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Accident Investigation

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1 Accident Investigation
Presented by Name Title Date

2 Course Outline Four modules 1. Definitions 2. Causation
3. Investigations 4. Case study In this interactive course, we will cover the following information: Definitions: We will be defining the following terms: - The difference between the words: Accident Incident - What is an: Accident Investigation Causation: Two types of causes will need to be properly identified if we want to stop the reoccurrence of an accident: - Immediate Causes Substandard Conditions Substandard Acts - Fundamental Causes Personal Factors Job Factors Investigation: You will learn about the safety committee and the employer responsibilities when reporting and investigation an accident You may find that when you return to your workplace, that two types of investigations will be implement. One for when doing an investigation of an accident and the other will be a less formal process for investigating an incident. We will be suggesting steps to undertake when doing investigations and interviewing witnesses Case study Once we have completed the theoretical part of this workshop, we will give you the opportunity to apply your knowledge by doing an investigation of a forklift accident shown on video. Option – The group may prefer doing an investigation of an accident that has recently occurred in their place of employment

3 You will gain an understanding of:
Workshop Objectives You will gain an understanding of When to do a formal investigation Immediate and fundamental causes When to give notification of an accident How to write a good accident report with recommendations You will gain an understanding of: When to do a formal investigation: A committee member or the health and safety representative must be offered a chance to do accident investigations. You may find that you need to consult with professional and technical experts All incidents and accidents must be reported and investigated as soon as possible. It is useful for Joint Health and Safety Committees to confirm that all reportable incidents/accidents have been investigated as required. The process should be defined in the Terms of Reference. Immediate and fundamental causes: An accident/incident investigation should, as far as possible, determine the cause or causes of the incident or accident, identify any unsafe conditions, acts or procedures which contributed in any manner to the incident and develop recommended corrective action to prevent similar incidents. When to give notification of an accident: You will learn about OH&S legislated and the Compensation legislation requirements and know when and how to report an accident. How to write a good accident report with recommendations: Identify hazards and make recommendations to the employers in order to eliminate hazards and improve conditions. Members are in a good position to promote cooperation throughout the operation. If corrective action is not taken to the satisfaction of the committee, the item should be included on the agenda for consideration at the next meeting. Unless the immediate and fundamental causes of incidents/accidents are investigated and eliminated, they may well happen again.

4 Accident Investigation
Module 1 - Definitions Accident Incident Accident Investigation Accident Incident Accident Investigation

5 Definition of Accident & Incident?
Accident - Can be defined as an unplanned event that interrupts the completion of an activity, and that may (or may not) include injury or property damage. Incident - Usually refers to an unexpected event that did not cause injury or damage,but had the potential to do so. How does your workplace define these terms? Accident: An accident may be defined as an event that results in unintended harm or damage. This may include anything in the work or external environment, It is usually the result of a contact with a source of energy (kinetic, chemical, thermal, acoustical, mechanical, electrical, radiation, etc.) or a substance above the threshold limit of the body or structure involved. In terms of people, contact may result in a cut, burn, abrasion, etc. In terms of damage, contact could result in property damage such as fire, breakage, distortion etc. Incident: William G. Johnson, author of MORT Safety Assurance Systems , states that the incident is similar to an accident, but without injury or damage. Johnson goes on to state that incidents are enormously important to safety. An incident with high potential for harm should be investigated as thoroughly as an accident. In this context, an incident is an event which could or does result in unintended harm or damage. Reference, Practical Loss Control Leadership, Chapter 1

6 What is an Accident Investigation?
An accident investigation is a conscientious examination of all factors leading up to and included in an incident or accident… An accident investigation is… The analysis and account of an accident is based on factual information gathered by a thorough and conscientious examination of ALL factors involved. Log and analyze accidents on a periodic basis. Look for trends by such characteristics as type of injury, department, location, job position, length of employment, accident cause, etc. The safety committee should complete and review a loss analysis report at least quarterly. Proper action should be taken to address the most frequent and severe injury trends. Create a log as a paper or electronic spread sheet. The electronic version has the advantage of easily creating reports based on specific fields. For instance, it is easy to pull all the accidents meeting the parameters: department name, time frame such as 1st quarter or January 1 to December 31 or a specific year.

7 Why should we investigate?
Reasons to investigate a workplace accident include: most importantly, to find out the cause of accidents to prevent similar accidents in the future to fulfill any legal requirements to determine the cost of an accident to determine compliance with applicable safety legislation to process workers' compensation claims

