Accident Investigations Part I

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Accident InvestigationsPart I
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Accident Investigation - Objectives

• By the end of this session the participants
  will
• Understand the importance of the need for
  effective and thorough investigation of an
  accident
• Demonstrate practical skills required to respond
  and investigate an incident/accident in a
  consistent manner
• Make meaningful recommendations for preventive
  actions to reduce potential risks that may
  contribute to accidents

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Effective Accident Investigations - Objectives
(cont.)

• By the end of this session the participants
  will
• Understand their critical role in the accident
  investigation and the accident reporting process
• Determine the cause(s) of this accident and make
  recommendations to help prevent a recurrence of
  this type of incident

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What is an Accident ?

• An accident is an undesired event that results
  in physical harm to a person or damage to
  property.

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Purpose of an Accident Investigation

• The purpose of an accident investigation is to
  prevent the recurrence of the accident. The focus
  should be on the accident , not the injury .

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Effective Accident Investigations

• What to Look for
• Policies/Procedures Equipment Materials
• Environment Task People/Operators
• Accidents generally have more than one cause

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Critical Injury Defined

• For the purpose of the Act and Regulations,
  critically injured means an injury of serious
  nature that,

• a) places life in jeopardy
• b) produces unconsciousness
• c) results in substantial loss of blood
• d) involves the fracture of a leg or arm but not
  a finger or toe

• e) involves the amputation of a leg, arm, hand or
  foot but not a finger or toe
• f) consists of burns to a major portion of the
  body or
• g) causes the loss of sight in an eye. O. Reg.
  714/82 s.1

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Who Investigates Accidents?

• Supervisors

• They have a personal interest to protect.
• They know their people, the conditions and the
  job.
• They know how to get the information needed.
• They will take action in any case.

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Who Investigates Accidents?

• JHSC Representative

• They are familiar with the people and workplace.
• They have a legal requirement in Critical
  Injuries
• They have been trained in Accident Investigation

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Who Investigates Accidents?

• Government and Business

• Ministry of Labour
• Ministry of the Environment
• Workplace Safety Insurance Board

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Before an Accident Occurs

• Create an accident action plan
• Create an Accident Investigation Policy
• Develop Investigation Procedures
• Practice

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When To Investigate An Accident

• Immediately or ASAP
• ( If a Critical Injury or Immediately Reportable
  Accident, secure the scene and advise the MOL )
• Accident Investigation Procedures should be in
  writing to ensure a consistent response to all
  accidents.

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At the Accident Scene

• Control the Scene
• People are the first priority send for help
  make sure area is safe administer first aid
• Stop Ongoing Hazards
• Get personal protective equipment provide
  emergency lighting, power, air, etc.
• Collect Evidence
• Take notes, pictures, sketches of tools,
  equipment, layout, etc.

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At the Accident Scene

• Contributing Factors
• Housekeeping
• Floor/surface conditions
• Noise
• Air quality/temperature
• Equipment malfunction
• Supervision
• Employee morale/attitude/health
• Alcohol/drug abuse

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What Equipment Is Required?

• Personal Protective Equipment
• Caution Tape
• Measuring Tape
• Graph Paper
• Pencils
• Lockout / Tagout
• Clipboard

• Camera (battery and film)
• Flashlight (with batteries)
• Emergency Phone Numbers
• Accident Investigation Forms
• Optional - tape recorder, photo log, flares, etc.

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Immediate Causes

• Contact with - Electricity - Heat or Cold -
  Radiation - Noise - Caustics - Toxic Substances

• Struck By
• Struck Against
• Caught In, On, Between, or Under
• Fall On, In, or From
• Scraped / Rubbed Against
• Overexertion or Body Strain

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Basic Causes

• Lack of preventative maintenance
• Servicing, Moving or Live Equipment
• Failure To Warn or Secure
• Tampering or Removing Safety Devices

• Unsafe Working or Travelling Speed
• Unsafe Working Posture or Position
• Incorrect Equipment or Body Use
• Poor or Improper Work Practices

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Root Causes

• Personal Factors
• Poor Motivation
• Labour Relations
• Lack of Skill or Knowledge
• Physical and/or Psychological Problems

• Job Factors
• Poor Purchasing Standards
• Poor Work Standards
• Poor Maintenance or Design
• Abnormal Usage
• Excessive Wear and Tear
• Lack of Programs and Procedures

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Equipment or Conditions Involved

• Equipment
• Metal Lab cart
• Specimen Blender
• Metal work counter
• electrical appliance
• plug-ins (cart counter)
• metal sink
• leather shoes
• eyeglasses

• Conditions
• water on floor
• damaged equipment
• running water

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Accident Scene

• Click here to view accident scene
• What happened?

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Flip Chart Layout

• Who was injured?
• What happened?
• How to prevent a recurrence?

