Accident Investigation

2 Bureau Veritas Presentation Learning from our Mistakes Accident Investigation

3 Bureau Veritas Presentation Instructor Instructor Schedule Schedule Participants Participants Materials Materials Objectives Objectives Incident Investigation Course Introduction Accident Investigation

4 Bureau Veritas Presentation Understand the critical importance of investigation and reporting Understand the critical importance of investigation and reporting Use tools presented in the course to arrive at the root causes of accidents Use tools presented in the course to arrive at the root causes of accidents Understand the importance of follow-up Understand the importance of follow-up Understand the critical importance of investigation and reporting Understand the critical importance of investigation and reporting Use tools presented in the course to arrive at the root causes of accidents Use tools presented in the course to arrive at the root causes of accidents Understand the importance of follow-up Understand the importance of follow-up Accident Investigation Course Objectives

5 Bureau Veritas Presentation To determine root causes and prevent recurrence of similar accidents To determine root causes and prevent recurrence of similar accidents To demonstrate to employees that management cares To demonstrate to employees that management cares To determine root causes and prevent recurrence of similar accidents To determine root causes and prevent recurrence of similar accidents To demonstrate to employees that management cares To demonstrate to employees that management cares Why Investigate? Accident Investigation

6 Bureau Veritas Presentation Everything Everything Serious Injuries Minor Injuries Non-injury Incidents Chances ,000 Accident Investigation What to Investigate?

7 Bureau Veritas Presentation Why don’t employees report everything? I said report EVERYTHING !! Accident Investigation

8 Bureau Veritas Presentation Resources to find out include: People People Accident Scene Accident Scene Records Records “PAR for the course” What Happened? Accident Investigation

9 Bureau Veritas Presentation Accident Immediate Causes Basic Causes Safety System Accident Sequence Accident Investigation

10 Bureau Veritas Presentation The Work System The Employee SystemFailures BasicCauses ImmediateCauses Causes Accident Investigation

11 Bureau Veritas Presentation Case #1 - How do you spell relief? Case #1 - How do you spell relief? Case #2 – Back to the Grind Case #2 – Back to the Grind Danger - High Pressure Workshop Accident Investigation

12 Bureau Veritas Presentation The Report The Repair The Review Follow-Up Accident Investigation

13 Bureau Veritas Presentation Understand the critical importance of investigation and reportingUnderstand the critical importance of investigation and reporting Use tools presented in the course to arrive at the root causes of accidents Use tools presented in the course to arrive at the root causes of accidents Understand the importance of follow-up Understand the importance of follow-up Summary Accident Investigation

14 Bureau Veritas Presentation We investigate to show we care and prevent recurrence We investigate to show we care and prevent recurrence We investigate everything a little to see where we need to investigate a lot We investigate everything a little to see where we need to investigate a lot We use people, the accident scene and records (PAR) to find out what happened We use people, the accident scene and records (PAR) to find out what happened We use the Accident Analysis Flow Chart and ask “Why” to help find out why the accident occurred and realize it’s almost always rooted in the management system We use the Accident Analysis Flow Chart and ask “Why” to help find out why the accident occurred and realize it’s almost always rooted in the management system We report, repair and review to make sure that the actions necessary to prevent recurrence are completed We report, repair and review to make sure that the actions necessary to prevent recurrence are completed Summary Accident Investigation

15 Bureau Veritas Presentation Closing Accident Investigation