8 Module 2 - Finding the Causes
Immediate and basic Accident statistics Immediate/fundamental Accident statistics

9 Why are we having accidents?
Finding the Causes ? Why are we having accidents? Management style and beliefs The way a manager approaches obligations, and the beliefs about personnel and the nature of work affect the way in which the person manages. Managers, as leaders, work within two dimensions—1) attention to task (i.e., what needs to be done), and 2) attention to relationships (i.e., interaction with subordinates). A manager’s beliefs about what really matters has a great impact on how she or he chooses to exert leadership. The issue of safety and the costs of accidents and injuries generally are not apparent to managers unless their organization provides clear data identifying these costs—and the financial impact of accidents and injuries on their chapter, department or, sometimes, on their individual performance evaluations. Some of the management styles and beliefs that contribute to breakdown in safety include: Arrogance Many managers believe that accidents are something that happen to other people, and therefore, workplace safety is not a priority. Without a genuine commitment to establishing and maintaining a culture of safety, management will try to remain ignorant of the cost of accidents and injuries. Worse yet—management knows too well how the reporting of claims will impact their compensation insurance and has instituted a culture of intimidation in which employees will be encouraged not to report injuries or accidents. They believe that no news is good news, and that by exerting their influence, they can suppress these reports. “Clueless” Managers Yogi Berra once said, “Ignorance isn’t what you don’t know, it’s what you know wrong.” Managers who are clueless display a lack of understanding about the costs—human and financial—of injury, illness and unsafe conditions. Some managers do not even know that their nonprofit must obtain compensation insurance. Perhaps they think that if they ignore it long enough, it will go away. Refusing to address workplace safety issues can have devastating results—and could possibly destroy the nonprofit in the wake of a huge claim or lawsuit by a client or a member of the public. Lack of Accountability Managers, who are not held accountable for insurance costs, generally ignore the incidence of accidents, injuries and/or other claims. Their belief is: “We have insurance—who cares?” This attitude will not change unless there are significant and unpleasant consequences associated with it. A safety conscious nonprofit needs to start at the top, literally. The board of directors needs to adopt and enforce consequences for unsafe conditions. Other causes could include: Lack of storage Lack of maintenance Lack of education and training Lack of enforcement

10 Substandard Conditions Inadequate protective equipment
Immediate Causes Substandard Conditions Inadequate protective equipment Defective tools, equipment, materials Poor housekeeping Inadequate ventilation Congested or restricted action Determining The Cause(s) Of The Accident There are many theories of accident causation that can be used when determining what caused a particular accident. Some focus on physical hazards (unsafe conditions), others on human behaviors (unsafe acts), and others on management system failures. An approach that combines all of these areas is the most productive since accidents are usually complex events that involve all of these areas. When conducting an investigation, look at all of the physical and environmental factors and hazards that may have contributed to the accident. Examples would be a slippery floor from spilled liquids, a defective ladder, an unguarded machine, an exposure to a chemical, etc. Immediate causes of accidents usually can be seen or sensed. Frequently they are called unsafe acts (behaviors which could permit the occurrence of an accident) and unsafe condition (circumstances which could permit the occurrence of an accident). We could say that unsafe acts and unsafe conditions are a deviation from accepted standard or practice. If a safety committee digs deep enough in their investigation, the answers will point the way to more effective control and therefore preventing an accident to reoccur. Other examples include: Inadequate guards or barriers Inadequate warning systems Fire & explosion hazards Hazardous environmental conditions, gases, dusts, smoke, fumes Noise/radiation exposures Reference, Practical Loss Control Leadership, Chapter 1

11 Immediate Causes Substandard Acts/Practices
Operating equipment without authority Operating at improper speed Removing safety devices Failure to use PPE/warn/secure/follow procedures Horseplay Under influence of alcohol/drugs Improper loading/lifting/placement After having examined the substandard conditions, look at all of the human behaviors or unsafe acts that contributed to the accident. Examples would be operating a machine without the guard or other safety device in place, not wearing proper personal protective equipment, horseplay, violating a safety rule or policy, engaging in risk-taking behavior, manually lifting a heavy object instead of using the hoist or handcart that was provided, etc. They usually can be seen or sensed. Frequently they are called unsafe behaviors which could permit the occurrence of an accident. There is a vast amount of research and error removal information from quality control research that is being increasingly used for managing losses. But the term error is often misunderstood as blame. Blame leads to defensive behavior and safety problems get disguised rather than solved. Also an increasing number of safety leader confirm the results from research in quality control that 85% or more of the mistakes (substandard acts) that people make are the result of factors over which only the management system has control. If the management system does not correct substances acts, they become substandard. Other examples include: Failure to warm/secure Using defective tools Using equipment improperly Improper loading/placement/position for task/lifting Failure to follow procedures Reference, Practical Loss Control Leadership, Chapter 1

12 Inadequate physical/mental capability Lack of knowledge Lack of skill
Basic Causes Personal Factors Inadequate physical/mental capability Lack of knowledge Lack of skill Stress Improper motivation Finding the root cause of accidents can offer means by which accidents can be reduced in frequency and/or severity. In other words, root cause analysis looks beyond whether the first aid box has adhesive bandages and antibiotic. Root cause analysis looks at the who, what, where, why, and how the accident occurred. W. Edwards Deming’s work in Total Quality Management found that studying “mistakes” was valuable, because the mistake generally took place because of a problem in the process. These factors can include the time of day that the accident occurred, weather conditions, level of training of the employee or volunteer, availability or condition of tools and vehicles, or safety standards. Root cause analysis can be effectively used in the process of accident/injury investigation. Examining the factors that contributed to the situation can often go beyond just the facts of the incident. Consider the organization’s cultural and attitudinal issues in developing an overall picture. While an unsafe act by a specific person or persons may have contributed to an accident or even been a major cause of the accident, a thorough investigation will often show that there were a number of other factors or causes also involved. Treat the unsafe act as one of the causes and simply report it as such. Personal Factors Inadequate physical/mental capability: Physical / Mental inadequate height, weight, size strength, reach fears/phobias restricted body movement emotional disturbances substance sensitive or allergies mental illness vision/hearing deficiency intelligences level respiratory incapacity poor judgment/coordination Lack of knowledge: - lack of experience - inadequate orientation/training Lack of skill: - inadequate practice/performance - lack of coaching/instructions Stress: Physical / Mental injury/illness emotional overload fatigue due to task load/duration/rest mental fatigue extreme temperatures extreme judgment/decision demands constrained movement conflicting/direction or demands Improper motivation: Inadequate performance is rewarding/punishing Lack of incentives Excessive frustration Improper attempt to save time/avoid discomfort/gain attention Inappropriate peer pressure

