accident investigation (2)

www.spin-safety.orgSubmitted by Felicia Thomason

ACCIDENT INVESTIGATION

A Total Hazard Control System.

Submitted by Felicia Thomason

PURPOSE

To Complete The Aspects Of A Total Hazard Control System.


THESE ASPECTS ARE:

Hazard analysis Inspection Measurement Accident investigation


WHY?

Determine cause(s) Uncover indirect accident

cause Document facts Provide information of cost Promote safety


WHO?

Supervisor Foreman Safety and health

professional Special committee Company safety committee


WHAT?

What was the person doing? What was the person’s normal

duties? Or what was different? What were others doing at the time? What was the proper equipment the

person should be using? What procedures were being

followed?

Was the process/task new? Was the person being supervised? What training did the person have? What was the location? What short-term actions taken to

prevent it? What long-term actions need to be

taken, and if previous corrective actions taken or recommendation followed?


TYPES

Failure Mode and Effect Analysis (FMEA) OPERATONS Hazard Analysis (OHA) Risk Tree aka Management Oversight &

Risk Tree analysis (MORT) 4M Man, Machine, Media, Management Cost Effectiveness Analysis

The C&E diagram is also known as the fishbone diagram because it was drawn to resemble the skeleton of a fish, with the main causal categories drawn as "bones" attached to the spine of the fish, as shown below.

Cause & effect diagrams can also be drawn as tree diagrams, resembling a tree turned on its side. From a single outcome or trunk, branches extend that represent major categories of inputs or causes that create that single outcome. These large branches then lead to smaller and smaller branches of causes all the way down to twigs at the ends. The tree structure has an advantage over the fishbone-style diagram. As a fishbone diagram becomes more and more complex, it becomes difficult to find and compare items that are the same distance from the effect because they are dispersed over the diagram. With the tree structure, all items on the same causal level are aligned vertically.


To successfully build a cause and effect diagram:

Be sure everyone agrees on the effect or problem statement before beginning.

Be succinct. For each node, think what could be its causes.

Add them to the tree. Pursue each line of causality back to its root

cause. Consider grafting relatively empty branches

onto others. Consider splitting up overcrowded branches. Consider which root causes are most likely to

merit further investigation.


DATA COLLECTION


ANALYSIS OF THE FACTS


CORRECTIVE ACTION PLANNING

Cost Time Human Element


RESOURCES AVAILABLE

OSHA Publications TWCC Publications National Safety Council

Publications OSHCON

1(800) 687-7080•www.oshcon.twcc.state.tx.us

accident investigation (2)

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