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TRANSCRIPT
Incident Investigation Training
Portage County Safety Council – April 2016
August 12, 2016
Don Elswick
https://youtu.be/CCbWyYr82BM
Elswick August 12, 2016 • Slide 1
August 12, 2016 • Slide 2
Pessimism –vs- Optimism
The pessimist sees difficulty in every opportunity. The optimist sees opportunity in every difficulty. Winston Churchill
The pessimist sees failure in every accident. The optimist sees opportunity to analyze, learn and prevent recurrence in every accident. The only time an accident is totally negative is when we do not learn from it. Dale Janes
August 12, 2016 • Slide 3
A Quiz!
Find a learning partner…..
Find out the first job (taxes paid) and discuss two (2)
safety and health myths
Example: Training should be required on all incident
investigations with attorneys involved…..
August 12, 2016 • Slide 4
Fallacies in the Safety Fable
Occupational H
azard
s,
Octo
ber
1997
Low recordable rates indicate safety programs that are working well
Safety professionals and attorneys can keep workers safe
Conditions cause Accidents
Enforcing rules improve safety
Rewards improve safety
Investigating to find the root cause of accidents will improve safety
Awareness Training improves safety
August 12, 2016 • Slide 5
A Quiz!
TO BE SURE YOU ARE COMFORTABLE
WITH THESE FACT WRITING IDEAS …..
LETS TAKE A QUIZ
August 12, 2016 • Slide 6
Timed Quiz
YOU WILL BE GIVEN A QUIZ
LEAVE IT FACE DOWN UNTIL THE TIME
STARTS
YOU WILL HAVE 60 SECONDS TO
ANSWER THE QUESTIONS
Our work is comp.
August 12, 2016 • Slide 7
On a bright sunny day, a contractor arrived at a construction
site. An accident had occurred.
A worker, wearing safety glasses, hard hat and safety
harness, was shouting, in Italian, at a co-worker standing
nearby. The other worker was wearing no safety
equipment.
It seems a beam had fallen and ruined a day’s work.
Watching the discussion were two other workers. One, a
young bearded worker, was chatting with another worker
who had long hair and wore jeans.
Read the Following Story.
Then Complete the Quiz.
August 12, 2016 • Slide 8
60 Seconds -----
1. There are 5 people at the site. T F ?
2. It is spring or summer. T F ?
3. A steel beam has fallen. T F ?
4. The contractor saw a worker shouting. T F ?
5. The worker was shouting to tell his friend the boss was coming. T F ?
6. One worker is Italian. T F ?
7. The worker wearing the safety equipment did not cause the accident. T F ?
8. The worker not wearing safety equipment caused the accident. T F ?
August 12, 2016 • Slide 9
60 Seconds -----
9. The worker not wearing safety equipment is not safety conscious. T F ?
10. Management is only concerned about meeting the work schedule. T F ?
11. The two workers chatting are wasting time. T F ?
12. The bearded worker is chatting with a woman. T F ?
13. If the long haired person in jeans is a man, is it possible that the
bearded man loves him? T F ?
Our work is comp.
August 12, 2016 • Slide 10
60 Seconds -----
14. This is a good time to have a safety meeting. T F ?
15. Did you identify any mental models that might allow you to jump to
unfounded conclusions? T F ?
16.Did answering these questions change your first impression
of the scene? T F ?
17. No one was injured so the accident is no big deal. T F ?
August 12, 2016 • Slide 11
Licensed Drivers and Numbers in Accidents by Age
Our work is comp.
1) What age group has the highest number of
accidents?
2) What group has the highest number of drivers in
fatal accidents?
3) Based on 2009 National Safety Council statistics
who would you want to be your driver?
a) 16-19
b) 20-24
c) 25-34
d) 35-44
e) 45-54
f) 55-64
g) 65-74
August 12, 2016 • Slide 12
Driving Survey
1) What age group has the
highest number of
accidents?
a) 16-19 | 10, 326
b) 20-24 | 17, 465
c) 25-34 | 36, 694
d) 35-44 | 38, 424
e) 45-54 | 41, 921
f) 55-64 | 33, 271
g) 65-74 | 19, 135
2) What group above has
the highest number of
drivers in fatal
accidents?.
a) 25-34 | 18.3%
b) 45-54 | 17.3%
c) 35-44 | 15.6%
3) Based on 2009 National
Safety Council statistics
who would you want to be
your driver?
16 year old
number of accidents: 1,311
fatality: 1.5%
Our work is comp.
August 12, 2016 • Slide 13
Session Objectives
Define when to investigate and how to collect information for and use
information from the investigation
Describe how to complete the four steps of an investigation including:
– How to list facts and conduct interviews
– Proper documentation for investigation
– How to decide upon appropriate actions to prevent recurrences
Practice completing investigation from example scenarios
August 12, 2016 • Slide 14
Why Do You Want To Know Why An Incident Occurs?
Prevent further incidents
Protect employees
Save company money / protect jobs
August 12, 2016 • Slide 15
An accident results from a combination of several causes.
The solution to each accident can be found in a detailed
analysis of the accident itself.
Basic Principles
August 12, 2016 • Slide 16
1. ASSEMBLE A TEAM
2. DEVELOP A LIST OF FACTS
3. CONSTRUCT A FACT DIAGRAM
4. IDENTIFY TARGET FACTS AND SELECT CORRECTIVE ACTIONS
Overview of the Method
August 12, 2016 • Slide 17
Step #2 – Develop a List of Facts
Rules:
– ONE FACT AT A TIME
– DO NOT MAKE VALUE JUDGMENTS
– DO NOT INTERPRET JUDGE
JUDGE
JUDGE
August 12, 2016 • Slide 18
Definitions / Discussion
ONE FACT AT A TIME
– Work through each fact on its own before moving on to
the next
– Order is not important at this point
NO INTERPRETATION
– Avoid to interpret facts in a particular way (i.e., Aisle too
narrow, etc.)