13 Basic Causes Job Factors Inadequate: Wear and tear
Unclear/conflicting leadership Engineering Purchasing Maintenance Tools, equipment, materials Work standards Wear and tear Abuse and misuse Improper training Finally, look closely at the management systems that you have in place and how a failure in the system or policies may have contributed to the accident. Examples would be failure to provide adequate training, failure to have a policy or a safe work practice in place, failure to consistently enforce the use of required personal protective equipment, failure to consistently ensure that employees are following established safe work practices, failure to provide the necessary safety equipment, etc. Job Factors Inadequate: Unclear/conflicting leadership Unclear or conflicting assignment / responsibility Improper or insufficient delegation Giving inadequate policy, procedures, practices Inadequate work planning/instruction Lack of supervision Inadequate performance feedback Engineering: Inadequate assessment/specifications/design Inadequate monitoring of construction Inadequate evaluation of changes Purchasing: Inadequate requisitions Inadequate research on materials/equipment Inadequate route of shipment Inadequate receiving inspection and acceptance (no MSDS’s) Inadequate handling/storage/transportation Maintenance: Inadequate prevention Inadequate reparative assessment need communication of needs lubrication/servicing scheduling of work adjustment/assembly examination of units cleaning/resurfacing part substitution Tools, equipment, materials: Inadequate assessment of needs/risks Ergonomics considerations Inadequate availability / maintenance / adjustment / repairs / removal Work standards: Inadequate development of standards Inadequate communication Inadequate maintenance Wear and tear: Inadequate planning of use Improper extension of service life Inadequate inspection / monitoring Improper loading / maintenance Used by unqualified or untrained worker Used for wrong purpose Abuse and misuse: Condoned by supervision intentional / unintentional Improper training: Of all of the above

14 Accident Ratios Report and investigate all accidents and incidents
1 Serious 10 - Minor At what level are accidents being investigated? This figure based on reported accidents - is that the same as actual accidents? There is a tendency in many workplaces to conduct accident investigations only when someone is seriously injured or there is substantial property damage. Accidents or incidents that involve only minor first aid treatment, minor property damage, or which result in a "near miss" but no actual injuries or property damage, are either not investigated at all or not investigated thoroughly. This results in a missed opportunity to learn from our mistakes and prevent future accidents that may have more serious outcomes. This study revealed that for every reported major injury (resulting in death, disability lost time or medical treatment), there were 9.8 reported minor injuries (requiring only first aid). For the 95 companies which further analyzed major injuries in their reporting , the ratio was one lost time injury per 15 medical treatment injuries. It should be remembered that this accident ratio represents the accidents and incidents reported and not the total number of accidents or incidents that actually occurred. In Frank Bird book “Loss Control Leadership” he indicates that if you only investigate the injury and not the property damage, you’ve only used 27% of the data and that companies who ignore to investigate property damage are communicating to the workers that safety is not high on their agenda. The relationships in the ratio indicate quite clearly how foolish it is to direct our major effort at the relatively few events resulting in serious or disabling injury when there are so many significant opportunities that provide a much larger basis for more effective control of total accident losses. This study does not necessary follow that the ratio will be identical for any particular occupational group or organization. That is not its intent. The significant point is that major injuries are rare events and that many opportunities are afforded by the more frequent, less serious events to take actions to prevent the major losses from occurring. Safety leaders have also emphasized that these actions are most effective when directed at incidents and minor accidents with a high loss potential. Keeping records and statistics: Records and statistics are important components of occupational health and safety programs for the prevention of injuries and illnesses. They help employers, managers, supervisors and Joint Health and Safety Committee members: identify the nature, extent and cause of health and safety hazards set prevention activities determine if control measures are working How Can Records And Statistics Help? Records and statistics are very useful tools for Joint Health and Safety Committees. They can be used to: collect and analyze data on causes of injury and disease so that specific control measures can be taken identify specific work locations, departments, occupations and tasks (such as heavy lifting) where there is a high risk of injury and/or illness so prevention efforts can be directed in those areas provide employers, managers, health and safety representatives and Joint Health and Safety Committees with factual information needed to objectively evaluate health and safety programs measure the progress and effectiveness of accident and injury prevention efforts 30 - Property Damage 600 - Near Misses Report and investigate all accidents and incidents

