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Accident /Incident InvestigationPaul Thornton
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Key learning points
KLP to first slide
Why investigate accidents and incidents?
Investigating accidents and incidents
Course raises awareness
The training yesterday has raised your awareness of the importance of identifying and controlling risks before harm
occurs
Things may go wrong
However, sometimes things may go wrong. You need to know what to do on these occasions, and how to learn from
them
DEF: Incident
An incident could be described as an undesired event that doesn’t result in harm, but has the potential to do so
DEF: Incident
An undesired event with this result may also be described as a near miss
DEF: Accident
An accident is an undesired event that does result in harm and/or property damage
Prevent from happening
Accidents and incidents should be investigated to identify the cause so that it can be prevented from happening again
Reasons to investigate
Other reasons to investigate accidents and incidents include:
• collecting information for insurance purposes
• determining the cost of an accident
• collecting the required information for notifying authorities
Reasons to investigate
Key benefits of investigation:
• developing useful skills andknowledge that can beapplied throughoutthe organisation
• making a safer work environment
• improving worker morale
• preventing further business losses from disruption, down-time and lost business
Incidents need investigations
Remember: incidents that don’t result in harm or loss still need to be reported and investigated.
- might happen again
Remember: incidents that don’t result in harm or loss still need to be reported and investigated.
An incident might result in more serious consequences if it were to happen again
How do accidents and incidents happen?
ACCIDENT intro
- 4:30 - head for fire exit
- Speedy forklift
- What was the cause?
Finding the Cause of Accidents
Accident investigation allows us to find out the cause of an
accident or incident.
However, accidents and incidents are rarely caused by a single factor – there are usually several contributory factors.
Also, these factors will include obvious and immediate causes and less obvious underlying causes.
Immediate causes
Are unsafe actions or lack of action (for example, operating equipment with missing guards and bypassing interlocks,
using the wrong personal protective equipment) and unsafe conditions (for example, damaged tools and equipment
and high noise and low lighting levels).
Finding the Cause of Accidents
Underlying Causes
Are factors that allow the unsafe actions and conditions to happen.
The majority of these are related to the way the organisation manages health and safety and how people perceive risk
Finding the Cause of Accidents
Root Causes
A root cause is a factor that may cause conditions that could result in an undesirable event. If the problem were corrected, it’d prevent the undesirable event from happening.
In other words, a root cause is an event from which all other causes spring.
Finding the Cause of Accidents
- struck = injury
Finding the Root Cause(s)
Work in your groups to identify the Immediate, Underlying and Root Causes of this incident
ACCIDENT intro
- 4:30 - head for fire exit
- Speedy forklift
- What was the cause?
- tipped + skidded
- skid = oil + brake
- oil = leak
- leak = no supervision
- brake = speed + step
- speed = rushing + work pressure
- governor
- governor = no supervision
- emergence = poor c&p
- causal tree
- Immediate, underlying, root
- management
Remember: immediate
Remember: if you only investigate as far as the immediate causes, there’s a much higher likelihood that it will happen
again
---== KLP3: Investigation? ==---
How do you carry out
an investigation?
Aftermath of accident
1. Ensure wellbeing
1. Ensure the wellbeing of the injured person
2. Preserve scene
2. Preserve the scene
3. Report
3. Report the accident (or incident)
- to whom
‣ senior management‣ enforcing authority‣ injured person’s family‣ owner of assets‣ insurance company‣ safety/employee
representatives‣ health and safety and
human resources departments
3. Report the accident (or incident)
- report form
3. Report the accident (or incident)
4. Assemble team
4. Assemble the investigation team
- someone familiar4. Assemble the investigation team
• someone familiar with the work location
- supervisor4. Assemble the investigation team
• supervisor or manager from work location
- senior mgmt
4. Assemble the investigation team
• senior manager with authority or influence
- h&s expert4. Assemble the investigation team• health and safety expert
- employee rep4. Assemble the investigation team
• employee representative
- involved in event4. Assemble the investigation team
• person involved in event (if possible)
- technical expert4. Assemble the investigation team• technical expert (if necessary)
- Size of team
The size of the team is determined by the size of the organisation
- Size of investigation
The level of investigation is determined by the likelihood of recurrence and the potential worst consequences of the
undesired event
5. Investigate
5. Investigate using a structured approach
- Gather5. Investigate using a structured approach• Gather information
- Gather points5. Investigate using a structured approach• Gather information
• physical• human• documentary
- Analyse5. Investigate using a structured approach
• Analyse findings
- Risk control5. Investigate using a structured approach• Review current risk controls
- Action plan5. Investigate using a structured approach
• Create an action plan
- Investigation report5. Investigate using a structured approach
6. Handle external6. Handle external relations
- enforcement6. Handle external relations• Enforcement authorities
- media6. Handle external relations• Media
- locals6. Handle external relations• Local residents and businesses
Getting it right
Getting it right:
• Investigation is about avoiding it happening again, not attributing blame
• Having plans in place before an accident will help for an effective investigation
• Sharing the findings is as important as ensuring the quality of the investigation
KLP Summary
‣ Why investigate accidents and incidents?‣ How do accidents and incidents happen?‣ How do you carry out an
investigation?
Key learning points:
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Key learning points:
• Why investigate accidents and incidents?• How do accidents and incidents happen?• How do you carry out an
investigation?
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