1. EFFECTIVE ACCIDENT/INCIDENT INVESTIGATION 15 FEBRUARY 2013 PHILIPPINE ASSOCIATION OF SAFETY ENGINEERS -QATAR- -QATAR- COMMITTEE ON SAFETY EDUCATION 2013 JONATHAN M. AZURIN HSE ENGINEER MBA, DipILM, DipHSE, CSP, MIIRSM, TechIOSH

2. COURSE OUTLINE 1.DEFINITION OF TERM 2. PURPOSE OF ACCIDENT/INCIDENT INVESTIGATION 3. CHAIN OF ACCIDENT/INCIDENT CAUSATION 4. ACCIDENT/INCIDENT INVESTIGATION PROCESS 5. BENEFITS OF ACCIDENT/INCIDENT INVESTIGATION 6. BASIC INCIDENT REPORT WRITING

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4. LEARNING OBJECTIVES At the end of this presentation, participants are expected to: Define and differentiate accident, incident, near-miss, accident/incident investigation report Understand the purpose/s of accident/incident investigation Understand the fundamental process of accident/incident investigation Know the benefits of conducting accident/incident investigation

5. DEFINITION Incident / Accident: It is an undesired event resulting to: - ill health - physical injury - damage to property - significant impact to environment. Near-miss: An undesired event which, under slightly difference, could have resulted to injury, ill-health or damage to property or impact to environment.

6. DEFINITION Investigation: It is a systematic examination of an events and its causes / contributing factors. Accident/Incident Investigation Report: It is a document containing information generated from a systematic examinations of events. This is a method of communicating the findings, corrective actions, recommendations and lessons learn. Root cause/s or underlying causes: Is the primary cause or causes of an accident that, when identified accurately and corrected, will prevent reoccurrence.

7. PURPOSE OF ACCIDENT/ INCIDENT INVESTIGATION Prevent accident reccurrence Identify weakness in the system Help improve standards Improve staff relations by demonstrating commitment to health and safety; thus increase workers’morale Determine economic losses due to accident (cost) Extent of compliance with legal requirements

8. BASIC PRINCIPLE 1.All ACCIDENTS are INCIDENTS but not all INCIDENTS are ACCIDENTS 2.All NEAR-MISSES are INCIDENTS but not all INCIDENTS are NEAR-MISSES 3.All ACCIDENTS and NEAR-MISSES are INCIDENT

9. FOCUS OF INVESTIGATION Positive: FACT FINDINGS: All relevant circumstances = positive implications Negative: FAULT FINDINGS: With personal interest or intention = negative implications

10. INVESTIGATIONS FLOW DOCUMENT THE FACTS: HARD EVIDENCE, WITNESS ENSURE IMMEDIATE MEDICAL TREATMENT GATHER FACTS ABOUT THE ACCIDENT: WITNESSES IDENTIFY THE ROOT CAUSE (CAUSAL FACTORS) CORRECTIVE ACTION FOLLOW-UP SECURE THE AREA

11. CHAIN OF ACCIDENT CAUSATION Human Factor Substandard Act Substandard Conditions ACCIDENT unplanned release of energy and/or hazardous material Fatality Personal injury Property damage UNDERLYING / ROOT CAUSES IMMEDIATE CAUSES INCIDENT - CONTACT ACCIDENT RESULTS Management system Personal Factors / Job Factors

12. INCIDENT INVESTIGATION PROCESS 1.Information gathering 2.Analyze information 3.Identify control measure 4.Develop action plan 5.Implementation

13. INCIDENT INVESTIGATION PROCESS 1.INFORMATION GATHERING: –Ensure immediate treatment (if any) –Investigate immediately –Secure the area –Record details of event (photo, sketch, etc.) –Collect physical evidence –Review other source (victim’s record, Supvr, friends, etc.) –Interview witness (5Ws + 1H)

14. INCIDENT INVESTIGATION PROCESS 1H + 5Ws = - was injured? - saw the accident? - was working with the injured? - had instructed/assigned the job to the injured? - else was involved? - has the information of events prior to the accidents? WHO