15 Iceberg Effect Accidents Cost Money
Insured Costs Medical Compensation $1 $5 to $50 Property Damage $1 to $3 Miscellaneous Uninsured Costs •Building damage Tool and equipment damage Product and material damage Accidents Cost Money (For both the employer and employee) Safety organizations, governments, small business owners and major corporations alike now realize that the actual cost of a lost workday injury is substantial. For every dollar you spend on the direct costs of a worker’s injury or illness, you will spend much more to cover the indirect and hidden costs. Consider what one lost workday injury would cost you in terms of: Productive time lost by an injured employee; Productive time lost by employees and supervisors attending the accident victim; Clean up and start up of operations interrupted by the accident; Time to hire or to retrain other individuals to replace the injured worker until his/her return; Time and cost for repair or replacement of any damaged equipment or materials; Cost of continuing all or part of the employee’s wages, in addition to compensation; Reduced morale among your employees, and perhaps lower efficiency; Increased workers’ compensation insurance rates; and Cost of completing paperwork generated by the incident. Controlling Losses If you would like to reduce the costs and risks associated with workplace injuries and illnesses, you need to address safety and health right along with production. Setting up an Injury and Illness Prevention Program helps you do this. In developing the program, you identify what has to be done to promote the health and safety of your employees and worksite, and you outline policies and procedures to achieve your safety and health goals. Many firms fail to understand that accidents cost them money. Some firms think because they take out insurance any claims will be dealt with. However the majority of accidents do not become claims, so the majority of the costs associated with accidents are not covered by insurance. To put this into perspective the costs of clearing up after an accident can include: The lost production whilst a machine is shut down Awaiting the installation of better guards Awaiting the arrival of an inspector from the HSE The cost of people having to attend court And the fines, if received, are not covered by insurance These uninsured costs can range from 10 times the amount received from insurance, to over 30 times. Managing risk and reducing the number of accidents makes sound business sense. Savings from the management of risk and reductions in accidents will improve the bottom line immediately. Hiring and training replacements Investigation time

16 Investigation procedures
Module 3 - Investigate Reporting Investigation procedures Reporting Procedures

17 15(i) investigate any complaint…
Committee may… 15(j) participate in all inspections, inquiries and investigations concerning the health and safety of employees, and in particular the investigation of any matter referred to in section 43 15(i) investigate any complaint… Even though safety committees do not have any directed investigative powers, the word “May” under section 15 is interpreted as giving a legislated right to the members of the safety to do what is stated under that section. 15(j) participate in all inspections, inquiries and investigations concerning the health and safety of employees, and in particular the investigation of any matter referred to in section 43; If a workplace accident results in a death or critical injury, the Act states that a NBOHS Officer’s permission is required before the scene can be disturbed. Until such permission is received, no person may interfere with, disturb, destroy, alter or carry away anything at the scene of, or connected with the occurrence. We understand the safety committee should be doing accident investigations, but who else should be involved? Both management and labour represented should investigate accidents and those investigators must be knowledgeable about the work processes involved. Should the immediate supervisor be on the team? The advantage is that this person is likely to know most about the work and persons involved and the current conditions. Furthermore, the supervisor can usually take immediate remedial action. The counter argument is that there may be an attempt to gloss over the supervisor's shortcomings in the accident. This situation should not arise if the worker representative(s) and the management members review all accident investigation reports critically.

18 Health and Safety Emergencies: 1-800-222-9776
Notices by Employers 43(1) Injuries causing fatality, loss of limb or occupational disease, notify WorkSafeNB immediately. 43(2) The employer shall immediately notify JHSC or representative. To report health and safety emergencies: 43(1) For injuries that causes or may cause a fatality, loss of limb or occupational disease, or have required or may require hospitalization, notify the Commission immediately. 43(2) The employer shall immediately give notification to the committee or to the health and safety representative. Health and Safety Emergencies: Incidents and accidents which do not result in lost time....what is your policy? Some accidents need to be reported to the enforcing authority, such as the Workplace Health, Safety and Compensation. This includes serious accidents, such as fatalities, major injuries such as burns and fractures, and any accident that results or may result in an absence from work.

19 Notices by Employers 43(3) No person shall disturb the scene, except   (b) to prevent further injuries; or (c) to protect property that is endangered as a result of the accident. 43(4) An accidental explosion, or an accidental exposure, notify WorkSafeNB within 24 hours. To report exposures or explosions: REPORTING ACCIDENTS In the event of an accident, injury or industrial disease at your jobsite, you must immediately: Provide or pay the cost of immediate transportation from the injury site to a medical treatment facility. Report the injury to the WHSCC: REPORT TO COMPLIANCE OFFICER immediately if the accident causes or may cause a fatality, loss of limb, or occupational disease; or REPORT TO CHIEF COMPLIANCE OFFICER within 24 hours of occurrence in the case of an accidental explosion or an accidental exposure to a biological, chemical or physical agent at a workplace [Subsection 43(4) of the Occupational Health and Safety Act]; or REPORT TO COMPENSATION BOARD within 3 days of notification if the scenario does not fit either of the above two descriptions. A complete report of the accident must be made even if the injured workers does not require medical attention. Along with the injured worker, complete an accident report (Form 67 - Report of Accident or OccupationalDisease) and ensure that the report is forwarded to the WHSCC. If there is disagreement between you and your employee, you must still complete a Form 67 and forward it to the WHSCC immediately. Please note: you and your employee cannot agree not to report the accident. All accidents must be reported to the WHSCC. When completing the accident report, it is important that you obtain information about the events leading up to the injury. You should ask the injured worker questions as to whether there were any witnesses to the accident, what specific activities they were engaged in at the time of injury - including their physical body movements. You should also speak with the injured worker’s co-workers and any other individual you have identified as a witness.

