Accident Investigations Health and Safety Office

Accident Investigation - Objectives Understand the importance of the need for effective and thorough investigation of an accident Demonstrate practical skills required to respond and investigate an incident/accident in a consistent manner Make meaningful recommendations for preventive actions to reduce potential risks that may contribute to accidents

Accident Training Investigations - Objectives (cont.) Understand the investigator’s critical role in the accident investigation and the accident reporting process Determine the cause(s) of an accident and make recommendations to help prevent a recurrence of a similar type of incident

What is an Accident ? An accident is an undesired event that results in physical harm to a person or damage to property.

Purpose of an Accident Investigation The purpose of an accident investigation is to prevent a recurrence of the accident. The focus should be on the accident , not the injury

Effective Accident Investigations What to Look for: Policies/Procedures Equipment Materials Environment Task People/Operators Accidents generally have more than one cause which enables investigators to get to the root cause

Who Investigates Accidents? Supervisors They know their people, the conditions and the job. They know how to get the information needed. They can take action to prevent a recurrence.

Who Investigates Accidents? JHSC Representative They are familiar with the people and workplace. They have a legal requirement to investigate Critical Injuries They have been trained in Accident Investigation

Who Investigates Accidents? Government and Business Agencies Ministry of Labour Ministry of the Environment Fire Department Officials Workplace Safety & Insurance Board

( If a Critical Injury, secure the scene and advise the MOL ) When To Investigate An Accident Immediately or ASAP ( If a Critical Injury, secure the scene and advise the MOL )

Critical Injury Defined The OHSA defines a critical injury as an injury of serious nature that: a) places life in jeopardy; b) produces unconsciousness; c) results in substantial loss of blood; d) involves the fracture of a leg or arm but not a finger or toe; e) involves the amputation of a leg, arm, hand or foot but not a finger or toe; f) consists of burns to a major portion of the body; or g) causes the loss of sight in an eye.

When A Critical Injury Occurs… The accident scene must be preserved as per the legislation, No person shall interfere with, disturb, destroy, alter or carry away any wreckage, article or thing at the scene of or connected with the occurrence until permission to do so has been given by a Ministry of Labour Inspector, except for the purpose of: Saving life or relieving human suffering; or Preventing unnecessary damage to equipment or other property.

Critical Injury Continued The accident scene will remain secured and no work activity will be performed in the area until Health & Safety has been notified by the Ministry of Labour that the investigation is complete and normal work activities can be resumed. An investigation shall commence immediately. External agencies such as Ministry of Labour, Windsor Police Services, Coroner, etc. may take charge of the scene and conduct their own independent investigation. Health & Safety shall complete the Critical Injury Report Form (OHS-5.2.2b) and notify a certified JHSC member

What Equipment Is Required? Personal Protective Equipment Caution Tape Measuring Tape Graph Paper Pencils Lockout / Tagout Clipboard Camera Flashlight (with batteries) Emergency Phone Numbers Accident Investigation Forms

At the Accident Scene Control the Scene People are the first priority- make sure the area is safe to enter; send for help; administer first aid if it is safe to do so; Stop Ongoing Hazards Get personal protective equipment; provide emergency lighting, power, air, etc. Shut down equipment if safe to do so;

At the Accident Scene Secure the Scene and Protect Evidence Rope off the area or use guards or barriers Issue lock outs/tag outs for defective equipment Record evidence during investigation and make sure no one moves or destroys evidence

At the Accident Scene Collect Evidence Take notes, pictures, sketches of tools, equipment, layout, etc. Note air quality and environmental conditions, observe(foot prints, tire tracks); collect logs, chart, records. Record ID numbers of equipment and get maintenance records; Take measurements and dimensions.

At the Accident Scene Look for Contributing Factors: Housekeeping Floor/surface conditions Noise Air quality/temperature/weather Equipment malfunction Supervision Employee morale/attitude/health Alcohol/drug abuse

Immediate Causes Struck By Struck Against Slip/Trip Caught In, On, Between, or Under Fall On, In, or From Scraped / Rubbed Against Overexertion or Body Strain Contact with - Electricity - Heat or Cold - Radiation - Noise - Hazardous Materials

Basic Causes Lack of preventative maintenance Servicing or Moving Equipment Failure To Warn or Secure Tampering or Removing Safety Devices or no Safety Device Unsafe Working / Travelling Speed Awkward Working Posture or Position Incorrect Equipment Inadequate or Improper Work Practices

Root Causes Maintenance or design Lack of Skill or Knowledge Abnormal Usage Excessive Wear and Tear Lack of Programs and Procedures Hazards not reported Lack of Skill or Knowledge Physical and/or Psychological Problems

Root Causes continued Improper Handling Wrong type of Materials Exposure to toxic Chemicals or Physical Agents Condition of surfaces Inadequate ventilation Extreme temperatures and/or noise Inadequate housekeeping or lighting

Equipment or Conditions Involved water on floor damaged equipment running water Ice and snow on ground Equipment Metal Lab cart Specimen Blender Metal work counter electrical appliance plug-ins (cart & counter) metal sink Eyeglasses Fume Hood

Accident Investigation Process Response Assess Scene / Identify Witnesses Preserve Evidence Notification Interview Witnesses Analysis and Conclusions Recommendations Follow up

Accident Investigation Forms Accident/Incident Investigation Report (OHS 5.2.2a) Campus Police Event Report

Who Are The Witnesses ? Eye Witness First Person (s) at the scene Witness Surrounding Events Witness Person Having Knowledge

Interview Process First - Get an overall summary Separate All Witnesses Interview Each Witness Alone and In Private Interview Eye Witnesses First Interview At Accident Scene (when safe to do so)

Effective Interview Technique Put person at ease Explain purpose of accident investigation Listen to the individual’s version Ask the right questions at the right time Repeat the information given back to the individual Always thank person for their cooperation Immediately document critical information Provide drawings and photos where useful Probe for Basic/ Root Causes Keep the door open for further information

Interviewing Questions To Ask Where were you when the accident occurred? What were you doing at the time ? What did you see and hear ? What were the environmental conditions ? What was the injured worker doing at the time ? In your opinion, what caused the accident ? How might similar accidents be prevented in the future ?

Determining Root Cause: Interviewing Questions to Ask Ask “WHY” 5 times to determine root cause “He was lying on the floor” - Why? “Because there was water on the floor” - Why? “Because there was a leak in the sink” - Why? “Because maintenance hadn’t fixed it” - Why? “Because they weren’t aware of the leak” - Why? “Because it wasn’t reported by the department”

Typical Investigation Who was injured? What happened? How to prevent a recurrence? John Doe Slipped on spill on floor and struck his head. All leaks should be reported to Maintenance. Spills should be cleaned up right away and a sign saying wet floor should be placed on the floor.

Recommendations & Follow-Up Have intermediate control measures been implemented prior to final corrective measure ? Have the intermediate or final corrective measures resulted in further hazards? Are the control measures sufficient? How effective are the control measures ? Has there been follow- up and an analysis of the corrective measures to ensure they have been implemented and are effective ?

ACCIDENT INVESTIGATION CONCLUSIONS Accidents generally have more than one cause Keep asking (5 times) WHY until you determine the root cause

Thank You. For more information contact Health and Safety at ext Thank You ! For more information contact Health and Safety at ext. 4521 www.uwindsor.ca/safety