August 12, 2016 • Slide 19
DON’T MAKE VALUE JUDGMENTS
– Above all do not be negative.
– Facts are facts, not good or bad, they just are what they
are. (i.e., Unsafe, careless, bad design, poor judgement,
etc.)
Definitions / Discussion
Communications
Class is canceled today.
We will meet again at 8:30 a.m.
three days
after two days before the day
before tomorrow.
August 12, 2016 • Slide 20
August 12, 2016 • Slide 21
Are We Close?
RULES
1. ONE FACT AT A
TIME
2. DO NOT MAKE
VALUE
JUDGMENTS
3. DO NOT
INTERPRET
Seven cm
long cut to left
forearm
He was using
a utility knife
Cut towards
himself
He was not
wearing a
forearm guard
He did not
know about
forearm
guards
Exposed
blade
August 12, 2016 • Slide 22
What Are The Key Questions Again?
What is the cause of this fact?
Was it necessary?
Was it sufficient?
August 12, 2016 • Slide 23
He was using
a utility knife
Cut towards
himself
He was not
wearing a
forearm guard
He did not
know about
forearm
guards
Exposed
blade
Find The End Result
Seven cm
long cut to left
forearm
Seven cm
long cut to
left forearm
Our work is comp.
August 12, 2016 • Slide 24
Cut towards
himself
He was not
wearing a
forearm guard
Exposed
blade
He did not
know about
forearm
guards
He was using
a utility knife
Select A New Result
Identify The Fact(s) That Directly Caused It To Occur
He did not
know about
forearm
guards
?
He was
using a
utility knife ?
Seven cm
long cut to
left forearm
August 12, 2016 • Slide 25
Organizational Solutions
Clarify Assignments
Upgrade training
Establish Operating Controls
Revise Procedure
Increase Audit Effort
Improve Work Planning
Use a checklist
Improve Supervisory
Example
Improve Hazard Assessment
Improve Training
Assessment
Resolve Conflict in Priorities
August 12, 2016 • Slide 26
Improve Hazard Recognition
Improve Procedure Use
Increase Knowledge
Re-Train on Procedure
Improve Clarity of Directions
Resolve Conflicting Demands
Address Physical Limitations
Address Mental Limitations
Address Fatigue
Address Drug / Alcohol Issues
Address Conduct or Behaviour
Problem
Human Solutions
August 12, 2016 • Slide 27
Modify Equipment Design
(Materials of Construction, Size,
Pressure and Temperature
Constraints, etc.)
Add Guarding
Instrumentation and Controls
Management of Change
Modify Preventative
Maintenance
Reduce Noise
Increase Lighting
Change Specifications
Communicate Limitations
Material Solutions
August 12, 2016 • Slide 28
Which Facts Would You Target?
Seven cm
long cut to left
forearm
Cut towards
himself
He was not
wearing a
forearm guard
Exposed
blade
He did not
know about
forearm
guards
He was using
a utility knife
•Human
•Organizational
•Material
August 12, 2016 • Slide 29
TARGET CORRECTIVE ACTIONS BY DATE
ORGANIZATION
HUMAN
MATERIAL
He did not
know about
forearm guards
Cut towards
himself
He was using
utility knife
Add use of forearm guards to
departmental rules and training. VLM x/x/xx
Employee has committed to
follow rule. PKL x/x/xx
Utility knifes will be replaced
with box cutting knives that
guard the blade. CKS x/x/xx
Step 4 – Identify Target Facts and Selecting
Corrective Actions
August 12, 2016 • Slide 30
Summing Up
Burn
On Arm
Steam In Pipe
Hot
Pipe
Uninsulated
Pipe
Pipe Dismantled
Previous
Day
No Insulation
In Stock
Delay
In Delivery
Arm On Pipe
Falling
Down
Slipping
Foot In
Oil
Puddle
Oil Puddle
On Floor
Overturned
Oil Can
Open Oil
Can
George Was
Passing By
Did Not See Oil
Puddle
George Called
By Charlie
Glass Fell Near
George
Fork-Lift
Passing By
Glass
Roofed Hall
Obstructed
Safety Panel On
Fork-Lift Damaged
Can In Alley
Pallets Stocked
In Alley
Ray On
Scaffolding
Replacing
Glass Panel
Glass
Panel
Broken
Previous
Day
Causal TreeTM
Diagram of the Accident
August 12, 2016 • Slide 31
1. ASSEMBLE A TEAM
(Consider: Injured, observers, safety professional, person experienced
in the method, safety committee member, decision maker, supervisor.)
2. DEVELOP A LIST OF FACTS
Rules:
a. One fact at a time.
b. No value judgments
c. No interpretations
3. CONSTRUCT A DIAGRAM
a. Find the end result
b. Identify the fact(s) that directly caused it to occur
c. Check your logic
i. Was it necessary?
ii. Is/are the fact(s) sufficient?
a. If not, what else directly caused it?
b. If the fact(s) are both necessary and sufficient, start again with a new result.
4. IDENTIFY TARGET FACTS AND SELECT CORRECTIVE ACTIONS
Investigation Method
August 12, 2016 • Slide 32
On Difficult Solutions
The things you refuse to meet
today always come back at
you later on, usually under
circumstances which make
the decision twice as difficult
as it originally was.
--- Eleanor Roosevelt
Thermometer or Thermostat
August 12, 2016 • Slide 33
https://youtu.be/JPOVwKPMG8o