20 Terms of Reference The size and scope of an investigation team as well as its purpose, duties and objectives should be clearly explained in the terms of reference or an investigation policy. The instructor should provide a copy to the “Terms of Reference” guidelines and give a brief explanation of that document. What is “Terms of Reference”? What is the purpose of “Terms of Reference”? Define: the establishment of your safety committee the details of your safety meetings the role and responsibilities of the committee members the details for doing workplace inspections the details for doing an accident investigation

21 Ensuring Accident Reporting
Initial training - all incidents must be reported Encouragement - thank the individual Take immediate action on all reports Reinforce the importance of accident investigations whenever possible Never place blame, as everyone is responsible Initial training - all incidents must be reported The Importance of Training The Investigators Effectively investigating accidents is not something that is intuitive. It must be learned. To determine the causes of accidents it is necessary to know the factors that cause accidents. It is critical that you provide training for everyone involved in how to conduct an accident investigation and in common accident causation theories. Simply handing an accident investigation form to a supervisor and requiring them to complete it without any training will result in investigations that are probably of little or no value. Encouragement - thank the individual Take immediate action on all reports: There are a number of issues that typically require a formal recommendation. They usually involve: Policy, directive or procedure creation or revision. Changes to equipment, office layouts or product purchasing normally requiring allocation of funds. Training or orientation programs for employees. Commitment and follow-up to issues where earlier approved corrective action has been ignored or gone unnoticed. Matters which require review and/or agreement of other divisions, departments, areas, etc. Reinforce the importance of accident investigations whenever possible: The instructor could ask the group as to how the employer could get the employees to report immediately?

22 Why Accidents May Not be Reported
Doesn’t want to be central person ‘Spoils’ safety record Fear/dislike of medical treatment Afraid co-workers will ‘kid’ Doesn’t like ‘red-tape’ Afraid supervisor will be angry Doesn’t want to lose time Doesn’t want to be central person in an investigation ‘Spoils’ safety record Fear/dislike of medical treatment Afraid co-workers will ‘kid’ Doesn’t like ‘red-tape’ Afraid Supervisor will be angry Doesn’t want to lose time Doesn’t want to be central person in an investigation: Often people don’t see any immediate, positive action after their report. They see this as a lack of concern, and they decide not to say either. This happens when there is little or no communication on the the benefits of not reporting. ‘Spoils’ safety record: The average person doesn’t want to spoil the safety record of the group. When group recognition and awards programs are based on accident-free records, the programs discourages good reporting. No one wants to be the person who spoiled the records with some minor injury, damage or incident. Fear of medical treatment: Fear - It’s surprising how many people dread simple medical care. May lose fingers, toes or even die because they waited too long to get treatment. Others fear that when they go for simple treatment some major disorder will be found. As a result, their injuries never get reported. Dislike – Some employees don’t want to be treated by certain medical personnel because of sex or personality. This might also be due to a previous experience or to distorted stories of bad treatment. Afraid co-workers will ‘kid’: People also don’t want to labeled as accident-prone or a dangerous worker by their supervisor or peers. Workers will try bring up negative attention to themselves so prevent workers to teasing them. In other cases some workers value their good relationships with their peers and leader. Often they feel that reporting an incident would be telling on another employee. That would threaten the relationship. Doesn’t like ‘red-tape’: Many individual recognition programs and performance appraisals are based on accident-free records. Incident analysis often include personal data. People who don’t fully understand these things see reporting incidents as giving themselves black marks and threatening their own job security. Other simply feel don’t have the time to do reporting. Many have heard people say, “Why, you have to answer two dozen questions just to get a band-aid!” Or, people asre asked to fill out long forms on incidents they report. Inconvenience is a sure way to stop getting reports but not to stop accidents. Afraid Supervisor will be angry: Many people see an investigation as fault-finding mission rather than fact-finding. No one is perfect and workers fear they might get punished for some contributory negligence. Good supervisors know that substandard actions are only symptoms of the problem. They don’t use their people as scapegoats. But the fact remains that many supervisors haven’t been well trained in how to manage people. Their reaction is to criticize and punish , so people keep things from them. Doesn’t want to lose time: Employees who get injured on the job and require time off from work will loose their first three day compensation of work unless they were admitted to hospital. Plus, they do not get their full benefits. This could be very difficult for fixed income earners. Most employees desire to avoid work interruption. They have a sincere interest in getting the job done. Once the instructor has talked about , “Why Accidents May not be Reported”, he/she could get into the topic of “How to Get Incidents/Accidents Reported?” Page 74 PLCL Book React in a positive way Give more attention to loss control performance Recognize individual performance promptly Develop awareness of the value of incident information Show personal belief by action Make mountains of molehills

23 Purpose of an Accident Investigation
It is to: Find all causes Prevent re-occurrence Ensure due diligence at every level Reduce accidents/costs Show workers that management cares about h&s Be sure that all accident investigators are taught that the purpose of the investigation is to determine the cause(s) of accidents and to develop corrective actions to prevent similar accidents in the future. It is NOT The purpose of accident investigation is not to place blame for the accidents! Using accident investigations to place blame will alienate the people involved in the accident and result in those employees and others withholding information or not reporting future accidents. While an unsafe act by a specific person or persons may have contributed to an accident or even been a major cause of the accident, a thorough investigation will often show that there were a number of other factors or causes also involved. Treat the unsafe act as one of the causes and simply report it as such. "The only good thing about an accident is what is learnt to prevent it happening a second time" All workplace accidents should be reported and investigated since the causes of accidents are rarely obvious. A detailed investigation is needed before one can be certain how an accident occurred and what went wrong. This information is necessary before action can be taken to prevent a repeat accident. After the cause has been established suitable control action should be taken. Typical controls might involve training of operators, a review of risk assessments or the introduction of new procedures. But one golden rule to remember is that the investigation is to determine cause – not to allocate blame. IMPORTANT: Establishing relevant facts as to how and why an accident occurred and recommending corrective actions can prevent re-occurrences. How to make sure that investigators are impartial? An investigator who believes that accidents are caused by unsafe conditions will likely try to uncover conditions as causes. On the other hand, one who believes they are caused by unsafe acts will attempt to find the human errors that are causes. Therefore, it is necessary to examine briefly some underlying factors in a chain of events that ends in an accident. The important point is that even in the most seemingly straightforward accidents, seldom, if ever, is there only a single cause. For example, an "investigation" which concludes that an accident was due to worker carelessness, and goes no further, fails to seek answers to several important questions such as: Was the worker distracted? If yes, why was the worker distracted? Was a safe work procedure being followed? If not, why not? Were safety devices in order? If not, why not? Was the worker trained? If not, why not? An inquiry that answers these and related questions will probably reveal conditions that are more open to correction than attempts to prevent "carelessness".

