Accident Investigation

1
Accident Investigation
Safety Awareness For Everyone from Cove Risk
Services
2
What is an Accident?

• An unintended happening, mishap
• Most often an accident is any unplanned event
  that results in personal injury or in property
  damage
• The failure of people, equipment, supplies or
  surroundings to behave or react as expected

3
Accident Investigation

• Will determine the how and why of failures
• Examine possible corrective action
• Aid in the accident prevention and elimination
  of a clearly identified hazard
• Most important Investigation is not intended
  to place blame

4
Be Prepared

• Designate an investigator (or a team)
• This should be one of this persons key
  responsibilities
• Should have a good working knowledge of operating
  procedures
• Be equipped with the right tools to do the job
  thoroughly

5
Record the Facts

• Interview witnesses as soon as possible
• Record all necessary information at the accident
  scene before any changes are made
• Take photos (camera or camera phone)
• Record measurements
• Gather support documents such as maintenance
  records, employee records, production schedules,
  training documents and records, or process
  diagrams

6
Record the Facts

• Keep all notes and remarks in a bound notebook
  or three ring binder
• Record
• Pre-accident conditions
• Accident sequence
• Post-accident conditions
• Document victim location, witnesses, equipment,
  machinery, energy sources and other contributing
  factors

7
Record the Facts

• Even the most insignificant detail may be useful
• Document and then document some more
• The investigator should be concentrating solely
  on the investigation at hand

8
Interviewing

• Excellent source of first hand knowledge
• May present pitfalls in the form of
• Bias
• Perspective
• Embellishment
• It is important to maintain a clear thought
  process and control of the interview

9
Interviewing

• Get preliminary statements as soon as possible
  from all witnesses
• Locate the position of each witness on a master
  chart (including the direction of view)
• Explain the purpose of the investigation
  (accident prevention) and put each witness at
  ease.

10
Interviewing

• Let each witness speak freely and take notes
  without distracting the witness (use a tape
  recorder only with consent of the witness)
• Use sketches and diagrams to help the witness
• Emphasize areas of direct observation and label
  hearsay accordingly
• Record the exact words used by the witness to
  describe each observation

11
Interviewing

• Word each question carefully and be sure the
  witness understands
• Identify the qualifications of each witness
  (name, address, occupation, years of experience,
  etc.)
• If they wish, supply each witness with a copy of
  their statements (signed statements are desirable)

12
Problem Solving Techniques

• This technique emphasizes change to correct the
  problem
• Examine the differences between the norm and what
  actually happened
• Consider all problems to result from some
  unanticipated change
• Analyze the changes to determine its cause

13
Problem Solving TechniquesChange Analysis

• Use the following steps in this method
• Define the problem (What happened?)
• Establish the norm (What should have happened?)
• Identify, locate, and describe the change (what,
  where, when, to what extent)
• Specify what was affected
• Identify the distinctive features of the change
• List the possible causes
• Select the most likely causes

14
Problem Solving TechniquesJob Hazard Analysis

• Job Hazard Analysis (JHA) is part of many
  existing accident prevention programs
• In general, JHA breaks a job into basic steps,
  and identifies the hazards associated with each
  step as well as prescribing controls for each
  hazard
• A JHA is a chart listing these steps, hazards,
  and controls
• Review the JHA during the investigation if a JHA
  has been conducted for the job involved in an
  accident
• Perform a JHA if one is not available to
  determine the events and conditions that led to
  the accident

15
Investigation Report

• An accident investigation is not complete until a
  report is prepared and submitted to the proper
  managers

16
Investigation Report

• Background Information
• Where and when the accident occurred
• Who and what were involved
• Personnel and other witnesses
• Account of the Accident (What happened?)
• Sequence of events
• Extent of injury
• Accident type
• Source

17
Investigation Report

• Discussion
• (Analysis of the Accident HOW WHY)
• Direct causes (energy sources hazardous
  materials)
• Indirect causes (unsafe acts and conditions)
• Basic causes (management policies personal or
  environmental factors)

18
Investigation Report

• Recommendations (to prevent a recurrence) for
  immediate and long-term corrective actions
• Engineering Controls
• Administrative Controls
• PPE

19
Accident Scenario
Jane, a C.N.A., strained her back while team
transferring a fully dependent patient from a
wheelchair to bed with another C.N.A. She (and
the other C.N.A.) was in a hurry, but used good
body mechanics while lifting the 90 lb. resident.
What questions need answering?
20
Some Questions

• Where did this happen? Which patient? What
  time/shift?
• What does the Care Plan call for? Does this
  current plan make sense?
• Was she trained? If yes, when? Is the training
  effective?
• Why or why not? When did the employee last
  complete competency on this safe procedure?
  When was competency
• last observed?
• Who is the supervisor? Are there any prior
  disciplinary action in place for a similar
  infraction? If notwhy not?
• Do we have the necessary tools (lift equipment,
  beds, etc) to do
• this job safely?
• Is disciplinary action necessary?
• Are new procedures necessary?

21
Potential Corrective Actions

• Develop policy requiring use of mechanical
  floor lift for all dependent patients no matter
  what they weigh.
• Re-train staff on all transfer techniques,
  specifying when they will be required, and how
  they will be able to recognize it on the Care
  Plan.
• Develop periodic observation program as an
  internal competency measurement system.
• Inform employees on the disciplinary policy for
  safety infractions related to these expectations
  and explain the benefits of high level
  competency.
• Inform all staff via posters, mailers,
  handouts, etc. as to what these new procedures
  are.
• Counsel employees with low level competency,
  using disciplinary policy as outlined in writing.
  Document this action.
• Praise employees for following expected
  procedure as trained. Document this action.
• Inform Supervisors and Managers that incidents
  that occur as a result of low competence will
  effect their performance review.

22
Any Questions

• ??

Safety Awareness For Everyone from Cove Risk
Services