ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION

OSHA 1994 - Regulation -SHC Section 13(1)Section 13(1)

A safety and health committee shall inspect theA safety and health committee shall inspect the place of work, as soon as it is safe to do so, after any accident, dangerous occurrence, occupational

i i i l di h dpoisoning or occupational disease has occurred at the place of work

ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION

POLICYObjective of incident investigation should notObjective of incident investigation should not

be to apportion blame or fault finding but to determine the cause(s) in order to prevent recurrence of accident

All i id t t b t d d dAll incidents must be report, recorded and investigated by competent

ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION

POLICYAll staff must give their full cooperation andAll staff must give their full cooperation and

assistance when requested, to the investigation team

All recommendations arising from incident i ti ti t b di d d dinvestigation must be discussed, agreed and executed by the relevant action parties

ACCIDENT INVESTIGATIONACCIDENT INVESTIGATIONDefinition

Incidentan unplanned event or chain of event, which has or could

h d i j ill l d/ d (l )have caused injury or illness to people and/or damage (loss) to assets, the enviroment e.g near miss, accident, fire

Accident an event which resulted injuries or illness to people and/or

damage (loss) to assets and the enviroments

Near missan event which did not result in injuries or illness to people j p p

and/or damage (loss) to assets and the enviroment

ACCIDENT INVESTIGATIONACCIDENT INVESTIGATIONACCIDENT - THE CONSEQUENCES

Immediate• Death

Short Term• Medical

T

Long Term•Suffering

• Injury• Pain

Di

Treatment• Repairs• Replacement

•Disability•Lost Income

• Disease• Damage• Loss

• Replacement• Lost

Production

•Insurance•Compensation

iLoss• Fear • Increased

CostDi i li

•Mistrust•Profitability

• Discipline• Low Morale

ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION

Safety IcebergSafety Iceberg

1 Fatality1

100

y

Lost Time InjuriesMi I j i /P t

1,000

10 000

Minor Injuries/Property damage

N Mi10,000

100,000

Near Misses

Unsafe Acts / Conditions,

ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION

INCIDENT INVESTIGATIONPurpose

Law (OSHA 1994) and Company requirementsPrevent recurrenceEssential element in Safety & Health ManagementContribute to good morale and overall safety

awarenessawarenessGeared towards continuous OSH improvement thus

increased productivity and improved work enviroment

ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION

AIMTo find the root cause and to prevent recurrenceTo find the root cause and to prevent recurrence

Not to apportion or assign blame, satisfyNot to apportion or assign blame, satisfy insurance claims or defend against liabilities

ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION

TYPES OF INCIDENTS

Injurious accident

Non-injurious incident with asset damage

Occupational illness or disease

Near missNear miss

ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION

INVESTIGATION PARTIESMinor accidentMinor accident

Relevant individual staff and/or line supervisor

Major accidentTeam comparising mixed discpline and expertise including safety personel and led by line manager

ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION

INVESTIGATION PARTIES

Be objective and be impartial

Gather the facts and information

Isolate the contributor factors

Determine corrective actions and action partiesDetermine corrective actions and action parties

Implement corrective actions with target dates

ACCIDENT INVESTIGATIONACCIDENT INVESTIGATIONMETHODOLOGY

Gather safety rules/procedures of the site and information on plant, machinery or facilitiesp , y

Isolate the scene of accident and do not disturb evidence

Take photos, sketch, diagrams of the accident site/facilities

Interview witnesses, affected or involed parties and obtain facts but not opinions or assumptions

Isolate key contributory factors

ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION

OUTCOMES OF THE INCIDENT

Negative results like death, injuries, production

loss, property damage

Positive results like rehabilitation, change in

safety procedures, improvement in processessafety procedures, improvement in processes

ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION

CONTRIBUTORY FACTORS

Environment e.g. noise, heat, light, fumes, bad weather

Design e.g. worksite layout, tools/equipment

Systems and procedures e.g. not present or inapproprite

H b h i f t h tHuman behaviour e.g unsafes acts, purchase wrong type

of equipment

ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION

CAUSES OF INCIDENTS

Immediate e.g. Unsafe act, using unsafe tools/equipment,

incorrect procedures, poor housekeeping, unsafe

condition

Uderlying e.g. Poor training, poor maintenance, lowUderlying e.g. Poor training, poor maintenance, low