24 Purpose of an Accident Investigation
It is not: Filling out an accident report (Form 67, application for claim) Fixing blame/finger pointing To be conducted with a courtroom mentality Be sure that all accident investigators are taught that the purpose of the investigation is to determine the cause(s) of accidents and to develop corrective actions to prevent similar accidents in the future. It is NOT The purpose of accident investigation is not to place blame for the accidents! Using accident investigations to place blame will alienate the people involved in the accident and result in those employees and others withholding information or not reporting future accidents. While an unsafe act by a specific person or persons may have contributed to an accident or even been a major cause of the accident, a thorough investigation will often show that there were a number of other factors or causes also involved. Treat the unsafe act as one of the causes and simply report it as such. "The only good thing about an accident is what is learnt to prevent it happening a second time" All workplace accidents should be reported and investigated since the causes of accidents are rarely obvious. A detailed investigation is needed before one can be certain how an accident occurred and what went wrong. This information is necessary before action can be taken to prevent a repeat accident. After the cause has been established suitable control action should be taken. Typical controls might involve training of operators, a review of risk assessments or the introduction of new procedures. But one golden rule to remember is that the investigation is to determine cause – not to allocate blame. IMPORTANT: Establishing relevant facts as to how and why an accident occurred and recommending corrective actions can prevent re-occurrences. How to make sure that investigators are impartial? An investigator who believes that accidents are caused by unsafe conditions will likely try to uncover conditions as causes. On the other hand, one who believes they are caused by unsafe acts will attempt to find the human errors that are causes. Therefore, it is necessary to examine briefly some underlying factors in a chain of events that ends in an accident. The important point is that even in the most seemingly straightforward accidents, seldom, if ever, is there only a single cause. For example, an "investigation" which concludes that an accident was due to worker carelessness, and goes no further, fails to seek answers to several important questions such as: Was the worker distracted? If yes, why was the worker distracted? Was a safe work procedure being followed? If not, why not? Were safety devices in order? If not, why not? Was the worker trained? If not, why not? An inquiry that answers these and related questions will probably reveal conditions that are more open to correction than attempts to prevent "carelessness".

25 Policy Every employer should have a written policy & procedure. The policy should include the following points: All incidents/accidents will be investigated Front line supervisor will conduct investigations How recommendations will be applied and assessed Employees are encouraged to report all incidents/accidents Every employer should have a written policy that includes the following points: There must be a process put in place to report accidents, incidents or near misses for immediate action and to help track causes. The organization needs to identify what needs to be reported, to whom it is to be reported, and how to report it, then put this process into a written procedure. Plan out how and when each step will be carried out and who will do it and put this plan in writing. In developing the plan, consider your company’s immediate needs and provide for ongoing worker protection. All accidents will be investigated. As a minimum, all injuries requiring professional medical treatment or involving time away from work need to be investigated.  Serious accidents involving only equipment or material losses should also be checked.  Who Should Conduct The Investigation? Accident investigations are usually more effective if more than one person is involved in the investigation. Each person may bring a different perspective to the investigation or have knowledge or past experience that will be helpful in determining the causes of the accident or recommending corrective actions that need to be taken to prevent future accidents. Therefore, it is a good idea to use a team approach. The team can either conduct the investigation together or they may review the initial investigation conducted by the person responsible for the area where the accident occurred to ensure that the investigation was thorough, all of the causes of the accident were determined, and that all of the appropriate corrective actions have been recommended and implemented. The immediate supervisor of the person or persons involved in the accident should always be included in the team that investigates the accident. They are the person who is most likely to know the circumstances surrounding the accident and to suggest practical corrective actions. In most cases, the immediate supervisor should have the ultimate responsibility for conducting the investigation and implementing the corrective actions. The other team members can assist in the investigation and provide additional resources, but the ultimate responsibility rests with the immediate supervisor. Other members of the team might include the Human Resource Manager, the Safety Director, the Department Manager, other employees in the department where the accident occurred, safety committee members, etc. Incident reporting will be encouraged so that they can receive a full investigation wherever possible. Ideally, all accidents, no matter how minor, should be reported.  This does not mean that all incidents have to be fully investigated.  But when there is a good accident/incident-reporting system it will show trends and patterns which can be used to prevent a serious accident.  The investigation of a serious injury or fatality accident can be stressful, disruptive, and a challenge for any organization. Properly carried out, a good investigation can dispel rumours, set the record straight, and reinforce management’s good intentions. Front line supervisor (JHSC, H&S reps) will conduct investigations. How recommendations stemming from investigations will be applied and assessed. Making a Recommendation Recommendations which well defines H&S problems and are logically supported by facts, are the ones most likely to be accepted by the employer. Safety committees should follow a certain process in developing recommendations: Define the problem. This often means looking for underlying causes of the situation. Unless the real problem is identified, it is difficult to come up with solutions. For example, simply defining the problem as "careless work habits" is not enough. Ask, "Are work procedures properly defined and communicated? Is the proper safety equipment readily available? Is there adequate training and information for the workers' concerned?“ 2. Assemble all necessary information. All background information should be collected and then considered before coming up with solutions. Such information might include: description of the job and workplace details about any previous accidents and investigations relating to this problem comments and suggestions from supervisors and workers equipment maintenance schedules and manufacturers' specifications 3. Consider possible solutions. Solutions must relate directly to the problem identified. Provide options for different solutions if possible. In considering solutions, the committee should take into account: the urgency and potential seriousness of the problem the range of possible solutions - sometimes the corrective action being proposed may be urgent, but there may be practical or cost difficulties in getting these implemented immediately; in such a case, the committee may wish to recommend interim solutions the practicality of the solution being recommended 4. Reach agreement. This may sometimes be more difficult than it sounds. However, it is easier to reach a unanimous agreement when the information gathering has been done using a step by step procedure. 5. Present the recommendation. The nature and the reasoning behind the recommendation should be clearly set out. Those who have to consider it will then have the benefit of the committee's deliberations. Have corrective actions taken in a timely manner: The employer must provide a response to committee recommendations. If recommendations are accepted, a timetable for action must be outlined and provided to the committee. If an employer decides against acting on the committee's recommendation, reasons must be given in writing. One thing to think about is, if it poses a hazard to the worker and the employer for whatever reason is unable to act upon the safety committee’s recommendation , what alternative will be taken in the meantime to ensure the worker’s H&S.

