Accident Reporting & Investigation Course Objectives
to understand: accident definition accident causation accident costs accident prevention accident reporting/notification accident investigation
Accident Reporting & Investigation Common Uninformed Comments
accidents just happen we don’t have many accidents safety is expensive the insurance will pay safety is just common sense
Accident Reporting & Investigation Accident Definition
what is an accident? unplanned & uncontrolled event
that led to, or could have led to:• injury to persons, damage to
property/plant/equipment, impairment to the environment or some other loss to the company
Accident Reporting & Investigation Accident Definition
accident types• minor dangerous occurrence• near miss• plant/equipment damage• minor injury• lost time injury• disablement/fatality
Accident Reporting & Investigation
Accident Definition
Frank Bird (Accident Triangle)• 600 near misses• 30 property damage• 10 minor injuries• 1 serious injury (lost time or fatal)
Accident Reporting & Investigation
Accident Causation
environment personal fault unsafe act unsafe condition accident injury/damage
Accident Reporting & Investigation
Accident Causation
causal factors• individual
– knowledge
– skills
– training
– experience
– personality
– attitude
– risk perception
Accident Reporting & Investigation
Accident Causation
causal factors• job
– task– workload– equipment– controls– procedures– environment
Accident Reporting & Investigation
Accident Causation
causal factors• organisation
– culture– leadership– resources– work patterns– communications
Accident Reporting & Investigation
Accident Causation
Kings Cross Fire (1987) - 31died• discarded cigarette• accumulation of rubbish• poor cleaning regime• wooden escalator• failure of fire fighting equipment• lack of emergency training• poor safety culture
Accident Reporting & Investigation
Accident Causation
Herald of Free Enterprise (1987) - 189 died
• failure to close bow doors• no checking/reporting system• commercial pressures• internal friction• disease of sloppiness
Accident Reporting & Investigation
Accident Causation
Clapham Junction (1988) - 35 died & 500 injured
• signal failure• incorrect maintenance• degradation of working practices• training problems• communication problems• poor supervision• excessive working hours• failure to learn lessons
Accident Reporting & Investigation
Accident Causation
Piper Alpha (1988) - 167 died• maintenance error• inexperience• poor maintenance procedures• communications breakdown• permit to work system fault• safety procedures not practised
Accident Reporting & Investigation
Accident Causation
Automotive Supplier (1999) - 1 died• poor safety culture• lack of guarding• lack of training• poor perception of risk• no safe systems of work• no risk assessment programme• no effective accident system• no communication
Accident Reporting & Investigation
Accident Prevention
control measures• safety procedures/work instructions
• adequate training
• effective communications
• good housekeeping
• guards/safety devices/warning signs
• adequate working environment
• regular safety inspections
• risk assessment
Accident Reporting & Investigation
Accident Reporting/Notification
• internal report form• HSE RIDDOR report• injury claim requirement
Accident Reporting & Investigation
Accident Investigation
reasons• identify root causes• identify faults• identify corrective/preventative action• prevent recurrence
Accident Reporting & Investigation
Accident Investigation
investigation team• supervisor• safety rep• engineer• manager• safety officer
Accident Reporting & Investigation
Accident Investigation
investigation objectives• establish chain of events• identify root causes• identify faults• identify corrective/preventative action
Accident Reporting & Investigation
Accident Investigation
investigation techniques• attend promptly
• ensure medical attention
• leave scene undisturbed
• take photographs/sketches
• take measurements
• take samples
• gather documentation
• interview witnesses
Accident Reporting & Investigation
Accident Investigation
investigation techniques• interviewing witnesses
– explain purpose
– their version of events
– do not listen to ‘hear say’
– ask open questions
– avoiding leading or implying
– do not apportion blame
– express appreciation
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