Accident investigation Procedure.doc

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1、Table of contentsHow to conduct effective investigationsPage3 Suggested accident investigation tools7Interviewing techniques8Sample investigation questions9Accident causes, unsafe acts and unsafe conditions11Accident Causes, job and personal factors12Example of corrective actions15Accident Investiga

2、tionsEMPLOYEE CONSIDERATIONIts important to keep in mind that your people are your most vital resource. During your investigation, be empathetic and supportive.Accidents can be psychologically traumatic experiences. A little bit of consideration and support shown to an accident victim will serve two

3、 purposes. It will help you effectively prevent a recurrence of such an accident, and it will promote a more rapid return to work. When an accident occurs, the investigation should begin. During the investigation process, make sure to get proper medical attention for the employee. Let the employee k

4、now that he/she is a valued member of your team and that you hope they return as soon as possible.ACCIDENT ANALYSISWhile accident investigations usually focus on a singular occurrence, there may be similarities with previous accidents that have occurred. Its very beneficial to also look at accident

5、information and data over longer time periods. This long-term accident analysis evaluates a history of accidents to identify similar trends that may help to provide additional insight. To guide us in accident investigation and accident analysis activities, an accident report should be completed. The

6、 use of accident reports together with a first report of injury, forms the data base for follow-up accident analysis. The compilation of this data will further strengthen your loss control efforts.ACCIDENT INVESTIGATION TECHNIQUESWe now point out the important information needed to effectively inves

7、tigate an accident and to complete the accident report.Effective accident investigation involves an inquisitive interviewer. The accident investigator needs to ask pertinent questions and consider possible solutions.Also remember that accident investigation is a fact-finding, not a fault-finding act

8、ivity.As we go through the accident report, lets consider some of the most important questions:What accidents should be investigated?Many accidents involve little or no property damage / physical injury. This type of accident is called a near miss accident. Its been found that a near miss may often

9、precede an accident producing physical injuries and or property damage. For this reason, all near misses should be investigated. There are valuable lessons to be learned from the investigation of near misses, and about the prevention of a more serious accident.Who was involved?The person involved in

10、 the accident is usually the person injured in the accident. When more than one person is injured through the same accident, an individual report for each person should be completed depicting each individuals perspective and circumstances.Also of importance is the: Age of the injured person Departme

11、nt in which the accident occurred Occupation at time of the accident Time of the accident Accident dateWhat happened?In describing what happened, its most beneficial to give a brief, accurate and clear description of the accident. Though its tough to do, try to resist the urge to describe the injury

12、. We will describe the injury separately. The accident description will help you to focus on the accident itself to prevent the accident from happening again. Adding injury information may cloud this particular issue.What injuries or property damages occurred?Describe any injuries and/or property da

13、mage that resulted from this accident. If this is a near miss, state that in this section.ACCIDENT CAUSESWhat caused the accident?Now we are getting into the core of effective accident investigation. Its important to define the two types of accident causes which must be considered:1. Contributing Ca

14、uses.The Root Causes can be thought of as the symptoms of the accident. These are the unsafe act(s) and or unsafe condition(s). Example: Operating a grinder without wearing safety glasses or oil on the floor.2. Root Causes.The Primary Causes are the reasons why the unsafe act(s) or condition(s) exis

15、ted. Example: Lack of instruction on why safety glasses should be worn while grinding, or why was oil leaking on the floor. These causes place the focus where it belongs - the management system. By strengthening the management system, accident symptoms or root causes will be prevented which will bre

16、ak the accident chain. This area of your investigation deserves a great deal of thought and consideration.PRIMARY CAUSESA key point to keep in mind is that we endorse the multiple causation theory of accident investigation. The multiple causation theory suggests that often there is more than one pri

17、mary cause that triggers the root cause and ultimately the accident occurrence.The four main areas of accident causes are: Unsafe acts Unsafe conditions Job factors Personal factorsCORRECTIVE ACTIONTo help you focus on the individual aspects of the accident chain, we have provided space for your rec

18、ommended corrective action for both the root and primary causes you have identified. To help you correct these causes and effectively prevent recurrence its important that action takes place once your investigation is completed.INTERVIEWINGImportant techniques to remember when interviewing injured p

19、arties and witnesses Conduct Interviews As Soon As Practical Discuss The Purpose Of The Investigation (Fact Finding Not Fault Finding) Be Diplomatic Establish Rapport Ask One Question At A Time Avoid The Implied Answer or Leading Question Keep Questions As Simple As Possible Dont Ridicule Stupidity,

20、 Poor Judgment, Etc. Do The Best You Can To Save The “Face Of The Person Being Interviewed Allow The Individual To Present His/Her Version In Its Entirety Without Interruption If Possible Ask Questions To Clarify Facts Or Fill In Any Gaps Interviewer Should Relate His/Her Understanding Of The Accide

21、nt Back To The Individual Discuss Methods To Prevent Recurrence End Interview On A Positive NoteThe Interview Should Be Conducted At The Accident Site If Possible, Unless It Interferes With Privacy, Or Is Causing A Distraction To Co-WorkersSAMPLE QUESTIONS TO ASK DURING THE ACCIDENT INVESTIGATION PR

22、OCESS IN ORDER TO COMPLETE A DETAILED ACCIDENT REPORTWHO1. Who Was Injured2. Who Saw The Accident3. Who Was Working With The Worker4. Who Had Instructed/Assigned The Worker5. Who Else Was Involved6. Who Else Can Prevent RecurrenceWHAT1. What Was The Accident2. What Was The Injury3. What Was The Work

