1. Accident Investigations Health and Safety Office

2. 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

3. 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

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

5. 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

6. 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

7. 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.

8. 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

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

10. ( 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 )

11. 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.

12. 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.

13. 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

14. 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

15. 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;

16. 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

17. 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.

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

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

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

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

27. 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)

28. 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

29. 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 ?

30. 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”

31. 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.

32. 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 ?

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

34. Thank You. For more information contact Health and Safety at ext
Thank You ! For more information contact Health and Safety at ext