Accident Investigation

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Accident Investigation
Massachusetts Retail Merchants Workers
Compensation Group, Inc. Safety Awareness For
Everyone from Cove Risk Services
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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

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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

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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

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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

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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

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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

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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

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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.

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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

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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)

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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

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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

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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

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Investigation Report

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

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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

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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)

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Investigation Report

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

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Accident Scenario
Karen, the cashier, strained her knee after
slipping and falling.
What questions need answering?
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Some Questions

• Where did this happen? What time of year is it
  (is this normal)? What time/shift? Was she the
  first person to go through this area and walk on
  this surface?
• What kind of floor is this? When was it last
  inspected for slip hazards? What are the normal
  inspection and maintenance procedures? Does this
  current procedure make sense?
• Was she trained to look for hazards like this?
  If yes, when? Is the training effective? Why or
  why not? Were there wet floor or other warning
  signs?
• Who is the supervisor? Are there other outside
  work factors that may have lead to this?
• Is there a carpet? Is it long enough? Is it of
  the appropriate quality? What kind of shoes does
  she wear?
• Is disciplinary action necessary? For her or
  anyone else?
• Are new procedures necessary?

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Potential Corrective Actions

• Develop a policy and procedure for inspecting
  and maintaining the floor at all employee
  entrances.
• Provide a runner carpet of the correct length
  (one that will extend far enough to capture all
  moisture). Provide more wet floor signs.
• Re-train staff on all slip hazards, including
  at entrances. Educate them on the importance of
  reporting hazards and wearing appropriate
  footwear when entering the building.
• Implement a slip-resistant footwear policy.
• Inform employees on measures taken to reduce
  future recurrence of this type of accident.
• Improve awareness for all staff via posters,
  mailers, handouts, etc. as to hazards and what
  the new procedures are.
• Praise employees for following expected
  procedure as trained.
• Counsel employees who fail to act as expected
  after receiving education (not identifying
  hazards, not wearing the correct footwear).
  Document this action.
• Inform Supervisors and Managers that incidents
  that occur as a result of low competence will
  effect their performance review.

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Any Questions

• ??

Massachusetts Retail Merchants Workers
Compensation Group, Inc. Safety Awareness For
Everyone from Cove Risk Services