicals Environmental Environmental

conditionsconditions Production Production

scheduleschedule

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Severity of IncidentSeverity of Incident (NOAA Safety Policy NAO-209-1)(NOAA Safety Policy NAO-209-1)

MajorMajor - Employee fatality,- Employee fatality, - Hospitalization of 3 or more employees,- Hospitalization of 3 or more employees, - Permanent employee disability,- Permanent employee disability, - Five or more lost workdays,- Five or more lost workdays,

- Conditions that could pose an imminent and - Conditions that could pose an imminent and threat of serious injury/illness to other threat of serious injury/illness to other

employeesemployees - Property losses in excess of $1 Million- Property losses in excess of $1 Million

MinorMinor - All other (less serious) incidents and unsafe- All other (less serious) incidents and unsafe conditions reported by employeesconditions reported by employees

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Who Investigates?Who Investigates? Major AccidentsMajor Accidents

- NOAA GO TEAM Investigation Team- NOAA GO TEAM Investigation Team

- LO Representative- LO Representative

- Other agencies such as NTSB, USCG, - Other agencies such as NTSB, USCG, OSHAOSHA

Minor AccidentsMinor Accidents

- First-Line Supervisor- First-Line Supervisor

- Site Director or Manager- Site Director or Manager

- Site Safety Representative- Site Safety Representative

- SECO (if needed) - SECO (if needed)

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When to Investigate?When to Investigate?

Immediately after incidentImmediately after incident Witness memories fadeWitness memories fade Equipment and clues Equipment and clues

are movedare moved

Finish investigation quicklyFinish investigation quickly

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What to Investigate?What to Investigate?

All accidents and near-missesAll accidents and near-misses

- Conduct investigation upon first - Conduct investigation upon first

notification notification

- Keeping the scene in-tact and - Keeping the scene in-tact and

recording witnesses statementsrecording witnesses statements

early is key to a successful early is key to a successful

investigation investigation

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Accident Investigation KitAccident Investigation Kit

May Include:May Include: Digital CameraDigital Camera Report forms, clipboard, pensReport forms, clipboard, pens Barricade tapeBarricade tape FlashlightFlashlight Tape measureTape measure Tape recorderTape recorder Personal Protective Equipment (as Personal Protective Equipment (as

appropriate)appropriate)

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The Accident OccursThe Accident Occurs Employee or co-worker immediately Employee or co-worker immediately

reports the accident to a supervisorreports the accident to a supervisor Supervisor secures/assesses the scene Supervisor secures/assesses the scene

to prevent additional injuries to other to prevent additional injuries to other employees, before assisting the employees, before assisting the injured employeeinjured employee

Supervisor treats the injury or seeks Supervisor treats the injury or seeks medical treatment for the injuredmedical treatment for the injured

The accident scene is left intactThe accident scene is left intact Site safety rep is contacted to assist Site safety rep is contacted to assist

the supervisor in the investigation of the supervisor in the investigation of the accident.the accident.

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Beginning the InvestigationBeginning the Investigation

Gather Gather investigation investigation members and kitmembers and kit

Report to the sceneReport to the scene Look at the big Look at the big

picturepicture Record initial Record initial

observationsobservations Take picturesTake pictures

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What’s Involved?What’s Involved?

Who was injured?Who was injured? Medication, drugs, Medication, drugs,

or alcohol?or alcohol? Was employee ill or Was employee ill or

fatigued?fatigued? Environmental conditions?Environmental conditions?

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WitnessesWitnesses

Who witnessed the Who witnessed the

accident?accident? Was a supervisor or Was a supervisor or

Team Lead nearby?Team Lead nearby? Where were other Where were other

employees?employees? Why didn’t anyone Why didn’t anyone

witness the accident witness the accident

(working alone, remote areas)?(working alone, remote areas)?

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Interviewing TipsInterviewing Tips

Discuss what happened leading Discuss what happened leading up to and after the accidentup to and after the accident

Encourage witnesses to describe Encourage witnesses to describe the accident in their own wordsthe accident in their own words

Don’t be defensive or judgmentalDon’t be defensive or judgmental Use open-ended questionsUse open-ended questions Do not interrupt the witness Do not interrupt the witness

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What was Involved?What was Involved?

Machine, tool, or Machine, tool, or equipmentequipment

ChemicalsChemicals Environmental Environmental

conditionsconditions Field season prep Field season prep

operationsoperations

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Date and time?Date and time? Normal shift orNormal shift or

working hours?working hours? Employee coming Employee coming

off a vacation?off a vacation?

Time of AccidentTime of Accident

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Accident LocationAccident Location

Work areaWork area On, under, in, nearOn, under, in, near Off-site addressOff-site address Doing normal job Doing normal job

dutiesduties Performing non-Performing non-

routine or routine routine or routine tasks (i.e., properly tasks (i.e., properly trained)trained)

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Employee’s ActivityEmployee’s Activity

Motion Motion conducted at conducted at time of accidenttime of accident

Repetitive Repetitive motion?motion?

Type of material Type of material being handledbeing handled

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Accident NarrativeAccident Narrative

Describe the details so the reader Describe the details so the reader can clearly picture the accidentcan clearly picture the accident

Specific body parts affectedSpecific body parts affected Specific motions Specific motions

of injured employeeof injured employee

just before, just before,

during, and during, and

after accidentafter accident

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Causal FactorsCausal Factors

Try not to accept single cause theoryTry not to accept single cause theory Identify underlying causes (root)Identify underlying causes (root) Primary causePrimary cause Secondary causesSecondary causes

Contributing causesContributing causes Effects Effects

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Corrective Actions TakenCorrective Actions Taken Include immediate interim controls Include immediate interim controls

implemented at the time of accidentimplemented at the time of accident Recommended corrective actionsRecommended corrective actions

Employee trainingEmployee training Preventive maintenance activitiesPreventive maintenance activities Better operating proceduresBetter operating procedures Hazard recognition (ORM)Hazard recognition (ORM) Management awareness of risks Management awareness of risks

involvedinvolved

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Immediate NotificationImmediate Notification

Supervisor shall complete the NOAA Supervisor shall complete the NOAA Accident Reporting Form (web-Accident Reporting Form (web-based) and submit within 24 hours of based) and submit within 24 hours of incident occurrence.incident occurrence.