26 Procedures (Detailed)
Steps to take when doing an incident investigation: 1. Encourage all staff to report incidents immediately 2. Examination of the situation by supervisory staff 3. Take immediate measures, if necessary 4. Refer to JHSC for follow-up A streamlined procedure will make it practical for all incidents to be examined: There is a tendency in many workplaces to conduct accident investigations only when someone is seriously injured or there is substantial property damage. Accidents or incidents that involve only minor first aid treatment, minor property damage, or which result in a "near miss" but no actual injuries or property damage, are either not investigated at all or not investigated thoroughly. This results in a missed opportunity to learn from our mistakes and prevent future accidents that may have more serious outcomes. Therefore, it is a good idea to have a policy that all accidents are investigated regardless of the severity of the outcome. Treat all accidents and incidents as important indicators that your safety systems, policies and procedures need to be improved to prevent future accidents. The difference between a minor first aid injury and a serious injury is often just a matter of luck. By eliminating or controlling the cause(s) of the minor injury or a "near miss", you can often prevent a more serious injury from occurring in the future.

27 Procedures (Detailed)
Steps to take when doing an accident investigation: Initial response activities Collect relevant information Analyze information Write report Follow up The first step is to assign responsibilities according to workers and supervisors authority. Decide exactly what you want to accomplish, and determine what steps are necessary to manage an accident scene. Then plan out how and when each step will be carried out and who will do it and put this plan in writing. In developing the plan, consider your company’s immediate needs and provide for ongoing worker protection. Respond to initial activities Victim is the first priority: In the event of an accident involving a serious injury there are a number of actions. Initially treatment will be a priority but after that thoughts should turn to reporting and investigation. Prevent further injury and property damage Secure the scene Call authorities and family Start accident investigation as soon as possible Collect information Some types of accidents need to be reported to the enforcing authority and it is necessary to have certain information available in order to complete the paperwork. An investigation of what happened must be undertaken to collect this information. Analyze information Accident records should be analysed periodically to identify if there are any significant changes or trends, such as changes in the number and type of an increase in the accidents from a particular location, a specific machine. These might indicate a breakdown of control. Write report Early contact with WHSCC is essential since the accident may lead to a claim. Ensure eyewitnesses' details are recorded and ask them to provide written statements. Photograph the machine or area involved. Review any previous complaints about machinery or work practices. Review the availability, suitability and use of any relevant Personal Protective Equipment. Review training – supplied or needed - for employees/contractors. Review the role of supervisors and management. If a substance or material is involved consider retaining a sample and reviewing Material Safety Data Sheets. Determine the cause and record steps to be taken to avoid a repeat of the situation Record the accident in the Accident Book. Preserve First Aid/Medical Centre records. Follow-up The responsibility to ensure that corrective actions are taken should be assigned to individuals such as the plant manager, supervisor, operations manager, etc.  They should follow up to a conclusion, insuring that remedial action has been taken, and report back to top management when completed. Corrective actions should be identified in terms of not only how it will prevent a recurrence of the accident or near miss, but also how it will improve the overall operation. This will assist the investigation in selling his/her solutions to management. The solution should be a means of achieving not only accident control, but also total operation control.

28 Supervisor as Accident Investigator
Two different viewpoints:  ‘This is an opportunity to prevent the next accident.’  ‘This is unnecessary paperwork and an improper use, waste of my time’ The supervisor must investigate the who, what, when, where, and how. The focus of any accident investigation is fact-finding, not faultfinding. The goal of an accident investigation is to find the cause(s) so that the supervisor can determine why it happened to help develop solutions to prevent recurrence. Striving for the goal of zero injuries can provide immediate rewards. One of the problems in eliminating injury is that often the workers simply do not believe that the company is truly serious about safety. When management clearly sets forth the expectation for zero injuries, the workers can then begin to believe that the company is truly serious about safety. From the standpoint of worker psychology, zero is the only supportable goal. Any other goal leaves the subtle message that injuries will occur and that injuries are acceptable.

