ACCIDENT INVESTIGATION

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ACCIDENT INVESTIGATION
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Definitions Accident An event that results in
unintended harm or damage Incident An event
which could or does result in unintended harm
or damage Investigation A systematic inquiry into
an event Safety Control of accidental loss
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The Cost of Accidents
Insured Costs
Employers Liability Public Liability
Damage
Business disruption Product Liability

Direct Costs
Indirect Costs
Sick Pay Repairs
Products damaged
Investigation Costs Loss of
Good Will Hiring/Training replacement staff
Corporate image
Product Liability
Uninsured Costs
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The Cost of Accidents at DMUK
2004/2005 26 Lost Time Accidents
388 Days lost due to accidents
5,133 paid is SSP (13.23
per day) 13,855 paid in Co. sick pay
(13K salary)
14,938 temporary labour cover
(5.50ph)
Total 33,926 ( hidden costs)
2005/2006 16 Lost Time Accidents
159 Days lost due to
accidents 2,169 paid is
SSP (13.64 per day) 8,611 paid
in Co. sick pay (13K salary) 6,558
temporary labour cover (5.50ph) Total
17,338 ( hidden costs)
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The Cost of Accidents at DMUK
A large UK insurer estimates that a non-absence
accident costs approximately 315 DMUK 2004/2005
211 accidents _at_ 315 66,465 DMUK 2005/2006
165 accidents _at_ 315 51,975
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Relationship between Injury, Damage Near Miss
Previously organisations have concentrated on
investigating only injury or lost time accidents.
All Incidents should be investigated as it is
likely that it was only by chance that there
wasnt an injury.
By reducing the number of near misses, where no
injury was sustained, we can hope to reduce the
numbers of damage, minor and more serious
incidents. This
confirms the importance of investigating ALL
accidents/incidents. All represent failures in
safety management and have valuable learning
opportunities
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Accident Investigation

• Why Investigate Accidents ?
• Monitor the effectiveness of the HS Policy
• Create information for statistical trend
  analysis
• Determine accident causation
• Develop actions / countermeasures
• Prevent reoccurrence
• Improve systems, procedures awareness learn
  from events
• Legislative requirement
• Management System / Audit requirements (OHSAS
  18001)
• Allow / ensure continuous improvement

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Accident Investigation - Causation
Accidents, incidents Ill-health are never
random events. They arise from failures of
control and often involve multiple contributory
elements. Immediate causes may be deemed as human
error of equipment failures, but such problems
often arise from underlying organisational
failures that are the responsibility of Senior
Management.
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Accident Investigation - Causation
Job Factors Including the adequacy of the
workplace precautions for the premises, plant
substances involved and the procedures systems
of work
Immediate/Basic Causes
Personal Factors Including the behaviour,
suitability competence of those doing the work
Job
Person (s)
Organisation Management
Underlying Causes

• Management Organisational Factors
• Adequacy of HS Policy
• How work controlled, co-ordinated supervised
• How co-operation involvement of Associates
  achieved
• Adequacy of HS communications
• Adequacy of audit and review arrangements

• How competency achieved, tested evaluated
• Adequacy of planning, risk assessment and the
  design of risk control measures
• Adequacy of measuring monitoring activity

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Immediate Causes

• Failure to warn
• Failure to follow rules procedures
• Removing safety devices
• Improper handling
• Failure to use PPE
• Running / rushing
• Taking risks / shortcuts
• Horseplay

Substandard / Unsafe Acts or Practices

• Inadequate guards barriers
• Inadequate PPE
• Defective tools equipment
• Congestion / obstruction
• Inadequate lighting
• Trailing cables
• Uneven surfaces
• Slippery floors

Substandard Conditions
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Basic Causes

• Inadequate physical capability
• Inadequate mental capability
• Lack of knowledge
• Lack of skill
• Stress

Personnel Factors

• Inadequate leadership
• Inadequate supervision
• Inadequate tools equipment
• Inadequate maintenance
• Inadequate work standards
• Wear tear

Job/System Factors
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Root Causes

• Management Organisational Factors
• Inadequate systems/procedures/standards
• Inadequate training
• Inadequate communications
• Inadequate assessment control of risk

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Accident Investigation - Example
Man Falls from Ladder Not following procedure
Man Falls from Ladder Uneven surface
Immediate Causes
Possible Basic Causes

• Possible Root Causes / Organisational Failures
• Lack of training provided in inspections/use of
  ladders
• Lack of resources to identify correct ladder
  standards specifications
• Lack of management commitment to proper time,
  planning, risk control
• Inadequate maintenance procedure for work
  equipment

Establishing Root Causes allows us to learn
from our mistakes and not mask the problem
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Who should investigate?

