Accident/Incident Investigation - Supervisor Training

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Accident/Incident Investigation - Supervisor
Training

• N.C. Department of Labor
• Mine and Quarry Bureau

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What is the root cause?
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Responsibilities under the ACT

• You are already aware of your responsibility as a
  supervisor
• You understand having reason to know
• You are familiar with the levels of negligence

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Accident Prevention is paramount

• Company safety culture - the atmosphere within
  the company that influences safe behavior
• Accomplished by shared beliefs, practices, and
  attitudes from management down to the newest
  hired worker
• A break-down of the culture leads to loss

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How is the safety culture created?

• Positive attitudes by management and employee
• Developing policy and procedures
• Supervisors taking responsibility and
  accountability
• Safety planning and goals
• Properly addressing unsafe behavior
• Motivate and train employees
• Employee involvement or buy-in

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Accidents do occur

• Any loss costs everybody
• Direct cost is only a small percentage of the
  actual cost of an accident medical expenses,
  workers compensation
• Indirect cost can be 4 to 7 times the direct cost
  wages of the injured, decreased productivity,
  emergency response cost, investigation cost,
  remediation cost to prevent recurrence,
  replacement cost of property and personnel, plus
  others

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The Three Basic Causes
Poor Management Safety Policy
Decisions Personal Factors Environmental Factors
Basic Causes
Unsafe Condition
Unsafe Act
Indirect Causes
ACCIDENT Personal Injury Property Damage
Unplanned release of energy and/or Hazardous
material
Direct Causes
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Minimize loss

• Promote an active accident prevention program
• Perform task analysis
• Train employees in hazard recognition
• Front line supervisor must understand NEGLIGENCE

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When loss occurs

• Root causes of accidents are identified through
  recognition and investigation of unsafe behavior
• As supervisors you must recognize and investigate
  all unsafe acts, unsafe conditions, and correct
  root cause
• Example An accident involving a fall from a
  ladder the broken rung on the ladder is easily
  recognized as a hazard and causation of the fall,
  however the root cause could be, improper
  maintenance, poor inspection technique, or
  inadequate training on recognizing the hazard
• Document the occurrence and train employees on
  recognizing and preventing future occurrence

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What is The Aim of the Investigation?

• EXONERATE INDIVIDUALS OR MANAGEMENT
• SATISFY INSURANCE REQUIREMENTS
• DEFEND A POSITION FOR LEGAL ARGUEMENT
• OR, TO ASSIGN BLAME

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The aim of any accident/incident investigation

• THE KEY RESULT SHOULD BE TO PREVENT A
  RECURRENCE OF THE SAME ACCIDENT

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THE ACCIDENT

• WHAT IS AN ACCIDENT?

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THE ACCIDENT

• AN UNPLANNED AND UNWELCOMED EVENT WHICH
  INTERRUPTS NORMAL ACTIVITY.

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THE ACCIDENT

• THREE BASIC TYPES OF ACCIDENTS

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THE ACCIDENT

• MINOR ACCIDENTS
• SUCH AS PAPER CUTS TO FINGERS OR DROPPING A
  BOX OF MATERIALS

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THE ACCIDENT

• MORE SERIOUS ACCIDENTS THAT CAUSE INJURY OR
  DAMAGE TO EQUIPMENT OR PROPERTY
• SUCH AS A FORKLIFT DROPPING A LOAD OR SOMEONE
  FALLING OFF A LADDER

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THE ACCIDENT

• ACCIDENTS THAT OCCUR OVER AN EXTENDED TIME
  FRAME
• SUCH AS HEARING LOSS OR AN ILLNESS RESULTING
  FROM EXPOSURE TO CHEMICALS