15. INCIDENT INVESTIGATION PROCESS - is the injury? - was the injured doing? - had the injured been instructed to do? - tools/equipment/machinery were being used? - did the injured & any witnesses saw? - training had been given? - were the contributory causes of the accident? - communication system was used? - state of health of the injured? - safety rules were violated? - safety system and procedures were there? WHAT

16. INCIDENT INVESTIGATION PROCESS - did the accident occur? - did the damage become evident? - did the injured person start the job? - was the explanation of hazard given? - did the supervisor last see the injured? - did the persons involved last have food & rest? WHEN

17. INCIDENT INVESTIGATION PROCESS - did the injury occur? - did the communication fail? - was the training not given? - were the unsafe condition permitted? - was the hazard not spotted at previous inspection? - was PPE not used or provided ? - was there no safe system of work? - no safety instruction given? - was supervisor consulted when things started go wrong? WHY

18. INCIDENT INVESTIGATION PROCESS - did the accident occur? - did the damage occur? - was the supervisor at that time? - was the witnesses at that time? WHERE

19. INCIDENT INVESTIGATION PROCESS - did the injury occur? - could the accident have been avoided? - could have been the injury avoided? - could the supervisor have prevented the accident? - could better design help? HOW

20. INCIDENT INVESTIGATION PROCESS 2.ANALYZE INFORMATION:ANALYZE INFORMATION: a)Immediate or Direct causes: Substandard or unsafe act Substandard or unsafe condition b) Underlying or Root causes: Personal factor Job or systemic factor ACTUAL BEHAVIOR or CONDITION STANDARD BEHAVIOR or CONDITION SAFE BEHAVIOR or CONDITION ACTUAL BEHAVIOR or CONDITION STANDARD BEHAVIOR or CONDITION UNSAFE BEHAVIOR or CONDITION

21. INCIDENT INVESTIGATION PROCESS 2.ANALYZE INFORMATION: a)Immediate or Direct causes: Substandard or unsafe act –Operating equipment without authority –Failure to wear PPE –Using defective equipment Substandard or unsafe condition –Inadequate guard or barriers –Defective tools or equipment –Poor housekeeping –Noise exposure

22. INCIDENT INVESTIGATION PROCESS 2.ANALYZE INFORMATION: b) Underlying or Root causes: Personal factor –Lack of knowledge –Lack of skills –Improper motivation –Stress Job or systemic factor –Inadequate supervision –Poor leadership –Inadequate tools & equipment –Inadequate/poorly written standard

23. INCIDENT INVESTIGATION PROCESS 2.ANALYZE INFORMATION: FISHBONE ANALYSIS Management ManpowerMother Nature MachineMethodMaterial scaffold accident Poor Performance Insufficient number of tools Lack of control system Wrong Sequence Poor supervision Unsafe behavior Poor working condition Lack of testing apparatus Incorrect Material Material Damaged unskilled Temp Lack of ventilation Difficulty of maneuver Rain Muddy site No inspection method. Inadequate material inspection Too old Personal problem Lack of management commitment

24. INCIDENT INVESTIGATION PROCESS 3.IDENTIFY CONTROL MEASURE: –Elimination –Reduction or Isolation –Engineering control –Personal Protective equipment –Disciplinary action People Equipment Management Material Environment

25. INCIDENT INVESTIGATION PROCESS 4. DEVELOP AN ACTION PLAN Door’s header Incident

26. BASIC INCIDENT REPORT WRITING 1.WORKSHOP Door’s Header Crushed FingersCrushed Fingers (illustration)(illustration) Overturned Crane Incident Investigation Report Form

27. SUMMARY How you can differentiate accident, incident, near- miss, accident/incident investigation report? What are the purpose/s of accident/incident investigation How fundamental process of accident/incident investigation flow? What are the benefits accident/incident investigation

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31. SAFETY BE ALWAYS OUR FIRST PRIORITY Thank you very much!!! COMMITTEE ON SAFETY EDUCATION 2013