• Designating an investigator or investigating team
  is critical to ensure a truthful and relevant
  investigation and outcome.
• Personnel who might be involved include
• Injured person
• Witnesses
• First line supervisor/Team Leader
• Senior/Middle Manager
• Safety Specialists
• Health Safety Promoters
• Experts
• External agencies

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Conducting Investigations

• Good investigations are prompt and thorough. If
  investigations are not completed quickly after an
  event, conditions and peoples memories may fade.
• Effective investigations include the following
  basic activities
• Respond quickly
• Gather as much information as possible
• Analyse causes
• Take remedial action
• Complete all appropriate documentation
• Ensure management follow-up

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Respond Quickly at the scene

• The Line Management or Manager for the area will
  be expected to take the lead, organise and
  control initial actions
• Take control at the scene. Ensure 1st aid
  emergency actions
• Control prevent potential secondary incidents
  by ensuring the area is safe
• Identify sources of evidence (materials,
  equipment, witnesses)
• Preserve evidence from alteration or removal
• Determine the loss potential
• Notify appropriate personnel and agencies (HS
  department, Environmental department, HSE etc)

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Information Gathering/Collecting Evidence

• A great deal of information will be available for
  every incident. The priority is to find and
  concentrate on the most important aspects.
• Information you will need for a suitable
  sufficient investigation will include
• Facts about the casualty (name, clock no., job,
  injuries etc)
• Accident location, date and time
• Visual look at and information about accident
  environment
• Establish exact sequence of events leading up to
  accident
• Identify all equipment involved
• Identify any witnesses and take statements
• Identify any unsafe conditions (floors, stairs,
  machinery, lighting etc)
• Take photographs and measurements if required
• Identify if risk assessments SSOW are available
• Identify root causes

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Information Gathering/Collecting Evidence

• Documents
• Written instructions, procedures, risk
  assessments, policies etc
• Records of earlier inspections, tests,
  examinations surveys

• Observation
• Information from physical circumstances,
  including
• Premises place of work
• Access egress
• Plant substances in use
• Location relationship of physical parts
• Any post-event checks, test, sampling or
  reconstruction

• Checking Reliability, accuracy
• Identifying conflicts resolving differences
• Identifying gaps in evidence

• Interviews information from
• Those involved their line management
• Witnesses
• Those observing or involved before event
  (maintenance etc)

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Analysing Information

• Review all the information you have gathered
  during the investigation
• Analyse the information in order to determine
  both immediate, basic and root causes of the
  accident/incident
• Analysis must be based on FACTUAL information,
  not supposition
• Ensure that findings are justifiable and can be
  backed up by relevant information

Conclusions

• From the information and evidence gathered make
  your conclusions as to the factors that
  contributed to the accident/incident
• Conclude as to whether these are personal
  factors pertinent to the individual or job/system
  factors relating to some part of the management
  system or process (remember, they can be both)
• Conclusions sill help determine appropriate
  countermeasures

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Countermeasures Remedial Action

• Consider what actions need to be taken to
  prevent reoccurrence of the situation
• These may include short, medium and long term
  countermeasures
• Countermeasures may be physical (machine
  guarding or alterations) or non-physical
  (additional training, instruction etc) or both
• Responsibility for each countermeasure must be
  assigned to an individual and a date given for
  completion
• Following each action date the items should be
  checked and confirmed as being completed before
  the investigation can be signed off as fully
  complete
• Once completed the Risk Assessment SSOW should
  be reviewed and amended as appropriate
• There would normally be 2 or 3 countermeasures
  per accident/incident as a minimum

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Communication

• It is vital that once the investigation has taken
  place that the findings and agreed actions be
  communicated to all relevant Associates
• SIB
• Team Briefings
• Toolbox Talks
• News Bulletin
• Additional training and instruction may be
  required if the risk assessment/SSOW has been
  amended (this must be recorded). Associates
  cannot be expected to be aware of the dangers or
  controls if they do not receive the appropriate
  communications
• In addition for auditing purposes and in
  mitigation of prosecution or civil claims we must
  be able to show records of appropriate
  communication, information, instruction
  training relating to accidents

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Accident Investigation at DMUK
Using the following table the Potential Severity
Rating must be determined for each
accident/incident in order to confirm the level
of investigation required
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Potential Severity Degree of Investigation
Using the following determine the Potential
Severity Rating and the level of investigation
required
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Requirements of Investigation
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DMUK Investigations
Departmental Investigations Level of
investigation used for all accidents with
potential severity rating of between 48 and 60
and for all Lost Time accidents
Panel Of Enquiry (No Major Injury) Level of
investigation used for all accidents with
potential severity rating of 61 and above

Panel Of Enquiry (Major Injury) Level of
investigation used for all accidents with
potential severity rating of 61 and above

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Efficient Effective Investigations
PREVENT REOCCURRENCE IMPROVE AWARENESS IMPROVE
SYSTEMS IMPROVE PROCEDURES PROVIDE VALUABLE
LEARNING OPPORTUNITIES
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Accident Investigation Key Messages

• ALL accidents/incidents must be investigated
• ALL accidents/incidents represent failures
  management/organisation
• ALL accidents/incidents have valuable learning
  opportunities
• Accidents often involve multiple contributory
  elements
• Consider immediate, basic and root causes during
  accident investigation
• To ensure a good investigation Respond quickly
• Gather as much information as possible
• Analyse causes
• Take remedial action
• Complete all appropriate documentation
• Ensure effective management follow-up
• Communicate event