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THE ACCIDENT

• ACCIDENTS HAVE TWO THINGS IN COMMON

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THE ACCIDENT

• THEY ALL HAVE OUTCOMES FROM THE ACCIDENT

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THE ACCIDENT

• THEY ALL HAVE CONTRIBUTORY FACTORS THAT CAUSE
  THE ACCIDENT

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OUTCOMES OF ACCIDENTS

• NEGATIVE ASPECTS
• DEATH INJURY
• DISEASE
• DAMAGE TO EQUIPMENT PROPERTY
• LITIGATION COSTS
• LOST PRODUCTIVITY

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OUTCOMES OF ACCIDENTS

• POSITIVE ASPECTS
• ACCIDENT INVESTIGATION
• CHANGE TO SAFETY PROGRAMS

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CONTRIBUTING FACTORS

• ENVIRONMENTAL
• DESIGN
• SYSTEMS PROCEDURES
• HUMAN BEHAVIOR

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CONTRIBUTING FACTORS

• ENVIRONMENTAL
• NOISE
• VAPORS, FUMES, DUST
• LIGHT
• HEAT
• CRITTERS

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CONTRIBUTING FACTORS

• DESIGN
• WORKPLACE LAYOUT
• DESIGN OF TOOLS EQUIPMENT

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CONTRIBUTING FACTORS

• SYSTEMS PROCEDURES
• LACK OF SYSTEMS PROCEDURES
• INAPPROPRIATE SYSTEMS PROCEDURES

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CONTRIBUTING FACTORS

• HUMAN BEHAVIOR
• COMMON TO ALL ACCIDENTS
• NOT LIMITED TO THE PERSON INVOLVED IN THE ACCIDENT

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WHO SHOULD INVESTIGATE

• DEPENDENT ON SEVERITY OF THE ACCIDENT
• INVESTIGATION TEAM
• INDIVIDUALS INVOLVED
• SUPERVISOR
• SAFETY SUPERVISOR
• UPPER MANAGEMENT
• OUTSIDE CONSULTANTS

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INVESTIGATION STRATEGY

• GATHER INFORMATION ESTABLISH FACTS
• ISOLATE ESSENTIAL CONTRIBUTORY FACTORS
• DETERMINE CORRECTIVE ACTIONS
• IMPLEMENT CORRECTIVE ACTIONS

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INVESTIGATION STRATEGY

• FACT GATHERING
• BE IMPARTIAL OBJECTIVE
• COMPILE PROCEDURES RULES FOR THE AREA
• GATHER MAINTENANCE RECORDS ON EQUIPMENT INVOLVED

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INVESTIGATION STRATEGY

• FACT GATHERING (CONTINUED)
• ISOLATE ACCIDENT SCENE
• PHOTOS DIAGRAMS
• DO NOT DISCARD OR DESTROY ANYTHING

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INVESTIGATION STRATEGY

• FACT GATHERING (CONTINUED)
• TIME IS OF THE ESSENCE
• OBTAIN INFORMATION
• INJURED
• WITNESSES
• SUPERVISORS
• OTHER PERSONNEL

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INVESTIGATION STRATEGY

• FACT GATHERING (CONTINUED)
• INTERVIEWS (SEPARATELY)
• WHAT WERE YOU DOING?
• HOW DO YOU THINK THE ACCIDENT OCCURRED?
• HOW WERE YOU TRAINED FOR THE JOB?
• WHAT IS THE SAFETY PROCEDURE FOR THIS JOB?

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INVESTIGATION STRATEGY

• FACT GATHERING (CONTINUED)
• OBTAIN FACTS NOT OPINIONS
• MAKE IT CLEAR THE OBJECT OF THE INVESTIGATION IS
  TO AVOID RECURRENCE, NOT TO APPORTION BLAME

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INVESTIGATION STRATEGY

• ISOLATE ESSENTIAL CONTRIBUTORY FACTORS
• INVESTIGATION TEAM
• EVALUATES ALL FACTORS CONCERNED

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INVESTIGATION STRATEGY

• ISOLATE ESSENTIAL CONTRIBUTORY FACTORS
• INVESTIGATION TEAM
• ISOLATES THE KEY FACTOR(S) BY ASKING THE
  FOLLOWING QUESTION....

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INVESTIGATION STRATEGY

• WOULD THE ACCIDENT HAVE HAPPENED IF THIS
  PARTICULAR FACTOR WAS NOT PRESENT?

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INVESTIGATION STRATEGY

• DETERMINE CORRECTIVE ACTIONS
• INVESTIGATION TEAM
• INTERPRETS DRAWS CONCLUSION
• DISTINCTION BETWEEN INTERMEDIATE UNDERLYING
  CAUSES

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INVESTIGATION STRATEGY

• DETERMINE CORRECTIVE ACTIONS
• INVESTIGATION TEAM
• RECOMMENDATIONS BASED ON KEY CONTRIBUTORY FACTORS
  AND UNDERLYING CAUSES

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INVESTIGATION STRATEGY

• IMPLEMENT CORRECTIVE ACTIONS
• INVESTIGATION TEAM
• RECOMMENDATION(S) MUST BE COMMUNICATED CLEARLY
• STRICT TIME TABLE ESTABLISHED
• FOLLOW UP CONDUCTED

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BENEFITS OF ACCIDENT INVESTIGATION

• PREVENTING RECURRENCE
• IDENTIFYING OUT-MODED PROCEDURES
• IMPROVEMENTS TO WORK ENVIRONMENT

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BENEFITS OF ACCIDENT INVESTIGATION

• INCREASED PRODUCTIVITY
• IMPROVEMENT OF OPERATIONAL SAFETY PROCEDURES
• RAISES SAFETY AWARENESS LEVEL

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BENEFITS OF ACCIDENT INVESTIGATION

• WHEN AN ORGANIZATION REACTS SWIFTLY AND
  POSTIVELY TO ACCIDENTS AND INJURIES, ITS ACTIONS
  REAFFIRM ITS COMMITMENT TO THE SAFETY AND
  WELL-BEING OF ITS EMPLOYEES