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SummarySummary Investigate accidents immediatelyInvestigate accidents immediately Determine who was involved and Determine who was involved and

who witnessed itwho witnessed it Ascertain what items or equipment Ascertain what items or equipment

were involvedwere involved Record detailed descriptionRecord detailed description Determine causal factorsDetermine causal factors Conduct corrective actionsConduct corrective actions

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1.1. What is an Accident Investigation?What is an Accident Investigation?

a.a. A systematic approach to the identification of A systematic approach to the identification of causal factors and implementation of corrective causal factors and implementation of corrective actions.actions.

b.b. Finding personal fault and placing blame. Finding personal fault and placing blame.

c.c. The appropriate steps to prevent future The appropriate steps to prevent future actions.actions.

d.d. The essential step to determine trends and The essential step to determine trends and taking action against person or persons at fault. taking action against person or persons at fault.

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2.2. Which Accidents should be Which Accidents should be Recorded or Reported?Recorded or Reported?

a.a. Only on the job accidents.Only on the job accidents.

b.b. ALL accidents (including illnesses) shall be ALL accidents (including illnesses) shall be recorded and reported.recorded and reported.

c.c. Only on the job accidents on illnesses that Only on the job accidents on illnesses that occur on the job and reported within 8 hours.occur on the job and reported within 8 hours.

d.d. All accidents shall be recorded and reported.All accidents shall be recorded and reported.

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3.3. Why Investigate Accidents?Why Investigate Accidents?

a.a. To develop and implement corrective actions.To develop and implement corrective actions.

b.b. To document the events.To document the events.

c.c. The Primary Focus is to PREVENT The Primary Focus is to PREVENT REOCCURENCE!!!REOCCURENCE!!!

d.d. To determine the cause.To determine the cause.

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4.4. Accident vs. Near-Miss?Accident vs. Near-Miss?

a.a. Any Any unplanned events arising out of work vs. Any events which did not result in injury.

b. Any unsafe work habit vs. Any Hazardous working conditions.

c. Any events which warns us a problem vs. Any circumstances that result in injury or property damage.

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5.5. Which of the following are the basic Which of the following are the basic areas that are looked at in an areas that are looked at in an Accident Investigation.Accident Investigation.

a.a. Policies.Policies.

b.b. Equipment.Equipment.

c.c. Training.Training.

d.d. All of the above.All of the above.

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QuizQuiz1.1. It is best to interview witnesses all together in It is best to interview witnesses all together in

order to save time. order to save time. True or FalseTrue or False2.2. Name two environmental factors that may be Name two environmental factors that may be

involved in an accident: ______________ and involved in an accident: ______________ and ______________.______________.

3.3. Define a “minor” accident according to Define a “minor” accident according to investigation procedures: investigation procedures: __________________________________.__________________________________.

4.4. The main reason for investigating The main reason for investigating accidents is to fix the blame somewhere.accidents is to fix the blame somewhere.

True or FalseTrue or False5.5. Employees need to report injuries only if they Employees need to report injuries only if they

think they need to see a doctor.think they need to see a doctor. True or FalseTrue or False

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Quiz Quiz (cont.)(cont.)

6.6.Prior to arriving at the accident scene, one team Prior to arriving at the accident scene, one team member should have taken the __________________.member should have taken the __________________.

7.7.Describe at least two factors to investigate about Describe at least two factors to investigate about the the injured employee: ______________ and _____________.injured employee: ______________ and _____________.

8.8.How could the time of the accident be considered How could the time of the accident be considered a causal factor?a causal factor?

9.9.Describing the general accident location Describing the general accident location is adequate for the report.is adequate for the report. True or FalseTrue or False

10.10.Describe at least two factors to investigate when Describe at least two factors to investigate when equipment is involved: ____________ and ___________.equipment is involved: ____________ and ___________.

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Quiz AnswersQuiz Answers1.1.False. Witnesses should be interviewed False. Witnesses should be interviewed

separately.separately.

2.2.Wet floor, poor lighting, cold or hot day, noise.Wet floor, poor lighting, cold or hot day, noise.

3.3.A “minor” accident is when the injured A “minor” accident is when the injured employee does not require outside medical employee does not require outside medical attention.attention.

4.4.False. Accidents are investigated so corrective False. Accidents are investigated so corrective actions can be taken to prevent another actions can be taken to prevent another accident.accident.

5.5.False. Employees need to report all injuries, no False. Employees need to report all injuries, no matter how small, and near-miss incidents.matter how small, and near-miss incidents.

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Quiz Answers Quiz Answers (cont.)(cont.)

6.6. Investigation kit.Investigation kit.

7.7. Alcohol or drugs, medication, illness, tired, Alcohol or drugs, medication, illness, tired, extra shift, eyesight.extra shift, eyesight.

8.8. Early morning accident related to tired, Early morning accident related to tired, inattentive employee. Late afternoon inattentive employee. Late afternoon accident related to fatigue of a full day of accident related to fatigue of a full day of work.work.

99.. False. The report requires very specific False. The report requires very specific details of the location of an accident.details of the location of an accident.

10.10. Equipment malfunction, employee training Equipment malfunction, employee training and skill level, amount of supervision.and skill level, amount of supervision.

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The EndThe End