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Accident InvestigationsPart I
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Accident Investigation - Objectives
By the end of this session the participants will:
Understand the importance of the need for effective and thorough investigation of an accident
Demonstrate practical skills required to respond and investigate an incident/accident in a consistent manner
Make meaningful recommendations for preventive actions to reduce potential risks that may contribute to accidents
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Effective Accident Investigations - Objectives (cont.)
By the end of this session the participants will:
Understand their critical role in the accident investigation and the accident reporting process
Determine the cause(s) of this accident and make recommendations to help prevent a recurrence of this type of incident
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What is an Accident ?
“An accident is an undesired event that results
in physical harm to a person or damage to
property.”
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Purpose of an Accident Investigation
The purpose of an accident investigation is to
prevent the recurrence of the accident. The focus
should be on the accident , not the injury .
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Effective Accident Investigations
What to Look for:
Policies/Procedures Equipment Materials
Environment Task People/Operators
Accidents generally have more than one cause
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Critical Injury Defined
a) places life in jeopardy;
b) produces unconsciousness;
c) results in substantial loss of blood;
d) involves the fracture of a leg or arm but not a finger or toe;
e) involves the amputation of a leg, arm, hand or foot but not a finger or toe;
f) consists of burns to a major portion of the body; or
g) causes the loss of sight in an eye. O. Reg. 714/82 s.1
For the purpose of the Act and Regulations, “critically injured” means an injury of serious nature that,
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Who Investigates Accidents?
They have a personal interest to protect.
They know their people, the conditions and the job.
They know how to get the information needed.
They will take action in any case.
Supervisors
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Who Investigates Accidents?
JHSC Representative
They are familiar with the people and workplace.
They have a legal requirement in Critical Injuries
They have been trained in Accident Investigation
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Who Investigates Accidents?
Government and Business
Ministry of Labour
Ministry of the Environment
Workplace Safety & Insurance Board
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Before an Accident Occurs…
Create an accident “action plan”
Create an Accident Investigation Policy
Develop Investigation Procedures
Practice
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When To Investigate An Accident
Immediately or ASAP
( If a Critical Injury or Immediately Reportable Accident, secure the scene and advise the MOL )
Accident Investigation Procedures should be in writing to ensure a consistent response to all accidents.
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At the Accident Scene
Control the Scene People are the first priority; send for help;
make sure area is safe; administer first aid
Stop Ongoing Hazards Get personal protective equipment; provide
emergency lighting, power, air, etc.
Collect Evidence Take notes, pictures, sketches of tools,
equipment, layout, etc.
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At the Accident Scene
Contributing Factors:Housekeeping
Floor/surface conditions
Noise
Air quality/temperature
Equipment malfunction
Supervision
Employee morale/attitude/health
Alcohol/drug abuse
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What Equipment Is Required?
Personal Protective Equipment
Caution Tape
Measuring Tape
Graph Paper
Pencils
Lockout / Tagout
Clipboard
Camera (battery and film)Flashlight (with batteries)Emergency Phone NumbersAccident Investigation FormsOptional - tape recorder, photo log, flares, etc.
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Immediate Causes
Struck ByStruck AgainstCaught In, On, Between, or UnderFall On, In, or FromScraped / Rubbed AgainstOverexertion or Body Strain
Contact with
- Electricity
- Heat or Cold
- Radiation
- Noise
- Caustics
- Toxic
Substances
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Basic Causes
Lack of preventative maintenance
Servicing, Moving or Live Equipment
Failure To Warn or Secure
Tampering or Removing Safety Devices
Unsafe Working or Travelling Speed
Unsafe Working Posture or Position
Incorrect Equipment or Body Use
Poor or Improper Work Practices
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Root Causes
Personal Factors
Poor Motivation
Labour Relations
Lack of Skill or Knowledge
Physical and/or
Psychological Problems
Job FactorsPoor Purchasing Standards
Poor Work Standards
Poor Maintenance or Design
Abnormal Usage
Excessive Wear and Tear
Lack of Programs and Procedures
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Equipment or Conditions Involved
EquipmentMetal Lab cartSpecimen BlenderMetal work counterelectrical applianceplug-ins (cart & counter)metal sinkleather shoeseyeglasses
Conditionswater on floor
damaged equipment
running water
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Accident Scene
• Click here to view accident scene
• What happened?
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Flip Chart Layout
Who was injured?
What happened?
How to prevent a recurrence?