23、er Doing4. What Had The Worker Been Told To Do 5. What Tools Were Being Used6. What Machine(S) Were Involved7. What Operation Was Being Performed8. What Instructions Had Been Given9. What Precautions Were Necessary10. What Precautions Were Given11. What Protective Equipment Was Being Used12. What Pr

24、otective Equipment Should Have Been Used13. What Other Persons Contributed To The Accident14. What Problem Or Question Was Encountered15. What Did The Witnesses Do When The Accident Occurred16. What Extenuating Circumstances Were Involved17. What Did The Witnesses See18. What Will Be Done To Prevent

25、 RecurrenceWHEN1. When Did The Accident Occur2. When Did The Worker Start On That Job3. When Was The Worker Assigned On The Job4. When Were The Hazards Pointed Out To The Worker5. When Had The Supervisor Last Checked On The Job Progress6. When Did The Worker First Sense Something Was Wrong7. When Wa

26、s The Last Safety Meeting The Worker AttendedWHY1. Why Was The Worker Injured2. Why Did The Worker Do What He/She Did3. Why Did The Other Worker Do What He/She Did4. Why Wasnt Protective Equipment Used5. Why Werent Specific Instructions Given6. Why Was He/She In The Position He/She Was7. Why Was He

27、She Using The Tools/Machine He/She Used8. Why Did He/She Continue Working Under The Circumstances9. Why Wasnt The Supervisor There At The Time10. Why Didnt He/She Check With The Supervisor When He/She Noted Things Werent As They Should BeWHERE1. Where Did The Accident Occur2. Where Was He/She At The

28、 Time3. Where Was The Supervisor At The Time4. Where Were Fellow Workers At The Time5. Where Were Other People Who Were Involved At The Time6. Where Were The Witnesses When The Accident OccurredHOW1. How Did He/She Get Injured2. How Could He/She Have Avoided It3. How Could Fellow Workers Have Avoide

29、d It4. How Could Supervisor Have Prevented It (Could He/She?)EXAMPLES OF ACCIDENT CAUSESUNSAFE ACTSREPRESENTS 90% OF ALL ACCIDENTS Operating Without Authority Failure To Make Secure Operating At Unsafe Speed Failure To Warn Or Signal Nullifying Safety Devices Using Defective Equipment Using Equipmen

30、t Unsafely Taking Unsafe Position Servicing Hazardous Equipment Riding Hazardous Equipment Horseplay Failure To Use Protection Failed To Follow Prescribed Procedures Improper Physical Effort/ActUNSAFE CONDITIONSREPRESENTS 10% OF ALL ACCIDENTS Inadequate Guards/Devices Inadequate Warning System Fire

31、And Explosion Hazards Poor Housekeeping Projection Hazards Congestion: Close Clearance Hazardous Atmospheric Conditions Hazardous Placement Or Storage Unsafe Equipment Defects Inadequate Illumination Hazardous Personal Attire Inadequate Visual Contacts Lack Of Personal Protective Equipment xxxxxxxxx

32、xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Inadequate Work Standards Inadequate Job Instruction Improper Or Failure To Use Personal Protective Equipment Poor Match Or Person To Job Ergonomic Considerations Improper Tools Or Equipment Inadequate Work Standards Inadequate Design Or Maintenance

33、 Substance Abuse Lack Of Skill/Knowledge Physical Or Mental Problem Inattentive14.Exactly What The Person Was Doing.15.How The Action Took Place (Chronological Order Is Most Helpful Here).16.The Who, What, When, Why, Where, And How Formula Is Most Helpful To Follow Each Time A Different Person Is In

34、troduced In The Action. 17.A Subsequent Interview Of The Witnesses Should Be Conducted At This Time. More Detail Should Be Noted And, If Possible, Assistance From Another Investigator.18.A Re-Examination Of The Area Should Be In Minute Detail Starting From Left To Right Or Reverse, But Each Time The

35、 Area Is Examined It Should Be Done In The Same Manner.19.Points Of The Compass Should Always Be Used In Describing The General Features Of Everything Important That Has Been Observed.21.Maps Of Drawings Showing Exact Position Of All Parties Involved And Location Of All Evidence.24.All Physical Cond

36、itions Must Be Listed In Detail With Regard To The Following: Guarding; Condition Of Equipment; Design Or Construction; Process, Operation Or Arrangement; Illumination; Dress Or Apparel And Weather Is Applicable.25.Personal Behavior Must Be Noted In Detail With Regard To The Following: Action Or Wha

37、t The Individuals Were Doing; Performing Operations Without Authority; Using Or Not Using Guards; Operating Speeds; Using Or Not Using Improper Equipment And Personal Protective Equipment.26.Length Of Time Injured Person(S) Has Been Working At The Job.EXAMPLES OF VARIOUS CORRECTIVE ACTIONS1. Institu

38、te Formal Training Program2. Give Personal Reinstruction3. Institute Proper Job Instructional Program4. Improve Employee Screening Program5. Temporarily Or Permanently Reassign Person(S)6. Institute A Job Hazard Analysis Program7. Order Or Revise Job Analysiss On Specific Tasks8. Institute Or Improv

39、e Self-Inspection Program9. Institute Pre-Use Checkout Of Equipment10. Establish Or Revise Indoctrination For New Or Transferred Employees11. Establish Ergonomic Req. On New Equipment12. Improve Design Or Establish Design Standards13. Repair Or Replace Equipment14. Identification Or Color Code For S

40、afety15.Install Or Improve Safeguards16.Eliminate Unnecessary Material In Area17.Institute Program Or Order Clean-Up18.Institute Mandatory Protective Equipment Or Improve Existing Coverage 19.Use Safer Material20.Establish Purchasing Standard(S) Or Control21.Institute Incident Recall Program22.Create Safety Incentive Program