1. Accident InvestigationSlide 1 The Basics of Accident Investigation

2. Accident InvestigationSlide 2 Professional Disclaimer u By no means am I a professional accident investigator… u But I did stay at a Holiday Inn Express last night! Introduction

3. Accident InvestigationSlide 3 Why do we need Accident Investigations? u To prevent future accidents. u To avoid spending money on accidents in the future. u To comply with the law and determine the total cost of an accident Introduction

4. Accident InvestigationSlide 4 Why do we need Accident/Incident Investigations? Introduction

5. Accident InvestigationSlide 5 PRE-ACCIDENT PLANNING u Formal written accident investigation policy u Emergency response plan and training u Accident investigation training u Accident investigation kit Program Evaluation

6. Accident InvestigationSlide 6 Typical Accident Investigation Kit u Barricade Tape u Cones u Tape Measure u Flashlight u Evidence Tags u Evidence Bags u Tweezers u Gloves (latex and work) u PPE u Binoculars u Camera u Graph Paper u Witness statement forms u Notepad and clipboard u Analytical technique forms u Copy of the accident investigation policy Program Evaluation

7. Accident InvestigationSlide 7 Decisions to be made before an Accident Investigation u Determine the level of accident u Decide who will investigate u How much time will be allotted to investigate u Determine if outside resources will be needed Program Evaluation

8. Accident InvestigationSlide 8 WHAT IS ACCIDENT INVESTIGATION? u 4 step Process to determine the underlying causes of accidents u 1. Analyzing the facts u 2. Developing an accident sequence u 3. Finding the causes u 4. Recommending corrective actions u Causal information used to identify and take preventive action Introduction

9. Accident InvestigationSlide 9 INVESTIGATIVE TECHNIQUES u Preservation of evidence u Types of evidence u Gathering evidence u When to stop collecting evidence Gathering Evidence

10. Accident InvestigationSlide 10 Preservation of Evidence u Cordon off the area u Photograph the scene u Interview emergency response personnel as soon as possible u Assess the evidence u Draw a picture or diagram of the scene Gathering Evidence

11. Accident InvestigationSlide 11 Types of Evidence u Photographic u People u Physical u Paper Gathering Evidence

12. Accident InvestigationSlide 12 Gathering Evidence Photographic Evidence u Take photos of the “Big Picture” u Include a reference object u Keep a photo log u Keep back-up copies in safe place Gathering Evidence

13. Accident InvestigationSlide 13 INTERVIEWING TIPS People Evidence u Choose site carefully. u Put the person at ease, explain purpose. u Fact-finding process, don’t assess blame. u Ask open-ended questions. u Take notes. u Ask for their opinion. u Get contact information. Gathering Evidence

14. Accident InvestigationSlide 14 Gathering Evidence Physical Evidence u Take universal precautions u Examine equipment, tools, debris, etc… u Note defects Gathering Evidence

15. Accident InvestigationSlide 15 Gathering Evidence Paper Evidence u Policies u Procedures u Training records u Equipment maintenance records u Accident records Gathering Evidence

16. Accident InvestigationSlide 16 Charting u Sequence of events: u Establishment of timelines and or charts provides: u The recording of events and conditions in a visual manor. u Validation and verification of facts. u Identification of multiple causes. u Elimination of memorization. Analyzing Data & Determining Causes

17. Accident InvestigationSlide 17 Charting Tips u Fill the chart with information u Make room for your chart u Keep the notes sticky u Leave some expansion room u Use computer charts Analyzing Data & Determining Causes

18. Accident InvestigationSlide 18 DETERMINING CAUSES u The root cause is the most fundamental and direct cause of an accident or incident u There may be one or more contributory causes, in addition to the root cause u Accident Investigation is ineffective unless all causes are determined and corrected Analyzing Data & Determining Causes

19. Accident InvestigationSlide 19 CATEGORIES OF ROOT CAUSES Can be classified as: u Workplace Factors - Largely a function of Management Practices u Employee Factors - Largely a function of Employee Behavior Analyzing Data & Determining Causes

20. Accident InvestigationSlide 20 The Analytical Process u The five whys? u The why staircase Analyzing Data & Determining Causes

21. Accident InvestigationSlide 21 The Five Whys? u Investigator: John, why did the pipe fall on your foot? u John: I dropped it. u Investigator: Why did you drop it? u John: It slipped out of my hand. u Investigator: Why did it slip? u John: It was wet. u Investigator: Why was it wet? u John: It rained earlier today. Analyzing Data & Determining Causes

22. Accident InvestigationSlide 22 The Why Staircase? u “Accident” u Why? u WHY? u “Solution” Analyzing Data & Determining Causes

23. Accident InvestigationSlide 23 Analytical Techniques u Event and Causal Factor Analysis u Root Cause Analysis u Change Analysis u Analytical Trees u Barrier Analysis Analyzing Data & Determining Causes

24. Accident InvestigationSlide 24 CORRECTIVE ACTIONS u Once the cause(s) are determined, corrective actions must be developed and implemented. u Must directly address each cause identified. u Consider short term CA’s if permanent CA’s are not readily available. u Reference the “Control Hit List” to make sure that the “best” corrective actions are used. Corrective Actions & Reporting

25. Accident InvestigationSlide 25 THE CONTROL HIT LIST 1. Eliminate the Hazard 2. Substitute a less hazardous material 3. Use Engineering Controls 4. Use Administrative Controls 5. Personal Protective Equipment (PPE) 6. Training of Employees Corrective Actions & Reporting

26. Accident InvestigationSlide 26 Accident Reports u Method of communicating A/I results to others. u Severity and scope of accident dictates which report to use. u Accident Logs u Accident Form u Accident Report Corrective Actions & Reporting

27. Accident InvestigationSlide 27 Accident Reports u Should include but not limited to: u Introduction u Methodology u Sequence of Events u Facts and Analysis u Causal Factors u Corrective Actions u Conclusion and Summary Corrective Actions & Reporting

28. Accident InvestigationSlide 28 Review of a Detailed Accident Investigation Report GROUP DISCUSSION & BREAK OUT SESSION

29. Accident InvestigationSlide 29 References u Oakley, Jeffrey S. Accident Investigation Techniques. The American Society of Safety Engineers: Des Plaines, Illinois, 2003. u Cianbro The Constructors. Yankee Rowe Decommissioning Project. 1997 u Rooney, James J., and Vanden Heuvel, Lee N. Root Cause Analysis For Beginners. Quality Progress, July 2004.