Download - Accident Reporting & Investigation
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Accident Reporting &
Investigation
Paul CraythorneHealth, Safety & Environmental Advisor
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Accident Reporting &
Investigation Course Objectives
to understand:
accident definition
accident causation
accident costs
accident prevention
accident reporting/notification
accident investigation
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Accident Reporting &
Investigation Common Uninformed Comments
accidents just happen
we dont have many accidents
safety is expensive
the insurance will paysafety is just common sense
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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, impairmentto the environment or some other loss
to the company
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Accident Reporting &
Investigation Accident Definition
accident types minor dangerous occurrence
near miss
plant/equipment damage
minor injury lost time injury
disablement/fatality
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Accident Reporting &
InvestigationAccident Definition
Frank Bird (Accident Triangle) 600 near misses
30 property damage
10 minor injuries
1 serious injury (lost time or fatal)
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Accident Reporting &
InvestigationAccident Causation
environment
personal fault
unsafe act
unsafe condition
accident
injury/damage
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Accident Reporting &
InvestigationAccident Causation
causal factors individual
job
organisation
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Accident Reporting &
InvestigationAccident Causation
causal factors individual
knowledge
skills
training experience
personality
attitude
risk perception
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Accident Reporting &
InvestigationAccident Causation
causal factors job
task
workload
equipment controls
procedures
environment
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Accident Reporting &
InvestigationAccident Causation
causal factors organisation
culture
leadership
resources work patterns
communications
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Accident Reporting &
InvestigationAccident 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
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Accident Reporting &
InvestigationAccident Causation
Herald of Free Enterprise (1987) -189 died
failure to close bow doors
no checking/reporting system
commercial pressures
internal friction
disease of sloppiness
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Accident Reporting &
InvestigationAccident 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
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Accident Reporting &
InvestigationAccident Causation
Piper Alpha (1988) - 167 died maintenance error
inexperience
poor maintenance procedures
communications breakdown
permit to work system fault
safety procedures not practised
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Accident Reporting &
InvestigationAccident Causation
Automotive Supplier (1999) - 1died
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
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Accident Reporting &
InvestigationAccident Costs
insured costs
uninsured costs
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Accident Reporting &
InvestigationAccident Prevention
reasons humane
economic
legal
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Accident Reporting &
InvestigationAccident 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
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Accident Reporting &
InvestigationAccident Reporting/Notification
internal report form HSE RIDDOR report
injury claim requirement
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Accident Reporting &
InvestigationAccident Investigation
reasons identify root causes
identify faults
identify corrective/preventative action
prevent recurrence
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Accident Reporting &
InvestigationAccident Investigation
investigation team supervisor
safety rep
engineer
manager
safety officer
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Accident Reporting &
InvestigationAccident Investigation
investigation objectives establish chain of events
identify root causes
identify faults
identify corrective/preventative action
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Accident Reporting &
InvestigationAccident Investigation
investigation techniques attend promptly
ensure medical attention
leave scene undisturbed
take photographs/sketches
take measurements
take samples
gather documentation
interview witnesses
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Accident Reporting &
InvestigationAccident 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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Accident Reporting &
InvestigationAccident Investigation
investigation report identify team
summarise consequential events
identify root causes
describe other weaknesses
identify corrective/preventative action
allocate responsibility & timescale