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Accident InvestigationPart II
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Effective Accident Investigations
What to Look for:
Policies/Procedures Equipment Materials
Environment Task People/Operators
Accidents generally have more than one cause
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Accident Investigation Process
Response
Assess Scene /
Identify Witnesses
Preserve Evidence
Notification
Interview Witnesses
Analysis and
Conclusions
Recommendations
Follow up
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Accident Investigation Forms
Internal Accident Report
Investigator’s Checklist
Witness Interview Form
JHSC Accident Investigation Report
Accident Findings Recommendation Form
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At the Accident Scene
Contributing Factors:Housekeeping
Floor / surface conditions
Noise
Air quality / temperature
Equipment malfunction
Supervision
Employee morale / attitude / health
Alcohol / drug abuse
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Basic Causes
Preventative MaintenanceServicing Moving or Live EquipmentFailure To Warn or SecureTampering or Removing Safety DevicesUnsafe Working or Travelling Speed
Unsafe Working Posture or Position
Incorrect Equipment or Body Use
Poor or Improper Work Practices
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Root Causes
Personal Factors
Poor motivation and/or labour relationship
Lack of skill or knowledge
Physical and/or psychological problems
Job FactorsPoor purchasing StandardsPoor work standardsPoor maintenance or designAbnormal usageExcessive wear and tear
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Who Are The Witnesses ?
Eye Witness
First Person (s) at the scene Witness
Surrounding Events Witness
Person Having Knowledge
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Interview Process
First - Get The Big Picture
Separate All Witnesses
Interview Each Witness Alone and In Private
Interview Eye Witnesses First
Interview At Accident Scene (when
advisable)
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Effective Interview Technique
Put person at ease
Explain purpose of accident investigation
Listen to the individual’s version
Ask the right questions at the right time
Repeat the information given back to the individual
Always thank person for their cooperation
Immediately document critical information
Provide drawings and photos where useful
Probe for Basic Causes
Keep the door open for further information
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Interviewing Questions To Ask
• Where were you at the time of the accident ?
• What were you doing at the time ?
• What did you see, hear ?
• What were the environmental conditions ?
• What was the injured worker doing at the time ?
• In your opinion, what caused the accident ?
• How might similar accidents be prevented in the future ?
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Interviewing Questions to Ask
• Ask “WHY” 5 times “He was lying on the floor” - Why?
“Because there was water on the floor” - Why?
“Because there was a leak in the sink” - Why?
“Because maintenance hadn’t fixed it” - Why?
“Because they’re short-staffed” - Why?
“Because of the hiring freeze”
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Typical Investigation
• Who was injured?
We should clean up spills right away or put sign up saying wet floor.
• How to prevent a recurrence?
Slipped on spill on floor and struck their head.
John Doe
• What happened?
Hot link to poster 2
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At the Accident Scene
• Contributing Factors: Housekeeping
Floor/surface conditions
Noise
Air quality/temperature
Equipment malfunction
Supervision
Employee morale/attitude/health
Alcohol/drug abuse
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Investigation Begins
• Individual shots of accident scene
• Click link(s) • Lab cart - first view
• Lab cart - second view
• Plug
• Water
• Feet
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Effective Investigation
Examples…
Immediate Causes?
Basic Causes?
Root Causes?
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Effective Investigation
Poor maintenance / housekeeping
Poor labour relations
Poor health
Tampering / removal of safety device (3 prong & insulating rubber feetWater on floor
Contact with live equipmentFall to the floorStruck head
Examples…
Immediate Causes?
Basic Causes?
Root Causes?
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Accident SceneRe-visited
• Click here to view accident scene
• What really happened?
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Recommendations & Follow - Up
Have intermediate control measures been implemented prior to final corrective measure ?
Have the intermediate or final corrective measures resulted in further hazards?
How adequate are the control measures ?
How effective are the control measures ?
Has there been follow-up and an analysis of the corrective measures to ensure they have been implemented and are effective ?
•Click to advance to optional Accident Scene
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Thank You
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OPTIONAL SCENARIO:OFFICE ACCIDENT
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OPTIONAL SCENARIO:OFFICE ACCIDENT
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OFFICE ACCIDENT
Contributing Factors:
Policies/Procedures Equipment Materials
Environment Task People/Operators
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Office Accident Investigation
Immediate Causes?
Basic Causes?
Root Causes?
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Office Accident Investigation
Working alone
Training
Using improper procedure / equipmentStanding on cabinet
Fall to the floorStruck back
Immediate Causes?
Basic Causes?
Root Causes?
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OFFICE ACCIDENTCONCLUSION
Accidents generally have more than one
cause Keep asking WHY until you determine the root cause
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Thank You
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