1. Accident Investigation Presented by Joanne Hall2013 ACM JIF Retreat

5. True or False Employees only need to report injuries if they think they need to see a doctor. Supervisors only need to investigate the really, really bad ones.  TRUE  FALSE

6. True or False The main reason for investigating accidents is to fix the blame on someone.  TRUE  FALSE

7. Fact-Finding, not Fault Finding Do workers see Accident Investigations as a positive thing ?

8. Overcoming Suspicions Actions speak louder than words Show concern for worker Show honest interest to get facts, not place blame Share lessons learned with all workers  Improved procedures  New equipment  Reinforce desirable behaviors

9. True or False Before you start the process of investigation, you need to have a plan.  TRUE  FALSE

10. BEFORE THE ACCIDENT Outline roles & responsibilities Train key staff members Establish communication flow Set up standard procedures Have an investigation kit on hand Establish post-accident drug / alcohol screening protocols

11. 3 Basic Steps Gather facts Front Line Supervisors Identify root cause & contributing factors Create plan to improve from lessons learned from investigation

12. Gathering the Facts Note paper & Accident Forms Camera Measuring tape Barricade tape Plastic bags and vials with caps Graph paper Clip board Just the facts

13. True or False It is best to interview witnesses all together to save time.  TRUE  FALSE

14. INTERVIEWING TIPS Put the person at ease Interview witnesses separately Establish facts and time line Ask open-ended questions Let the person talk Separate the investigation process from the disciplinary process Listen, then summarize

15. Who? What? Where? When? How? Why? Note: Body Position of Interviewer

16. True or False It’s better not to ask too many questions because it just muddies the water.  TRUE  FALSE

17. Asking the Right Questions Who was involved, present, nearby? What was their training and experience? What happened? What equipment/materials were used ? Where did it happen? Note relevant facts, i.e. lighting, weather, floor conditions, etc.

18. MORE KEY QUESTIONS TO ASK When time? Note exact time, date and other factors, such as shift change, work cycle, break period, etc. How did it happen? Determine sequence of events Why was this job being done and, why that way?

20. Let’s try some information gathering

21. What information is critical ? A worker was loading a trailer with landscaping tools, supplies, and equipment. When walking down the ramp of the trailer, he slipped and fell.

22. Small Group Exercise How many questions can you come up with for each scenario?

23. Using the Information Gathered Gather facts - COMPLETED Identify root cause & contributing factors Create plan to improve from lessons learned from investigation

24. True or False Once you come up with an obvious answer, it’s better not to dig any deeper.  TRUE  FALSE

25. DETERMINING CAUSES The Root Cause is the most fundamental and direct cause of an accident or incident There may be one or more Contributing Factors, in addition to the root cause Accident Investigation is ineffective unless all causes are determined and addressed

26. Ask WHY until can’t ask more Worker wasn’t wearing gloves - WHY ? Gloves don’t fit - WHY ? Only one size purchased - WHY ? Purchaser didn’t know more sizes needed or available - WHY ? Lack of communication between workers, managers, & purchaser - WHY ?

27. ROOT CAUSE ANALYSIS WORKSHEET Copy in your packet

28. PEOPLE Lack of Procedure Procedure not followed Procedure not understood Task too difficult to perform PPE not used or not available People not trained Training inadequate Distractions or Emotion Fatigue MANAGEMENT No management system to control hazard Supervision did not detect unsafe conditions or behaviors Supervision did not correct Lack of Supervisor training Lack of Supervisor accountability EQUIPMENT / TOOLS Equipment not maintained Wrong equipment used for the job Poor equipment design Correct equipment not available. ENVIRONMENT Location of employee Temperature extremes Poor Lighting Poor Housekeeping Inadequate ventilation Excessive vibration Excessive noise Condition of work surface

29. Completing the paperwork

30. WATCH FOR“WEASEL WORDS” Careless... Accident Prone... Unlucky.. Rushing... If your investigation leads to one of these phrases, you need to dig deeper

31. Using the Information Gathered Gather facts - COMPLETED Identify root cause & contributing factors - COMPLETED Create plan to improve from lessons learned from investigation

32. CORRECTING THE CAUSES Identify controls to address root cause & each cause  More than one control may be needed  Reinforce good things  Correct undesirable conditions / behaviors Consider short term controls if permanent controls are not readily available Use the “Control Hit List”

33. THE “CONTROL HIT LIST” 1. Eliminate the Hazard 2. Substitute a Less Hazardous Material 3. Use Engineering Controls 4. Use Administrative Controls 5. Use Personal Protective Equipment (PPE) 6. Train Employees

34. ACCIDENT REVIEW - RESULTS For motor vehicle crashes:  Was incident “preventable” or “non preventable?”  What corrective actions are needed? For Workers Comp accidents:  What can be done to create a positive learning experience.  Adopt a Zero-tolerance for accidents

35. OUTCOME OF COMMITTEE DECISION Document in Safety Committee minutes Respect privacy / medical issues Written decision to employee from supervisor  Written copy in personnel file  Possibly, copies to other parties

36.  Better instructions or job planning  Repairs / Replacement of equipment  Better methods (SOPs)  Training / Re-training  Better decision-making  Progressive discipline TYPICAL CORRECTIVE MEASURES

37. Group Exercise In your groups Work s a team to investigate an accident and make recommendations for corrective action. Assign a scribe, someone to complete investigation report and a spokesperson. Look for Root Causes, Corrective Actions and how this incident can lead to positive changes in the operation.

38. Feedback from Groups

39. True or False Nothing good ever comes out of an accident.  TRUE  FALSE

40. Challenge: Have workers report near misses

41. Closing Thoughts Accident Investigation is a REACTIVE process Employers need to stress improving PROACTIVE approach to worker safety  Job Site Observations  Near miss investigation

42. GROUP DISCUSSION What are you going to do differently as a result of today’s discussion?