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![Page 1: Accident Investigation Massachusetts Manufacturing Self-Insurance Group, Inc. S afety A wareness F or E veryone from Cove Risk Services.](https://reader030.fdocuments.in/reader030/viewer/2022032607/56649ec55503460f94bcf7d1/html5/thumbnails/1.jpg)
Accident Investigation
Massachusetts Manufacturing Self-Insurance Group, Inc.
Safety Awareness For Everyone from Cove Risk Services
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What is an Accident?
• An unintended happening, mishap
• Most often an accident is any unplanned event that results in personal injury or in property damage
• The failure of people, equipment, supplies or surroundings to behave or react as expected
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Accident Investigation
• Will determine the “how” and “why” of failures
• Examine possible corrective action
• Aid in the accident prevention and elimination of a clearly identified hazard
• Most important – Investigation is not intended to place blame
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Be Prepared
• Designate an investigator (or a team)– This should be one of this persons key
responsibilities– Should have a good working knowledge of
operating procedures
• Be equipped with the right tools to do the job thoroughly
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Record the Facts
• Interview witnesses as soon as possible
• Record all necessary information at the accident scene before any changes are made– Take photos (camera or camera phone)– Record measurements
• Gather support documents such as maintenance records, employee records, production schedules, training documents and records, or process diagrams
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Record the Facts
• Keep all notes and remarks in a bound notebook or three ring binder
• Record:– Pre-accident conditions– Accident sequence– Post-accident conditions
• Document victim location, witnesses, equipment, machinery, energy sources and other contributing factors
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Record the Facts
• Even the most insignificant detail may be useful
• Document and then document some more
• The investigator should be concentrating solely on the investigation at hand
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Interviewing
• Excellent source of first hand knowledge
• May present pitfalls in the form of:– Bias– Perspective– Embellishment
• It is important to maintain a clear thought process and control of the interview
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Interviewing• Get preliminary statements as soon as possible
from all witnesses
• Locate the position of each witness on a master chart (including the direction of view)
• Explain the purpose of the investigation (accident prevention) and put each witness at ease.
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Interviewing
• Let each witness speak freely and take notes without distracting the witness (use a tape recorder only with consent of the witness)
• Use sketches and diagrams to help the witness
• Emphasize areas of direct observation and label hearsay accordingly
• Record the exact words used by the witness to describe each observation
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Interviewing
• Word each question carefully and be sure the witness understands
• Identify the qualifications of each witness (name, address, occupation, years of experience, etc.)
• If they wish, supply each witness with a copy of their statements (signed statements are desirable)
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Problem Solving Techniques
• This technique emphasizes change to correct the problem
• Examine the differences between the norm and what actually happened
• Consider all problems to result from some unanticipated change
• Analyze the changes to determine its cause
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• Use the following steps in this method:
– Define the problem (What happened?)
– Establish the norm (What should have happened?)
– Identify, locate, and describe the change
(what, where, when, to what extent)
– Specify what was affected
– Identify the distinctive features of the change
– List the possible causes
– Select the most likely causes
Problem Solving TechniquesChange Analysis
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Problem Solving TechniquesJob Hazard Analysis
• Job Hazard Analysis (JHA) is part of many existing accident prevention programs
• In general, JHA breaks a job into basic steps, and identifies the hazards associated with each step as well as prescribing controls for each hazard
• A JHA is a chart listing these steps, hazards, and controls
• Review the JHA during the investigation if a JHA has been conducted for the job involved in an accident
• Perform a JHA if one is not available to determine the events and conditions that led to the accident
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Investigation Report
• An accident investigation is not complete until a report is prepared and submitted to the proper managers
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Investigation Report• Background Information
– Where and when the accident occurred – Who and what were involved – Personnel and other witnesses
• Account of the Accident (What happened?)
– Sequence of events – Extent of injury– Accident type – Source
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Investigation Report
• Discussion
(Analysis of the Accident – HOW & WHY)
– Direct causes (energy sources; hazardous materials)
– Indirect causes (unsafe acts and conditions)
– Basic causes (management policies; personal or environmental factors)
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Investigation Report
• Recommendations (to prevent a recurrence)
for immediate and long-term corrective actions
– Engineering Controls
– Administrative Controls
– PPE
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Accident Scenario
Joe, the maintenance worker, strained his knee after slipping and falling.
What questions need answering?
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Some Questions• Where did this happen? What time of year is it (is this normal)? What time/shift? Was he the first person to go through this area and walk on this surface?
• What kind of floor is this? When was it last inspected for slip hazards? What are the normal inspection and maintenance procedures? Does this current procedure make sense?
• Was he trained to look for hazards like this? If yes, when? Is the training effective? Why or why not? Were there wet floor or other warning signs?
• Who is the supervisor? Are there other outside work factors that may have lead to this?
• Is there a carpet? Is it long enough? Is it of the appropriate quality? What kind of shoes does he wear?
• Is disciplinary action necessary? For him or anyone else?
• Are new procedures necessary?
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Potential Corrective Actions• Develop a policy and procedure for inspecting and maintaining the floor at all employee entrances.
• Provide a runner carpet of the correct length (one that will extend far enough to capture all moisture). Provide more wet floor signs.
• Re-train staff on all slip hazards, including at entrances. Educate them on the importance of reporting hazards and wearing appropriate footwear when entering the building.
• Implement a slip-resistant footwear policy.
• Inform employees on measures taken to reduce future recurrence of this type of accident.
• Improve awareness for all staff via posters, mailers, handouts, etc. as to hazards and what the new procedures are.
• Praise employees for following expected procedure as trained.
• Counsel employees who fail to act as expected after receiving education (not identifying hazards, not wearing the correct footwear). Document this action.
• Inform Supervisors and Managers that incidents that occur as a result of low competence will effect their performance review.
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Any Questions
??
Massachusetts Manufacturing Self-Insurance Group, Inc.
Safety Awareness For Everyone from Cove Risk Services