1. Introduction to effective Incident/Accident Analysis

2. Objectives After attending this workshop you should be able to:
1. Describe the primary reasons for conducting an accident investigation.
2. Discuss employer responsibilities related to workplace accident investigations.
3. Conduct the six step accident investigation procedure
© 2003 Steven J. Geigle. All rights reserved.
This material, or any other material used to inform employers of compliance requirements of OSHA standards through simplification of the regulations should not be considered a substitute for any provisions of the Occupational Safety and Health Act of 1970 or for any standards issued by OSHA. The information in this publication is intended for training purposes only.

3. A Hazard and Exposure Incidents and accidents
What’s the definition of an accident?
Identify two key conditions that must be present for any accident to occur.
A Hazard and Exposure

4. What’s the difference between accident investigation and Analysis?
The basics
What’s the difference between accident investigation and Analysis?
What's the purpose of an OSHA investigation?
First - determine what happened to see if the employer violated safety rules.
To gain the greatest benefit, why does the employer conduct accident analysis?
First - determine what happened to see safety management system weaknesses exist.

5. The process Step 1 - Secure the accident scene
What are the basic steps in doing the accident investigation and report?
Step 1 - Secure the accident scene
Step 2 - Collect facts about what happened
Step 3 - Determine the sequence of events
Step 4 - Determine the causes
Step 5 - Recommend improvements
Step 6 - Write the report

6. Step 1: Secure the Scene
When is it appropriate to begin the investigation?
What are effective methods to secure an accident scene?

7. Step 2: Collect facts about what happened
List methods to document the scene and collect data about what happened.
What documents will you be interested in reviewing?
Why?

8. Interviewing When is it best to interview? Why?
Who should we interview? Why?
Where should we conduct the interview?

9. Cooperate, don’t intimidate
What are are effective interviewing techniques?
Always say this Why?
Always do this Why?
Never say this… Why?
Never do this Why?

10. Team Exercise: Cooperation is the Key
Instructions. Your instructor has had an accident. Your team and the instructor are located at the scene of the accident (classroom) and your job now is to ask initial and follow-up questions to gather information about the accident.

11. Step 3: Develop the sequence of events
Each event in the unplanned accident process describes one:
Actor - The, object, person that is initiating action.
Action- The thing being done, behavior
“Dale slipped on a banana.”
“As Dale lay on the floor, a brick fell on his head .”
“Larry discovered Dale unconscious on the floor and immediately began initial first aid procedures.”

12. Team Exercise: Develop the sequence
Instructions. Use the information in the interview summaries below to construct a sequence of events listing the events prior to, during and after the accident they describe.
1. Determine the “injury event.”
2. List the events that led up to the injury.

13. Step 4: Determine the causes
W. H. Heinrich's domino Theory
"The occurrence of an injury invariably results from a completed sequence of factors, the last one of these being the accident itself."
Dan Petersen's Multiple Cause Theory
"Behind every accident there are many contributing factors, causes, and subcauses. These factors combine in a random fashion causing accidents."
What may be the cause(s) of the accident according to the multiple causation theory?
What might be the solutions to prevent the accident from recurring?

14. 17

15. The causes of Injury, Illness and Accidents
1. Direct Cause of Injury
2. Surface Causes of the Accident
3. Root Causes of the Accident
Steps in root cause analysis
1. Injury cause analysis
2. Surface Cause analysis
3. Root Causes analysis
Accident Causes

16. Team Exercise: “Getting to the roots by asking why, why, why, why”
1. Analyze the injury event to identify and describe the direct cause of injury.
a. Describe the injury and it’s cause.
b. Identify the accident type.

17. -1 -2 -3 -4 -5 -6 -7 -8 The guard slows work No one is disciplined
Corrective MX, blade is broken
Others use the unguarded saw
Replace blade
Blade cuts Bob
Bob decides to ignore missing guard
Ralph removes guard
Injury
Bob saws wood
Ralph doesn’t replace guard
Bob behind schedule
Ralph directed to stop and fix chipper
Doesn’t want to make boss mad
Wood shipment arrives late
High priority emergency repair

18. Exercise: Digging up the roots
1. Enter the direct cause of injury within the circle below.
2. List one hazardous condition and unsafe behavior from the sequence of events your group developed.
3. Determine contributing surface causes for the hazardous condition and unsafe behavior.
4. Determine implementation and design root causes for contributing surface causes.

19. Step 5: Recommend corrective actions and improvements
Use control strategies to make corrective actions
Engineering Controls. Eliminate/reduce hazards through equipment redesign, replacement, substitution, etc.
Management Controls. Eliminate/reduce exposure to hazards by controlling employee behaviors.
Interim Measures. These include strategies that are used as a temporary fix while permanent controls are being developed.

20. Team Exercise: Recommending Corrective actions
Purpose: In this exercise you’ll develop and recommend immediate actions to correct the surface causes of an accident.
Instructions. Using the control strategies as a guide, determine corrective actions that will eliminate or reduce one of the hazardous conditions or unsafe behaviors identified in the previous exercise. Write your recommendation below.

21. Recommend system improvements
Make improvements to policies, programs, plans, processes, and procedures within one or more of the following elements of the safety management system.
Management commitment
Accountability
Employee involvement
Hazard identification and control
Incident and accident analysis
Education and training
System evaluation

22. Making system improvements might include some of the following:
Including "safety" in a mission statement.
Improving safety policy so that it clearly establishes responsibility and accountability.
Changing a training plan to include using checklists.
Revising purchasing policy to include safety considerations as well as cost.
Changing the safety inspection process to include all supervisors and employees.

23. Team Exercise: ”Fix the system...not the blame"
Purpose: In this exercise you’ll develop and recommend one improvement to make sure the case study accident does not recur.
Instructions. Develop and write a recommendation to improve one or more policies, plans, programs, processes, procedures, and practices identified as design weaknesses.

24. Step 6: Write the report SECTION I. BACKGROUND
SECTION II. DESCRIPTION OF
ACCIDENT
SECTION III. FINDINGS
SECTION IV. RECOMMENDATIONS
SECTION V: SUMMARY
SECTION VI: FOLLOW-UP: ACTIONS
SECTION VII: COMMENTS/ATTACHMENTS:

25. The report is an open document until all actions are complete!
Take Corrective Action
Conduct follow-up evaluation
Conduct annual review of reports

26. That's it!
Be safe