3Bureau Veritas Presentation
• InstructorInstructor• ScheduleSchedule• ParticipantsParticipants• MaterialsMaterials• ObjectivesObjectives
IncidentIncidentInvestigationInvestigation
Course Introduction
Accident Investigation
4Bureau Veritas Presentation
• Understand the critical importanceUnderstand the critical importance of investigation and reporting of investigation and reporting• Use tools presented in the course toUse tools presented in the course to arrive at the root causes of accidents arrive at the root causes of accidents• Understand the importanceUnderstand the importance of follow-up of follow-up
• Understand the critical importanceUnderstand the critical importance of investigation and reporting of investigation and reporting• Use tools presented in the course toUse tools presented in the course to arrive at the root causes of accidents arrive at the root causes of accidents• Understand the importanceUnderstand the importance of follow-up of follow-up
Accident Investigation
Course Objectives
5Bureau Veritas Presentation
• To determine root causes and preventTo determine root causes and prevent recurrence of similar accidents recurrence of similar accidents• To demonstrate to employees thatTo demonstrate to employees that management cares management cares
• To determine root causes and preventTo determine root causes and prevent recurrence of similar accidents recurrence of similar accidents• To demonstrate to employees thatTo demonstrate to employees that management cares management cares
Why Investigate?
Accident Investigation
6Bureau Veritas Presentation
EverythingEverything EverythingEverythingSeriousSerious InjuriesInjuries
Minor InjuriesMinor Injuries
Non-injury IncidentsNon-injury Incidents
ChancesChances
112929
300300
350,000350,000
Accident Investigation
What to Investigate?
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Why don’t employees report everything?Why don’t employees report everything?
I saidI saidreportreport
EVERYTHINGEVERYTHING!!!!
Accident Investigation
8Bureau Veritas Presentation
Resources to find out include:Resources to find out include:• PPeopleeople• AAccident Sceneccident Scene• RRecordsecords
““PAR for the course”PAR for the course”
What Happened?
Accident Investigation
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Acc
ident
Acc
ident
Imm
edia
te C
ause
sIm
media
te C
ause
s
Basi
c C
ause
sB
asi
c C
ause
s
Safe
ty S
yst
em
Safe
ty S
yst
em
Accident Sequence
Accident Investigation
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The Work SystemThe Work System The EmployeeThe Employee
SystemSystemFailures
Failures
BasicBasic
CausesCauses
ImmediateImmediateCausesCauses
Causes
Accident Investigation
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• Case #1 - How do you spell relief?Case #1 - How do you spell relief?• Case #2 – Back to the GrindCase #2 – Back to the Grind
Danger - HighDanger - HighPressurePressure
Workshop
Accident Investigation
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The ReportThe Report The RepairThe Repair The ReviewThe Review
Follow-Up
Accident Investigation
13Bureau Veritas Presentation
•Understand the critical importanceUnderstand the critical importance of investigation and reporting of investigation and reporting• Use tools presented in the course toUse tools presented in the course to arrive at the root causes of accidents arrive at the root causes of accidents• Understand the importanceUnderstand the importance of follow-up of follow-up
Summary
Accident Investigation
14Bureau Veritas Presentation
• We investigate to show we care and prevent recurrenceWe investigate to show we care and prevent recurrence• We investigate everything a little to see where we needWe investigate everything a little to see where we need to investigate a lot to investigate a lot• We use people, the accident scene and records (PAR) toWe use people, the accident scene and records (PAR) to find out what happened find out what happened• We use the Accident Analysis Flow Chart and ask “Why” We use the Accident Analysis Flow Chart and ask “Why” to help find out why the accident occurred and realize it’s to help find out why the accident occurred and realize it’s almost always rooted in the management system almost always rooted in the management system• We report, repair and review to make sure that the actionsWe report, repair and review to make sure that the actions necessary to prevent recurrence are completed necessary to prevent recurrence are completed
Summary
Accident Investigation
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