29 Key Attributes of Competent Investigators
Assumes all accidents are preventable Looks for many causes not just the first, most obvious cause Be a good listener Never attempts to find a culprit Is as objective as possible Always keeps the purpose of the investigation in mind

30 JHSC Investigation Kit
Camera, film, and flash Tape measure Clipboard/pad Flashlight Pencils/pens Accident Investigation Form Investigation policy Chalk (yellow/white) Checklist JHSC Investigation Kit

31 Investigation Interview Techniques
Try to have private interviews Put the person in the right frame of mind Get their story in their own words Probe for the full understanding Conclude the interview on a positive note Investigation Interview Techniques Try and have a private interview with person Each interview should be as private as possible. A courteous explanation that each person will be given a chance to talk will usually be accepted without taking offense. Separate interviews are important to keep people from influencing each other’s memories. Where there are significant differences of opinion, follow-up interviews may be needed. that doesn’t make the individual’s interview invalid. - Avoid public embarrassment. - Encourage honest evaluation of circumstances. 2. Put the person in the right frame of mind One of the best way ways to create the favorable rapport necessary for good racall is to talk briefly about employee’s work, family or a subject discovered in advance to be of interest. Advance planning is vital to this important effort. Make sure you use his/her first name rather than last. Be friendly, warm, cheerful, sympathetic and most of all sincere. This step appeals to the basic psychological needs of the average person and motivates cooperation. - Relaxed surroundings, coffee, etc. - Don’t show up with a nasty looking form and sharp pencil, tape recorder, etc. - Give the purpose of the interview (get a verbal understanding from the individual). - Tell them what will happen with the report you will write. 3. Get their story in their own words first Start the interview with, Would you please tell me about…? Ask very simply, “Tell me, how did this accident happen?”, “What did you see happen?” Be quiet and listen to what they say. Don’t take notes yet. Don’t ask any questions. Just listen. 4. Probe for full understanding of the incident - Have them go over the story again, this time take notes, ask questions, etc. - Repeat their story back to them. - Ask if there are any details that might have had a bearing on the incident (no matter how unimportant they may seem). - Ask about personal factors (How were you doing that day? Did he/she seem rushed, worried, upset?) - Use prepared questions if you are interviewing several people or re-interviewing for final confirmation. - Ask the person for their thoughts on how it happened and how to avoid any future incidents. 5. Conclude the interview on a positive note. - Tell them what will happen with this information. - If they think of anything else to come back. - Thank them for their contributions.

32 There are a number of basic questions to answer in an investigation
Who? What? Where? When? Why? How? There are a number of basic questions to answer in an investigation What type of answers will the 6 W’s provide you? Who? Names of everyone involved, witnesses, and anyone near or present. What? Describe materials, equipment, or substances involved. Get the accurate name of any chemicals. Check for defects. Where? Describe exact location, down to the foot or inch, and make note of all relevant facts poor lifting, weather, slippery snow, etc. When? Note exact time and date and other important information such as shift changes or stages in work cycle. How? Describe the sequence of events before, during, and after the accident. Why? List all possible direct and indirect causes of the accident. Questions to ask in an accident investigation include: What happened? The investigation should describe what took place that prompted the investigation: an injury to an employee, an incident that caused a production delay, damaged material or any other conditions recognized as having a potential for losses or delays. Why did the incident happen? The investigation must obtain all the facts surrounding the occurrence: what caused the situation to occur; who was involved; was/were the employee(s) qualified to perform the functions involved in the accident or near miss; were they properly trained; were proper operating procedures established for the task involved; were procedures followed, and if not, why not; where else this or a similar situation might exist, and how it can be corrected. What should be done? The person conducting the investigation must determine which aspects of the operation or processes require additional attention. It is important to note that the purpose here is not to establish blame, but to determine what type of constructive action can eliminate the cause(s) of the accident or near miss. What action has been taken? Action already taken to reduce or eliminate the exposures being investigated should be noted, along with those remaining to be addressed. Any interim or temporary precautions should also be noted. Any pending corrective action and reason for delaying its implementation should be identified.

33 Be conscious of the feelings of others
Points to Remember Be conscious of the feelings of others Arrange for comfortable quarters in which to interview Don’t jump to conclusions or pre-judge Don’t let your personal bias take over Never pass on information given to you in confidence by another party Stick around after you have finished your formal investigation

34 Investigation Report The report should include the pertinent information collected from all sources, as well as the immediate and basic causes, and recommended actions to be taken Should respect confidentiality Recommendations should be concrete, precise, realistic and measurable

35 It is now time to investigate an accident Another Option
Module 4 - Case Study It is now time to investigate an accident Another Option The group may prefer to investigate an accident that has already occurred at their workplace At this point the instructor would show the forklift video and explain that the video is showing two case scenarios. One showing the proper way to doing an accident investigation and another showing an improper investigation. Instructor needs: Forklift accident video Case Study sheets (Provide to learners so they can take notes while watching the video) Accidents investigation forms (Have learners use the Commission accident investigation form to do the investigation)

36 Summary During this session, you were made aware: Of the difference between accident & incident That root causes are the real reasons as to why accidents are occurring That a proper investigation will reduce probability of accidents re-occurrence

37 Effective accident investigations prevent physical injury, reduce costs, and contribute to the safety mindset of the workplace.


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