accident investigation
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HU151_Lect 9. Accident Investigation. Fall 2012/13. OUTLINE. Accident/Incident Investigation Outcome Investigation Steps Three Types of Causes Example. What Is An Accident?. - PowerPoint PPT PresentationTRANSCRIPT
HU 151, Lecture9, Accident Investigation
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OUTLINE Accident/Incident Investigation Outcome Investigation Steps Three Types of Causes Example
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What Is An Accident?An unplanned, unwanted, but controllable event which disrupts the work process and causes personal injury and/or in property damage.
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BP's Deepwater Horizon oil well explosion last year - killed 11 workers and caused the biggest offshore spill in US history.
According to BP's September 2010 report, the accident started with a "well integrity failure". This was followed by a loss of control of the pressure of the fluid in the well. The "blowout preventer", a device which should automatically seal the well in the event of such a loss of control, failed to engage. Hydrocarbons shot up the well at an uncontrollable rate and ignited, causing a series of explosions on the rig.
http://www.bp.com/liveassets/bp_internet/globalbp/globalbp_uk_english/incident_response/STAGING/local_assets/downloads_pdfs/Deepwater_Horizon_Accident_Investigation_Report.pdf
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What Is An Incident? An unplanned and unwanted event which disrupts the
work process and has the potential of resulting in injury, harm, or damage to persons or property.
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Incident Investigation
Incidents should be investigated as well, since they are potential “accidents”.
Criteria for investigating an incident:
- What is reasonably the worst outcome, equipment damage, or injury to the worker? - What might the severity of the worst outcome have been? - If it would have resulted in significant property loss or a serious injury, then the incident should be investigated with the same thoroughness as an accident investigation.
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Accident Investigation
Will determine how and why of failures. Examine possible corrective action. Aid in the accident prevention and elimination
of a clearly identified hazard.
Most important -Investigation is not intended to place blame.
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Investigation Outcome
1. Prevent future incidents (leading to accidents).
2. Identify and eliminate hazards.
3. Expose deficiencies in process and/or equipment.
4. Reduce injury and worker compensation costs.
5. Maintain workers’ morale.
6. Meet regulations.
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Main Steps
1. Develop a plan
2. Assemble an investigation kit
3. Investigate all incidents and accidents immediately
4. Collect facts
5. Interview witnesses
6. Write a report
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Begin Investigation Immediately
It’s crucial to collect evidence and interview witnesses as soon as possible because evidence will disappear and people will forget.
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CAUSES Direct Cause – the actual energy (movement or
source) that caused injury to employee. If this energy wasn’t present, the injury would not have occurred.
Indirect Causes – any unsafe acts or conditions that contribute to the injury occurring.
Basic Causes – policies, procedures, environment or personal factors that contribute to the injury occurring.
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The Three Basic CausesPoor Management Safety Policy & Decisions
Personal FactorsEnvironmental Factors
Unsafe ActUnsafe
Condition
Unplanned release of energyand/or
Hazardous material
Basic Causes
Indirect Causes
Direct
Causes
ACCIDENTACCIDENTPersonal Injury
Property Damage
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Preparing for the Investigation Develop contingency plans prior to the
accident. Designate an investigator
This person should only be responsible for investigating.
Should have a good working knowledge of operating procedures.
Be equipped with the right tools to do the job thoroughly.
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Record the Facts
Interview witnesses as soon as possible. Document the accident scene before any
changes are made. Take photos Draw scaled sketches Record measurements
Gather support documents such as maintenance records, reports, production schedules or process diagrams.
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Record the Facts
Keep all notes and remarks in a bound notebook or three ring binder.
Record: Pre-accident conditions Accident sequence Post-accident conditions
Document victim location, witnesses, machinery, energy sources and other contributing factors.
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Record the Facts
Even the most insignificant detail may be useful.
Document and then document some more. The investigator should be concentrating
solely on the investigation at hand.
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Interviewing
Excellent source of first hand knowledge. May present pitfalls in the form of:
Bias Perception Exaggeration
It is important to maintain a clear thought process and control of the interview.
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Interviewing
Get preliminary statements as soon as possible from all witnesses.
Locate the position of each witness on a master chart (including the direction of view)
Explain the purpose of the investigation (accident prevention) and put each witness at ease.
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Interviewing
Let each witness speak freely and take notes without distracting the witness (use a tape recorder only with consent of the witness).
