Leading Causes of Workplace Deaths

Motor Vehicles32%

Struck by Moving, Falling or Stationary

Objects18%

Gunshot Wounds8%

Miscellaneous11%

Slips and Falls8%

Heart Attacks/Strokes13%

Airplanes5%

Caught Between Object/Equipment

5%

Learning ObjectivesLearning Objectives

Recognize the need for an investigation

Investigate the scene of the accident Interview victims & witnesses Distinguish fact from fiction Determine root causes Compile data and prepare reports Make recommendations

THE ACCIDENTTHE ACCIDENT

THEY ALL HAVE OUTCOMES FROM THE ACCIDENT

THE ACCIDENTTHE ACCIDENT

THEY ALL HAVE CONTRIBUTORY FACTORS THAT CAUSE THE ACCIDENT

OUTCOMES OF OUTCOMES OF ACCIDENTSACCIDENTS

NEGATIVE ASPECTS

– DEATH & INJURY– DISEASE– DAMAGE TO EQUIPMENT & PROPERTY– LITIGATION COSTS– LOST PRODUCTIVITY

OUTCOMES OF OUTCOMES OF ACCIDENTSACCIDENTS

POSITIVE ASPECTS

– ACCIDENT INVESTIGATION– CHANGE TO SAFETY PROGRAMS

CONTRIBUTING FACTORSCONTRIBUTING FACTORS

ENVIRONMENTAL

DESIGN

SYSTEMS & PROCEDURES

HUMAN BEHAVIOUR

CONTRIBUTING FACTORSCONTRIBUTING FACTORS

ENVIRONMENTAL

– NOISE– VAPORS, FUMES, DUST– LIGHT– HEAT– CRITTERS

CONTRIBUTING FACTORSCONTRIBUTING FACTORS

DESIGN

– WORKPLACE LAYOUT– DESIGN OF TOOLS & EQUIPMENT

CONTRIBUTING FACTORSCONTRIBUTING FACTORS

SYSTEMS & PROCEDURES

– LACK OF SYSTEMS & PROCEDURES– INAPPROPRIATE SYSTEMS &

PROCEDURES

CONTRIBUTING FACTORSCONTRIBUTING FACTORS

HUMAN BEHAVIOUR

– COMMON TO ALL ACCIDENTS– NOT LIMITED TO THE PERSON

INVOLVED IN THE ACCIDENT

Be PreparedBe Prepared

Develop contingency plans prior to the accident.

Designate an investigator– This person should only be responsible for

investigating.– Should have a good working knowledge of

operating procedures.

Be equipped with the right tools to do the job thoroughly.

WHO SHOULD WHO SHOULD INVESTIGATEINVESTIGATE DEPENDENT ON SEVERITY OF THE

ACCIDENT

– INVESTIGATION TEAM• INDIVIDUALS INVOLVED• SUPERVISOR• SAFETY SUPERVISOR• UPPER MANAGEMENT• OUTSIDE CONSULTANTS

Why Investigate Accidents?Why Investigate Accidents?

Find the cause Prevent similar accidents Protect company interests

BENEFITS OF ACCIDENT BENEFITS OF ACCIDENT INVESTIGATIONINVESTIGATION

PREVENTING RECURRENCE

IDENTIFYING OUT-MODED PROCEDURES

IMPROVEMENTS TO WORK ENVIRONMENT

Investigation is 4 Step ProcessInvestigation is 4 Step Process

Control the Scene

Gather Data

Analyze Data

Write Report

Control the SceneControl the Scene

Provide medical care for injured– First Aid– On Scene Evaluation– Transport for Medical Care

Control existing hazards– Prevent further injuries– Get more help if needed

Preserve evidence

Gather DataGather Data

Photos of accident scene Drawings & sketches & measurements Data

– Persons involved– Date, time, location– Activities at time of accident– Equipment involved– List of witnesses

InterviewingInterviewing

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.

Information InterviewsInformation Interviews

Gather just the facts… make no judgments or statements

Conduct interviews one on one Be friendly but professional Conduct interviews near the scene in

private Interview all supervisors

Ask all witnessAsk all witness

Name, address, phone number What did you see What did you hear Where were you standing/sitting What do you think caused the accident Was there anything different today

Ask SupervisorsAsk Supervisors

What is normal procedure for activities involved in the accident

What type of training persons involved in accident have had.

What, if anything was different today What they think caused the accident What could have prevented the

accident

Analyze DataAnalyze Data

Gather all photos, drawings, interview material and other information collected at the scene.

Determine a clear picture of what happened

Formally document sequence of events

Data Analysis ListData Analysis List

Accident Title Date, Time, Location Persons involved Witnesses Work & Environmental Conditions at

time of accident Immediate actions taken at scene

Basic CausesBasic Causes

Unsafe Acts – what activities contributed to the accident

Unsafe conditions – what material conditions, environmental conditions and equipment conditions contributed to the accident

Contribution of Safety Contribution of Safety Controls such asControls such as Engineering Controls - machine guards, safety

controls, isolation of hazardous areas, monitoring devices, etc.

Administrative Controls - procedures, assessments, inspection, records to monitor and ensure safe practices and environments are maintained.

Training Controls - initial new hire safety orientation, job specific safety training and periodic refresher training.

What controls failed?What controls failed?

List the specific engineering, administrative and training controls that failed and how these failures contributed to the accident.

What controls worked?What controls worked?

List any controls that prevented a more serious accident or minimized collateral damage or injuries.

DetermineDetermine

What was not normal before the accident

Where the abnormality occurred When it was first noted How it occurred.

Unsafe ActsUnsafe Acts

List all unsafe acts involved in the accident Examples of unsafe acts

– Unauthorized operation of equipment

– Running - Horse Play

– Not following procedures

– By-passing safety devices

– Not using protective equipment

– Under influence of drugs or alcohol

– Taking short-cuts

Unsafe ActsUnsafe Acts

Unsafe conditionsUnsafe conditions

List all unsafe conditions involved in the accident

Examples of unsafe conditions– Ergonomic Hazards– Environmental hazards– Inadequate housekeeping– Blocked walkways– Improper or damaged PPE– Inadequate machine guarding

Change AnalysisChange Analysis 1. Define the problem (What happened?). 2. Establish the norm (What should have

happened?). 3. Identify, locate, and describe the change

(What, where, when, to what extent). 4. Specify what was and what was not affected. 5. Identify the distinctive features of the

change. 6. List the possible causes. 7. Select the most likely causes.

PreventionPrevention

What needs to change or be improved to prevent similar accidents in the future?– Engineering Controls– Administrative Controls– Training Controls

Final ReportFinal Report

Background Information – where, when, who & what

List of those involved & other witnesses

Account of the Accident - sequence of events, extent of damage, accident type, source

Report CausesReport Causes

Analysis of the Accident – HOW & WHY

a. Direct causes (energy sources; hazardous materials)

b. Indirect causes (unsafe acts and conditions)

c. Basic causes (management policies; personal or environmental factors)

RecommendationsRecommendations

Action to remedy– Basic causes

– Indirect causes

– Direct causes

Recommendations - as a result of the finding is there a need to make changes to:– Employee training

– Work Stations Design

– Policies or procedures

Send & File ReportSend & File Report

After developing a formal report, forward it for review & action.

File a copy of the report and all raw data, photos, interview notes, etc. in a single file