ACCIDENT INVESTIGATION PRESENTATION 04:2011

Provide participants with the basic skills necessary to conduct an effective accident investigation in your workplace. You will identify; Primary Reasons, Benefits, and Employer Responsibilities to conducting an accident investigation Three Steps for an Effective Investigation Investigate and Analysis CB106 Accident Investigation

The most important things in an accident are: When an accident happens, the most important thing is taking care of the victim or victims. After that, the most important thing is finding the causes of the accident. All of us, including employers, need help and advice to identify the causes of accidents. CB106 Accident Investigation

ACCIDENT INVESTIGATION PRESENTATION What is an accident ? An unwanted, unplanned event that causes injuries, illnesses, or property damage. What is an incident ? An unwanted, unplanned event that almost causes injuries, illnesses, or property damage. The term "accident" can be defined as an unplanned event that interrupts the completion of an activity, and that may (or may not) include injury or property damage. An incident usually refers to an unexpected event that did not cause injury or damage this time but had the potential. "Near miss" or "dangerous occurrence" are also terms for an event that could have caused harm but did not. Please note: The term incident is used in some situations and jurisdictions to cover both an "accident" and "incident". It is argued that the word "accident" implies that the event was related to fate or chance. When the root cause is determined, it is usually found that many events were predictable and could have been prevented if the right actions were taken -- making the event not one of fate or chance (thus, the word incident is used). For simplicity, we will use the term accident to mean all of the above events. CB106 Accident Investigation 04:2011

we have to investigate the accidents and the incidents! For each accident, 300 incidents occurred, or you lost 300 chances to prevent the accident! 300 INCIDENTS 1 ACCIDENT If we are going to prevent accidents, we have to investigate the accidents and the incidents! CB106 Accident Investigation

Causes of Accidents Unsafe Conditions Poorly maintained machinery or equipment. Defective or missing personal protective equipment. Unguarded machinery or equipment. Missing or inadequate warnings or safety and health signs. Lack of housekeeping. CB106 Accident Investigation

Causes of Accidents Unsafe Acts Conduct work operations without prior training Block or remove safety devices. Clean, lubricate, or repair equipment while its in operation. Working without protection in hazardous places. CB106 Accident Investigation

Investigate Analyze Report CB106 Accident Investigation

Seal the accident area. Interview witnesses. Draw and take measurements of the accident area. Take samples. CB106 Accident Investigation

Say what happened step-by-step. Analyze the events with the 6 key questions: Who? What? When? Where? Why? How? . Who saw the crash? What happened to the brakes? When did the brakes fail? Where were the replacement brakes? Why wasn’t the mechanic told? How did the crash happen? CB106 Accident Investigation

Say which were the surface causes. Say which were the root causes. Say what happened. Say which were the surface causes. Say which were the root causes. Say what needs to be done so the accident doesn’t happen again. CB106 Accident Investigation

Accidents must be investigated and analyzed from three different points of view: 1 . Direct cause of injury 2. Surface causes of accident 3. Root causes of the CB106 Accident Investigation

ACCIDENT INVESTIGATION PRESENTATION A harmful transfer of energy that produces injury or illness. The worker suffered two broken legs when the truck crashed into the wall. Accidents must be analyzed from three different points of view: DIRECT COUSE OF INJURY; Burns, Strains, Cuts, Fractures. SURFACE CAUSES; Unguarded machine, Broken Tools, Chemical spill, Defective PPE ,Untrained workers, Lack of time, Too much work. ROOT CAUSES; Inadequate training, No discipline procedures, No orientation process, Inadequate training plan, No accountability policy, No recognition, Inadequate labeling procedures ,Outdated procedures, No recognition plan, No inspection policy. CB106 Accident Investigation 04:2011

ACCIDENT INVESTIGATION PRESENTATION Specific unsafe conditions or unsafe behaviors that result in an accident. The truck crashed into the wall because the brakes failed. Accidents must be analyzed from three different points of view: DIRECT COUSE OF INJURY; Burns, Strains, Cuts, Fractures. SURFACE CAUSES; Unguarded machine, Broken Tools, Chemical spill, Defective PPE ,Untrained workers, Lack of time, Too much work. ROOT CAUSES; Inadequate training, No discipline procedures, No orientation process, Inadequate training plan, No accountability policy, No recognition, Inadequate labeling procedures ,Outdated procedures, No recognition plan, No inspection policy. CB106 Accident Investigation 04:2011

ACCIDENT INVESTIGATION PRESENTATION Common conditions and behaviors that ultimately result in an accident. The company did not have a maintenance program for its vehicles. Accidents must be analyzed from three different points of view: DIRECT COUSE OF INJURY; Burns, Strains, Cuts, Fractures. SURFACE CAUSES; Unguarded machine, Broken Tools, Chemical spill, Defective PPE ,Untrained workers, Lack of time, Too much work. ROOT CAUSES; Inadequate training, No discipline procedures, No orientation process, Inadequate training plan, No accountability policy, No recognition, Inadequate labeling procedures ,Outdated procedures, No recognition plan, No inspection policy. CB106 Accident Investigation 04:2011

ACCIDENT INVESTIGATION PRESENTATION Weed out the causes of injuries and illnesses Strains Direct Causes of Injury/Illness Burns Cuts Unguarded machine Horseplay Surface Causes of the Accident Broken tools Create a hazard Chemical spill Ignore a hazard Defective PPE Fails to report injury Untrained worker Fails to inspect Conditions Behaviors Lack of time Fails to enforce To much work Fails to train Inadequate training No recognition No discipline procedures Inadequate labeling procedures No orientation process Outdated Procedures Inadequate training plan No recognition plan No accountability policy No inspection policy Root Causes of the Accident Accident Weed CB106 Accident Investigation 04:2011

Summary Secure the accident scene Collect facts about what happened Develop the sequence of events Determine the causes Recommend improvements Write the report CB106 Accident Investigation