Accident Investigation: Why Similar Accidents Keep Duplicating Themselves

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Accident InvestigationWhy Similar Accidents
Keep Duplicating Themselves
The Goal Prevent Recurrence of Similar Accidents
and Injuries
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Why do the same accidents happen over and over?

• Time is dedicated.
• Reports are written.
• Follow-up is completed.
• Yet in a little while a similar accident and an
  exact injury occurs again.

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Traditional Accident Investigation

• Who caused it? Place Blame.
• Emphasis on causes.
• Root cause correction.

In the early 1980s people began talking about
Root Causes and had the audacity to suggest that
management might be at fault.
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Words Of Wisdom
A Good Ol Boy from Georgia once said. If
the same accident happens again------- Shame On
Us!
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Course Objectives
LEARN HOW TO OBTAIN INFORMATION from which
RECOMMENDATIONS FOR CORRECTIVE ACTION can be made
to PREVENT SIMILAR OCCURRENCES, either in same
area or elsewhere.
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Actions Or Outcomes
To STRENGTHEN and refine accident INVESTIGATION
SKILLS and capabilities and ESTABLISH a basic
STANDARD accident investigation PROCEDURE.
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Accidents

• The consequences of an unplanned event. The
  consequences may be personal injury or illness,
  property damage, or all, or none of these.

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Example 1

• An employee was using a ladder to reach a valve
  when the ladder slipped. The employee fell,
  striking his head on the curb causing a
  concussion.

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Example 2

• An employee was operating a forklift at an
  excessive speed. While turning a corner the
  forklift overturned causing 1,000 damage to the
  truck. The employee received no injuries.

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Example 3

• While changing a belt on a vacuum pump, the pump
  inadvertently started, but there were no
  injuries.
• What is the unplanned event? The consequences?

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Define Accident Investigation
A determination of all the events that led to an
accident including understanding causal
relationships between events.
WHY DO WE INVESTIGATE ACCIDENTS?
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Relationship Between Accident Investigation
Accident Prevention?

• Planned safe design.
• Enforcement.
• Audit/Inspection.
• Positive Feedback System.
• Hazard Recognition.
• Safe Operating Methods and Practices.

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Prevention activities continued

• Education and Training.
• Accountability Systems.
• Effective Accident Investigation.

Note that all, with the exception of Accident
Investigation, are done prior to an accident, are
(pro-active) activities. Although Accident
Investigation is re-active, its value is that it
can identify deficiencies, especially those in
the management system.
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Contributory Causes
Those actions or deficiencies that directly led
to the unsafe act or unsafe condition.

• Examples
• Poor Housekeeping
• Hoses left in aisles
• Failure to lock out
• Machine guarding not in place
• Failure to follow procedure
• Horseplay
• Failure to use protective equipment

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Root Causes
Actions or deficiencies that permit the
contributory causes to exist and when corrected
result in long term solutions to similar
accidents. Root Causes are often related to how
our work activities are planned and managed.
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Examples of Root Causes

• No Enforcement
• No Accountability
• Poor Example
• Poor Observation Techniques
• Poor Communication Procedures
• Tolerance

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Unsafe Act
Any behavior which is outside standard or
acceptable practice which could increase the
possibility of an unplanned event and possible
accident.
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Unsafe Condition
Any departure from the designed or expected
conditions which could increase the probability
of an unplanned event.
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First-Aid Case

• One-time treatment, and follow-up visit for the
  purpose of observation of minor scratches, cuts,
  burns splinters or other minor injuries which do
  not ordinarily require medical care.

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Recordable Case

• Work- related fatalities
• Work-related illnesses
• Work-related injuries which require medical
  treatment (other than first aid)
• Injuries which involve days away from work
  restriction of work or motion
• Transfer to another job or loss of
  consciousness.

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Lost Work Day Case

• Any work-related recordable injury or illness
  which prevents the employee from being able to
  work the next scheduled shift or future workdays.

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Restricted Activity Case

• Any Work-related injury or illness which prevents
  the employee from completing any or all of the
  tasks required by the job, or from completing an
  entire work shift.

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More Definitions(See p.2 of HIS-13)

• Incident
• Serious Incident
• Incident Investigation Report
• Motor Vehicle Accident
• Near Miss-An incident that does not result in
  injury, but has the potential for serious bodily
  harm or results in property or product damage.

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Accident Investigation is a Logical Flow of
Events

• The accident happens.
• You become aware of it.
• Gather data to define the problem.
• Define problem.
• Determine the need to investigate and who
  investigates.
• Gather more specific data.
• Analyze what happened to determine causes.
• Conclude causes.
• Ask why questions in three distinct areas-
  what was going on?, What went wrong? And the
  consequences. (Ask at least 5 whys)

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LOGICAL STEPS, (Cont.)

• Analyze causes for corrective actions.
• Determine the most effective actions.
• Set completion dates.
• Implement corrective actions.
• Follow-up on corrective actions.

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Dont Confuse FACTS and CAUSES.
Investigative Corrective Phase

Phase
CAUSES FACTS
RECOMMENDATIONS
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Difference Between a Computer a Human.

• A Computer will not attempt to answer a question
  until it has sufficient data.
• Humans dont let a lack of information stop them
  from making conclusions.

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FLOW OF EVENTS CHART

• Notice the investigative and corrective phases.
• Dont try to make judgmental decisions or
  conclude causes before you have sufficient data.
• This is a logical flow of events.

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The Written Report

• It should describe
• What Happened?
• Why Did It Happen?
• What Will Be Done About It?
• When and by Whom?

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Management Commitment

• The fact that an accident occurred usually means
  something went wrong in the management system.
  There was an oversight, an omission, or a lack of
  control of circumstances that permitted the
  accident to occur. The AI process must determine
  not only causes but also the deficiencies in the
  management system that permitted the accident to
  occur.
• National Safety Council-1983

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Summary
Remember the definition of an Accident The
Consequences of an Unplanned Event.
Incident vs Accident- Why our definition includes
Incidents.
Near-Misses are unplanned events. They must be
investigated.
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So, Why do the same accidents and injuries happen
again and again?

• Not Investigated and Documented.
• Poor Quality.
• Not Publicized.
• Root Causes are not found and ELIMINATED!
• No one is held accountable.

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Change The System!

• If our results do not effect long term changes in
  the system, we are doomed to committing the same
  errors.
• People want to do well. If they dont its
  because management and the system do not allow
  it.