Use sketches and diagrams to help the witness.
Emphasize areas of direct observation and label hearsay accordingly.
Record the exact words used by the witness to describe each observation.
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Interviewing
Word each question carefully and be sure the witness understands.
Identify the qualifications of each witness (name, address, occupation, years of experience, etc.).
Supply each witness with a copy of their statements (signed statements are desirable).
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Problem Solving TechniquesChange Analysis
This technique emphasizes change to correct the problem.
Examination of deviations from the norm are scrutinized.
Consider all problems to result from some unanticipated change.
Analyze the changes to determine its cause.
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Problem Solving TechniquesChange Analysis
Use the following steps in this method:
Define the problem (What happened?).
Establish the norm (What should have happened?).
Identify, locate, and describe the change (What, where, when, to
what extent).
Specify what was and what was not affected.
Identify the distinctive features of the change.
List the possible causes.
Select the most likely causes.
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Problem Solving TechniquesJob Safety Analysis
Job safety analysis (JSA) is part of many existing accident prevention programs.
In general, JSA breaks a job into basic steps, and identifies the hazards associated with each step as well as prescribing controls for each hazard.
A JSA is a chart listing these steps, hazards, and controls. Review the JSA during the investigation if a JSA has been
conducted for the job involved in an accident. Perform a JSA if one is not available to determine the
events and conditions that led to the accident.
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Investigation Report
An accident investigation is not complete until a report is prepared and submitted to the proper authorities.
Suggestion of items to include in your report.
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Investigation Report
Background Information Where and when the accident occurred Who and what were involved Operating personnel and other witnesses
Account of the Accident (What happened?) Sequence of events Extent of damage Accident type Agency or source (of energy or hazardous
material)
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Investigation Report
Discussion (Analysis of the Accident - HOW; WHY) Direct causes (energy sources;
hazardous materials) Indirect causes (unsafe acts and
conditions) Basic causes (management policies;
personal or environmental factors)
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Investigation Report
Recommendations (to prevent a recurrence) for immediate and long-range action to remedy: Basic causes Indirect causes Direct causes (such as reduced quantities or
protective equipment or structures)
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CASE STUDY - Bus
Accident Description:
“I was checking the steering fluid in bus engine. I had to climb up on the front tire and when I was getting down, I felt my left knee pop.”
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QUESTIONS TO UNCOVER CAUSES
Why did employee have to stand on the tire? Are there other ways of checking fluids? What is the process for getting down? What type of training did you receive for checking
fluids? By who? What is the distance between tire and first step to get
down? Each additional step? Tell me what you did from the time you arrived at work? What was going on/happening around you at the time
you were getting down? What type of shoes were you wearing? Have there been similar incidents? Explain. What was the weather?
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Investigation Findings – Bus Driver was not trained how to check fluids on this type of
bus. There are two step ladders available, but none close by. No process or procedures in place for checking fluids. Ladder use is covered in Accident Prevention Program
but there was no training specific to ladder use provided to drivers.
Distance from tire to the peg step is 90 cm, step to ground is 50 cm.
Driver had washed bus prior to checking fluids and area around the bus was still wet.
Shoes being worn did not have good tread on soles to prevent slipping.
Another driver came up and started talking as driver was getting down.
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Accident Causes – Bus
Direct causes Improper body movement
Indirect causes Failure to use proper equipment - step ladder Wearing inappropriate footwear Lack of step ladders available and not close by Employee was distracted
Basic causes Inadequate training in pre-trip procedures for all
types of buses No designated bus wash area
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CORRECTIVE ACTION PLANCAUSES CORRECTIVE ACTIONS TIME SCALE
Improper body movement Develop procedures and train drivers on procedures
Immediately
Mr. Y.
Failure to use proper equipment – step ladder
Enforce safety rules/discipline policy
Immediately
Mr. X
Wearing inappropriate footwear
Develop, implement and enforce safety procedures
6 Months
Ms R
Lack of step ladders available and not close by
Ensure adequate number of step ladders and ensure they are
readily available
6 Months
Mr. F
Employee was distracted Safety awareness training Immediate, Ongoing
Mr. T
Inadequate training in pre-trip inspections for all types of
buses
Train staff on use of all equipment and procedures
1 Year
Mr. J
No designated bus wash area Designate bus wash area 2 Years
Mr. V