Accident Investigation Workshop Why investigate accidents? Why investigate accidents? Investigation Process Investigation Process Root Cause & Contributing Causes Root Cause & Contributing Causes Methods Methods Supervision, Policies, Procedures, Rules Supervision, Policies, Procedures, Rules Equipment Equipment Materials, Safeguards, Product, Machinery Materials, Safeguards, Product, Machinery Environment Environment Facilities, Heat/Cold, Agents, Atmosphere Facilities, Heat/Cold, Agents, Atmosphere Personnel Personnel Training, Fatigue, Protection, Fitness Training, Fatigue, Protection, Fitness Corrective Action Response Fact-Finding Analysis Follow-Up

WHY DO ACCIDENTS OCCUR? SUPERVISION POLICES METHODS PROCEDURES RULES FACILITIES HEAT/COLD ENVIRONMENT AGENTS ATMOSPHERE MATERIAL SAFEGUARDS EQUIPMENT PRODUCT MACHINERY TRAINING FATIGUE PERSONNEL PROTECTION FITNESS ACCIDENT SYSTEM FAULTS

Round Robin Accident Investigation

Accident Investigation Case Study Describe in detail, how the incident occurred and what part of the body it affected: Describe in detail, how the incident occurred and what part of the body it affected: Employee fractured left foot. Employee slipped while climbing up ladder. Employee fractured left foot. Employee slipped while climbing up ladder. Describe the root causes and how they contributed to this accident: Describe the root causes and how they contributed to this accident: Employee failed to maintain three points of contact. Employee failed to maintain three points of contact. What should be done, and by whom to prevent recurrence of this type of incident in the future: What should be done, and by whom to prevent recurrence of this type of incident in the future: Employee should be more careful while on ladders. Employee should be more careful while on ladders.

Accident Investigation Case Study Describe in detail, how the incident occurred and what part of the body it affected: Describe in detail, how the incident occurred and what part of the body it affected: Employee sustained burns to hands and face while filling the hot lugger for the fill pipe. Employee sustained burns to hands and face while filling the hot lugger for the fill pipe. Describe the root causes and how they contributed to this accident: Describe the root causes and how they contributed to this accident: Employee failed to wear proper clothing and PPE while working with hot materials. Employee failed to wear proper clothing and PPE while working with hot materials. What should be done, and by whom to prevent recurrence of this type of incident in the future: What should be done, and by whom to prevent recurrence of this type of incident in the future: Face shields should be placed near fill-pipe. Face shields should be placed near fill-pipe.

Accident Investigation Case Study Describe in detail, how the incident occurred and what part of the body it affected: Describe in detail, how the incident occurred and what part of the body it affected: 65 year-old male struck in the head and neck from debris that blew off the scaffold system. Claimant was walking across the parking area at time of accident. 65 year-old male struck in the head and neck from debris that blew off the scaffold system. Claimant was walking across the parking area at time of accident. Describe the root causes and how they contributed to this accident: Describe the root causes and how they contributed to this accident: Foreman did not secure debris against high winds. Foreman did not secure debris against high winds. What should be done, and by whom to prevent recurrence of this type of incident in the future: What should be done, and by whom to prevent recurrence of this type of incident in the future: Crew should review housekeeping practices and weather forecasts. Crew should review housekeeping practices and weather forecasts.

Accident Investigation Case Study Describe in detail, how the incident occurred and what part of the body it affected: Describe in detail, how the incident occurred and what part of the body it affected: While traveling back from the jobsite, the foreman was involved in a three vehicle accident. Pete, who was sitting in the passenger seat sustained a neck strain. While traveling back from the jobsite, the foreman was involved in a three vehicle accident. Pete, who was sitting in the passenger seat sustained a neck strain. Describe the root causes and how they contributed to this accident: Describe the root causes and how they contributed to this accident: Driver was not at fault – no further actions required. Driver was not at fault – no further actions required. What should be done, and by whom to prevent recurrence of this type of incident in the future: None What should be done, and by whom to prevent recurrence of this type of incident in the future: None

Accident Investigation Case Study Describe in detail, how the incident occurred and what part of the body it affected: Describe in detail, how the incident occurred and what part of the body it affected: Employee was carrying 5-gallon buckets of bonding adhesive from the loading area to the work area. Employee claims he felt soreness in his back two days later. Employee was carrying 5-gallon buckets of bonding adhesive from the loading area to the work area. Employee claims he felt soreness in his back two days later. Describe the root causes and how they contributed to this accident: Describe the root causes and how they contributed to this accident: No specific incident event identified. Employee may have tried to hurry to move buckets without using proper body mechanics. No specific incident event identified. Employee may have tried to hurry to move buckets without using proper body mechanics. What should be done, and by whom to prevent recurrence of this type of incident in the future: What should be done, and by whom to prevent recurrence of this type of incident in the future: Employees should be reminded to lift with their legs, keep stomach tight, and inspect their path of travel. Employees should be reminded to lift with their legs, keep stomach tight, and inspect their path of travel.