Accident Investigation You Did What…Again?
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Transcript of Accident Investigation You Did What…Again?
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Accident InvestigationYou Did What…Again?
Presented by:John Dietrich, Atkinson, Andelson, Loya, Rudd & RomoLaFaye Platter, Hemet USDLucy Rebuck, Hemet USDSuzanne Trowbridge, Keenan & Associates
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Why Investigate?
• Prevent future incidents (leading to accidents). • Identify and eliminate hazards. • Expose deficiencies in process and/or equipment.• Reduce injury and worker compensation costs.• Maintain employee morale.• Meet DOSH rule requirement that you investigate
serious accidents.
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“You can’t manage risk and change culture from behind a desk”
John Dietrich
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“Common sense is not so common”
Lucy Rebuck
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Investigate All Incidents and Accidents
Conduct and document an investigation that answers:
• Who was present? • What activities were occurring?• What happened?• Where and what time?• Why did it happen?
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How Do You Investigate??
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How To Investigate – Main Steps• Develop a plan• Assemble an investigation
kit• Investigate all incidents
and accidents immediately
• Collect facts• Interview witnesses• Write a report
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Tips for Developing An Accident Investigation Plan
• Develop your action plan ahead of time.• Your plan might include:• Who to notify in the workplace?• How to notify outside agencies?• Who will conduct the internal
investigation?
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Tips for Developing a Plan (continued)
• What level of training is needed?• Who receives report?• Who decides what corrections will be taken and
when?• Who writes report and performs follow up?
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What Should Be in The “Investigation Kit”• Camera • Tape recorder• Gloves• Tape measure • Large envelopes• High visibility tape • Scissors• Personal protective equipment• First aid kit Report Forms
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Root Cause Analysis
• Direct Cause – Unplanned release of energy or hazardous materials
• Indirect Cause – Unsafe acts and/or unsafe conditions
• Root Cause – Policies and decisions, personal factors, environmental factors
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The Five Whys
Basic Question - Keeping asking “What caused or allowed this condition/practice to occur?”
The “five whys” is one of the simplest of the root cause analysis methods.
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5 Whys In ActionSuzy had an unwitnessed trip and fall accident:
1)Why? She wasn’t looking where she was going2)Why? She was carrying a box3) Why? She was wearing inappropriate shoes4) Why? There was water on the ground5) Why?
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Begin Investigation Immediately
• It’s crucial to collect evidence and interview witnesses as soon as possible because evidence will disappear and people will forget.
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Fact Finding• Witnesses and physical evidence• Employees/other witnesses• Position of tools and equipment• Equipment operation logs, charts, records• Equipment identification numbers• Take notes on environmental conditions, air quality • Take samples• Note housekeeping and general working environment• Note floor or working surface condition• Take many pictures• Draw the scene
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Interview Witnesses
• Interview promptly after the incident• Choose a private place to talk• Keep conversations informal• Talk to witnesses as equals• Ask open ended questions• Listen. Don’t blame, just get facts• Ask some questions you know the answers to
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Write The Report• Who• What• Where • When• Why – Root Cause• Prevention & Action Steps• Follow through
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Case Study #1• Handout to be provided
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Case Study #1 - Findings• Morale a result of poor supervision &
management
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Case Study #2
• Eye Injury• Investigation results: wasn’t following safety
protocol; training provided on correct chemical handling
• Action steps:– Disciplined employee for failing to follow safety
protocols
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Case Study #3
• Bus Driver Crashes Bus While Texting• Investigation:– Employee trained not to text– Employee observed texting on run in the am– Letter of reprimand at end of am shift for texting– Accident in pm while texting
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Conclusion
• Root Cause Analysis
• Close Loop On Accident Investigation Findings
• Hold Everyone Accountable for Safety