Accident.incident Investigation 2012

8/20/2019 Accident.incident Investigation 2012

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ACCIDENT/INCIDENT ACCIDENT/INCIDENT

INVESTIGATIONINVESTIGATION


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OverviewOverview!! Values of Effective InvestigationValues of Effective Investigation

!! What to InvestigateWhat to Investigate

!! Who Should InvestigateWho Should Investigate

!!

Steps in InvestigationSteps in Investigation!! Supervisor Supervisor ’’s Initial Actionss Initial Actions

!! Gathering InformationGathering Information

!! Analyzing Causes Analyzing Causes

!! Taking Remedial ActionsTaking Remedial Actions!! Writing A Good ReportWriting A Good Report


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Values of

alues of

ffective Investigation

ffective Investigation

"" Describe what happenedDescribe what happened

""

Determine the real causesDetermine the real causes

"" Decide the risksDecide the risks

"" Develop controlsDevelop controls

"" Define trendsDefine trends

"" Demonstrate ConcernDemonstrate Concern


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What to InvestigateWhat to Investigate## InjuryInjury

## Occupational illnessOccupational illness

## Damage to propertyDamage to property

## Near-missesNear-misses

## Chemical spillChemical spill

## FireFire

## TheftTheft


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Who Should Investigate Who Should Investigate

$$ The Line SupervisorsThe Line Supervisors

$$ The Middle ManagersThe Middle Managers

$$ Staff PersonnelStaff Personnel


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Why Supervisors The Best Why Supervisors The BestInvestigatorsInvestigators

%% They have a personalThey have a personal

interestinterest

&& They know the people andThey know the people and

conditionsconditions

'' They know best how andThey know best how and

where to get thewhere to get the

information.information.


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Why Supervisors The Best Why Supervisors The BestInvestigatorsInvestigators

(( They will start or take theThey will start or take the

actionsactions

)) They benefit fromThey benefit frominvestigating.investigating.


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Middle Managers ParticipationMiddle Managers Participation

%% There is a major loss or high potentialThere is a major loss or high potentialincident.incident.

&& The circumstances cross into other The circumstances cross into other supervisor supervisor ’’s areas.s areas.

'' The remedial actions have a broadThe remedial actions have a broadscope or significant costs.scope or significant costs.


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Steps in InvestigationSteps in Investigation

** Respond to the emergencyRespond to the emergencypromptly and positively.promptly and positively.

++ Collect pertinentCollect pertinentinformation about theinformation about theincident.incident.

,, Analyze all significantAnalyze all significantcausescauses


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Steps in InvestigationSteps in Investigation

-- Develop and take remedialDevelop and take remedialactions.actions.

.. Review findings andReview findings andrecommendations.recommendations.

// Follow through on theFollow through on the

effectiveness of theeffectiveness of theactions.actions.


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SupervisorSupervisor’’s Initial Actionss Initial Actions

%% Take control at the scene.Take control at the scene.

&& Ensure first aid and call for emergencyEnsure first aid and call for emergency

services.services.

'' Control potential secondary accidents.Control potential secondary accidents.

(( Identify sources of evidence at theIdentify sources of evidence at the

scene.scene.


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SupervisorSupervisor’’s Initial Actionss Initial Actions

)) Preserve alteration from alteration.Preserve alteration from alteration.

00 Investigate to determine the lossInvestigate to determine the loss

potential.potential.

11 Notify appropriate managers.Notify appropriate managers.


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Gathering InformationGathering Information

WitnessesWitnesses Sketches

and Maps

Sketches

and Maps

Equipment

Examination

Equipment

Examination

Records

Check

Records

Check

Accident

Photography

Accident

Photography

Material

Failure

Analysis

Material

Failure

Analysis


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INTERVIEWING WITNESSES

Interview separately.

Interview at an appropriate place.

Put the person at ease.

Get the individual’s version.

Ask the necessary question at the right time.


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Give the witness some feedback.

Record critical information quickly.

Use visual aids.

End on a positive note.

Keep the line open.

INTERVIEWING WITNESSES


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SKETCHES and MAPS

Help people visualize what happened.

Make it simple.

Sketch location of:

> People Involved

> Key Facilities and Equipment

Note: Label them clearly


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EQUIPMENT EXAMINATION

Check If Things Don’t Look Right For:

Tools

Equipment

Materials


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RECORDS CHECK

Training Records

Maintenance Logs/Records

Schedules

Job Procedures and Practices

Previous Accident Reports


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ACCIDENT PHOTOGRAPHY

Photograph the scene from all sides.

Use a long/medium/close-up sequence.

Get the correct exposure.


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MATERIAL FAILURE ANALYSIS

High Loss Potential :

Failure of Equipment or Structures

Overloading

Material Defects

Improper Construction

Inadequate Servicing


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Analyzing Causes Analyzing Causes

%% Write down each loss.Write down each loss.

&& Under each loss, write allUnder each loss, write allthe contacts with forms or the contacts with forms or

energy or substance thatenergy or substance thatwere responsible for thewere responsible for theloss.loss.

'' Under each contact factor,Under each contact factor,

list the substandard actionslist the substandard actionsand conditions that createdand conditions that createdit.it.


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Analyzing Causes Analyzing Causes

(( Under each standardUnder each standardaction or condition list allaction or condition list allbasic causes whichbasic causes which

prompted it.prompted it.)) Review of programs, itsReview of programs, its

standards and compliancestandards and compliancewith standards.with standards.


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Taking Remedial Actions Taking Remedial Actions

!! TemporaryTemporary

ActionsActions

!! PermanentPermanent

ActionsActions


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Temporary Actions Temporary Actions

Correct the symptoms of accidents:Correct the symptoms of accidents:

"" Substandard ActsSubstandard Acts

"" Substandard ConditionsSubstandard Conditions


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Permanent ActionsPermanent Actions

Remedy or treat:Remedy or treat:

"" Personal and job factorsPersonal and job factors

"" Oversights and omissions in programs,Oversights and omissions in programs,standards and compliance.standards and compliance.


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Writing a Good Report Writing a Good Report

%% Identifying InformationIdentifying Information

&& EvaluationEvaluation

'' DescriptionDescription

(( Cause AnalysisCause Analysis

)) Action PlanAction Plan


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Report ReviewsReport Reviews

## Allows objective look at findings andAllows objective look at findings and

recommendations.recommendations.

##

Prompts thoroughness and accuracy.Prompts thoroughness and accuracy.

## Prompts sharing of the report information.Prompts sharing of the report information.


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Report ReviewsReport Reviews

## Analyzes inadequacies in programs,Analyzes inadequacies in programs,

standards and compliance.standards and compliance.

## Provides middle manager to applyProvides middle manager to apply

his greater experience and wider his greater experience and wider

knowledge.knowledge.


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Review Review

!! Values of Effective InvestigationValues of Effective Investigation

!! What to InvestigateWhat to Investigate

!! Who Should InvestigateWho Should Investigate

!! Steps in InvestigationSteps in Investigation

!! Supervisor Supervisor ’’s Initial Actionss Initial Actions

!! Gathering InformationGathering Information

!! Analyzing CausesAnalyzing Causes!! Taking Remedial ActionsTaking Remedial Actions

!! Writing A Good ReportWriting A Good Report

Accident.incident Investigation 2012

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