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Accident InvestigationPart II
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Effective Accident Investigations

• What to Look for
• Policies/Procedures Equipment Materials
• Environment Task People/Operators
• Accidents generally have more than one cause

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Accident Investigation Process

• Response
• Assess Scene / Identify Witnesses
• Preserve Evidence
• Notification

• Interview Witnesses
• Analysis and Conclusions
• Recommendations
• Follow up

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Accident Investigation Forms

• Internal Accident Report
• Investigators Checklist
• Witness Interview Form
• JHSC Accident Investigation Report
• Accident Findings Recommendation Form

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At the Accident Scene

• Contributing Factors
• Housekeeping
• Floor / surface conditions
• Noise
• Air quality / temperature
• Equipment malfunction
• Supervision
• Employee morale / attitude / health
• Alcohol / drug abuse

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Basic Causes

• Preventative Maintenance
• Servicing Moving or Live Equipment
• Failure To Warn or Secure
• Tampering or Removing Safety Devices
• Unsafe Working or Travelling Speed

• Unsafe Working Posture or Position
• Incorrect Equipment or Body Use
• Poor or Improper Work Practices

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Root Causes

• Personal Factors
• Poor motivation and/or labour relationship
• Lack of skill or knowledge
• Physical and/or psychological problems

• Job Factors
• Poor purchasing Standards
• Poor work standards
• Poor maintenance or design
• Abnormal usage
• Excessive wear and tear

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Who Are The Witnesses ?

• Eye Witness
• First Person (s) at the scene Witness
• Surrounding Events Witness
• Person Having Knowledge

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Interview Process

• First - Get The Big Picture
• Separate All Witnesses
• Interview Each Witness Alone and In Private
• Interview Eye Witnesses First
• Interview At Accident Scene (when advisable)

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Effective Interview Technique

• Put person at ease
• Explain purpose of accident investigation
• Listen to the individuals version
• Ask the right questions at the right time
• Repeat the information given back to the
  individual

• Always thank person for their cooperation
• Immediately document critical information
• Provide drawings and photos where useful
• Probe for Basic Causes
• Keep the door open for further information

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Interviewing Questions To Ask

• Where were you at the time of the accident ?
• What were you doing at the time ?
• What did you see, hear ?
• What were the environmental conditions ?
• What was the injured worker doing at the time ?
• In your opinion, what caused the accident ?
• How might similar accidents be prevented in the
  future ?

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Interviewing Questions to Ask

• Ask WHY 5 times
• He was lying on the floor - Why?
• Because there was water on the floor - Why?
• Because there was a leak in the sink - Why?
• Because maintenance hadnt fixed it - Why?
• Because theyre short-staffed - Why?
• Because of the hiring freeze

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Typical Investigation

• Who was injured?

John Doe
Slipped on spill on floor and struck their head.

• What happened?

• We should clean up spills right away or put sign
  up saying wet floor.

• How to prevent a recurrence?

Hot link to poster 2
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At the Accident Scene

• Contributing Factors
• Housekeeping
• Floor/surface conditions
• Noise
• Air quality/temperature
• Equipment malfunction
• Supervision
• Employee morale/attitude/health
• Alcohol/drug abuse

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Investigation Begins

• Individual shots of accident scene
• Click link(s)

• Lab cart - first view
• Lab cart - second view
• Plug
• Water
• Feet

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Effective Investigation
Examples
Immediate Causes?
Basic Causes?
Root Causes?
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Effective Investigation
Examples
Contact with live equipment Fall to the
floor Struck head
Immediate Causes?
Tampering / removal of safety device (3 prong
insulating rubber feet Water on floor
Basic Causes?

• Poor maintenance / housekeeping
• Poor labour relations
• Poor health

Root Causes?
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Accident Scene Re-visited

• Click here to view accident scene
• What really happened?

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Recommendations Follow - Up

• Have intermediate control measures been
  implemented prior to final corrective measure ?
• Have the intermediate or final corrective
  measures resulted in further hazards?
• How adequate are the control measures ?

• How effective are the control measures ?
• Has there been follow-up and an analysis of the
  corrective measures to ensure they have been
  implemented and are effective ?

• Click to advance to optional Accident Scene

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Thank You
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OPTIONAL SCENARIOOFFICE ACCIDENT
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OPTIONAL SCENARIOOFFICE ACCIDENT
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OFFICE ACCIDENT

• Contributing Factors
• Policies/Procedures Equipment Materials
• Environment Task People/Operators

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Office Accident Investigation
Immediate Causes?
Basic Causes?
Root Causes?
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Office Accident Investigation
Fall to the floor Struck back
Immediate Causes?
Using improper procedure / equipment Standing on
cabinet
Basic Causes?

• Working alone
• Training

Root Causes?
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OFFICE ACCIDENTCONCLUSION

• Accidents generally have more than one cause
• Keep asking WHY until you determine the root
  cause

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Thank You