safety morale, lack of enforcement of safety rules

ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION

INVESTIGATION INTERVIEWINVESTIGATION INTERVIEW TECHNIQUES

InprivateInprivate

Put them at ease

S bj i f id iState objective for accident prevention

Blame - free environment

Establish facts only

No leading question

Give appreciation

ACCIDENT INVESTIGATION

1. Event leading to the accident

• System of work• Work instruction

2. Facts of the Incident itself

• State of system• Parties involed

3. Relevant facts of what happened immediately after the incident

• Direct resultant injuries • Variations from safe

practice/instruction• Workplace condition• Environment condition

• Material/Equipment/Tool/fixtures in direct involement

jto people damage to assets or environment

• Event leading to ti l i j i

• Exact location of incident• Material/Equipment/Tool

used or handled

consequential injuries or assets/environment damage

• Parties involed including emergency respons or recovery

• Effectiveness of emergency respons or recovery

CHECKLIST TO ESTABLISHCHECKLIST TO ESTABLISH FACTS OF INCIDENTWHO

• was injured• saw incident

WHAT• is the injury• is the damaged or loss

• working with injured• assigned job to injured• else was involved• has information leading to the incident

• is the injured doing• had the injured been instruced to do• tools were being used• machine/plant/equipment was in use• has information leading to the incident • machine/plant/equipment was in use• previous similar accident or near misses

and whether action had been taken to prevent recurrencedid th i j d d it• did the injured and witnesses see

• safety rules were violated• safe system of work, permit/procedures• were the contributory causes of the

accident• communication system was in use

CHECKLIST TO ESTABLISHCHECKLIST TO ESTABLISH FACTS OF INCIDENT

WHERE

• did accident occur

HOW

• did the injury occur• did the damage occur• was the supervisor at that time• were the witnesses at that time

• was the medical response• could the accident been avoided• could better design help• could the supervisor have prevented the• could the supervisor have prevented the

accident

CHECKLIST TO ESTABLISH FACTS OF INCIDENTFACTS OF INCIDENT

WHEN• did the accident occur

WHY• did the injury occur• did the accident occur

• did the comunication fail• did the injured start the job• was hazards explained

• did the injury occur • did communication fail• was training not given• were the unsafe condition permitted

• did the supervisor last see the injured• as something observed to be wrong

• were the hazard not evaluated• was PPE not given or not worn• was there no safe system of work,

permitted or proceduresp p• were specific instructions not given• was there no safety inspection or audit• was the level of safety awareness and

commitment lowcommitment low• was there no safety program• was the injured there• was supervisor not notified when things

went wrong• was the supervisor not there at the time

ACCIDENT INVESTIGATIONACCIDENT INVESTIGATIONACCIDENT CAUSATION

Over 90% of all accident are caused by the action or inaction’s of people which are unsafe acts or unsafe conditionsR i tt f id tRecognise patterns of accident

people - any particular group or individualbehaviour - poor safety attitudetime- particular time, day, start/end week, shiftplace - particular place, type of place, indoor/outdooractivity - during a particular task, type of task, boring job, high y g p , yp , g j , gspeed, during difficult or complex tasksystem or procedures - any particular operations, system or procedurespequipment - specific type, old or new

ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION

1. Unsafe Actsfailure to wear PPE

i f l hiwearing unsafe clothinghorseplayimproper use of hands and other parts of the bodyimproper use of hands and other parts of the bodybypassing safety devicesunsafe position or posturep pdriving errorsunsafe operation acts

ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION

2. Unsafe Conditionsdefective tools and equipmentd f i d idefective designunsafe clothing or PPEunsafe workplaceunsafe workplaceinadequate layout and storageunsafe guardingg gpublic hazards

BENEFIT OF ACCIDENT INVESTIGATION

Prevent recurrenceIdentify out-moded operartion methodsI d k iImproved work environmentIncreased productivity due to upgrading of process systemsystemRaising of safety awareness and moraleLower medical costs due to fewer accidentsAvoid lawsuits or liabilities due to accidentsGreater efficiency due to no work stoppages

ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION

ACCIDENT REPORTING FORM(refer to handout)

DOSH - Accident Reporting Form

Company - Accident Reporting Form

Witness Interview FormWitness Interview Form

ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION

PRINCIPLES OF ACCIDENT PREVENTION

The identification of hazards, risk assessment and risk

control

OSH promotion and communication to influence

behaviour and encourage safe attitudesbehaviour and encourage safe attitudes