Responsibility/Accountability BASIC CONCEPT MEASURE PERFORMANCE ACCOUNTABILITY: Put the “I” back in
ACCIDENTS DON’T JUST HAPPEN DON’T JUST HAPPEN ARE THE LEADING CAUSE OF DEATH ARE THE LEADING CAUSE OF DEATH RESULT OF UNSAFE OR SUBSTANDARD ACTS AND CONDITIONS RESULT OF UNSAFE OR SUBSTANDARD ACTS AND CONDITIONS
INCIDENTS ACCIDENTS ARE INCIDENTS ACCIDENTS ARE INCIDENTS HAVE THE POTENTIAL TO HARM HAVE THE POTENTIAL TO HARM SHOULD ALWAYS BE INVESTIGATED SHOULD ALWAYS BE INVESTIGATED
An incident is: HUnwanted HUnplanned HUnforeseen HDisruptive HCan be major or minor
Is an incident and an injury the same thing? NO!
Obvious Injury Costs HInsurance Premiums HMedical Expenses HWorker Compensation HRest of work crew “takes up the slack” HAccident Cost Iceberg
Hidden Injury Costs HLost time at work HReduced or lost income HPain and suffering HPossibly having to learn a new job HTraining costs to the company HAdministrative costs (Investigation, ES&H, HR)
Actions vs. Attitudes Which is easier to see and report?
Actions vs. Attitudes HWhich is easier to change?
What we would like to see…. HThat you understand why people do the things they do. HThat you know there are many factors that cause an incident. HBut mostly………That you look deeply into why incidents happen!
Why do we investigate?? HProve the victim was at fault? …..no HCYA …….no HAvoid law suits against the company….no HTry to make the work place safer!!
Incident Investigation = An opportunity to change the work climate by correcting unsafe conditions, procedures, or actions.
Elements of the Investigation HDescribe who was involved HDescribe what happened HEstablish a time line HDetermine location of incident & all factors HEstablish a chain of events to understand how the incident occurred HDetermine the cause & root cause
First Goals of the Investigation Establish the following: 1. Who 2. What 3. When 4. Where 5. How 6. Why
Who Establish the person(s) who were involved in the incident, including witnesses. This includes all persons and not just an injured employee.
When Ensure times and dates are included in the statements.
Where Get specific about the location, to include what Site, what facility, road name, etc.
How Make sure your description of the incident is clear and describes the factors that caused the incident.
Why Based on who/what/when/where/& how, you should be able to piece together why the incident happened. This involves piecing information together to form a conclusion of the cause & root cause of the incident.
Drawing Conclusions From the who/what/when/where/how & why that you just gathered, you now need to determine both the cause and root cause of the incident.
“All things are hidden, obscure, and debatable if the cause of the phenomena be unknown, but everything is clear if this cause be known.” Louis Pasture
Cause of the incident The “cause” of the incident should describe what the immediate symptoms are of the incident. Example: An employee slipped on the floor because there was spilled coffee that made the floor slippery.
Root Cause The “root cause” of the incident is the basic underlying reason, not always apparent, that caused the incident. Example: The root cause of the incident was that the person who spilled the coffee did not clean it up or establish a warning method to alert others of a hazard.
Causal Factors Incident Loss Causation Precedes The loss Slip, Trip, Fall
Causal Factors Basic Causes THE DISEASE THIS IS THE “WHY” IT HAPPENED PEOPLE, EQUIPMENT, MATERIALS, ENVIRONMENT PERSONAL & JOB FACTORS
Causal Factors Lack of Control STARTS THE SEQUENCE 3 WAYS TO GAIN CONTROL: PROGRAM STANDARDS COMPLIANCE
Multiple Source Causes-Controls CHAINCHAIN 90/10 RULE90/10 RULE 3 STAGES OF CONTROL:3 STAGES OF CONTROL:PRE-CONTACTCONTACT POST CONTACT
So how do I use this information when an incident occurs? ? ? ? ?
Begin Your Investigation HGet the affected person’s statement. HGet onlookers’ statements. HNote the positions of people and things. HGather other information as needed, like manuals, records of training, safety, and maintenance. HGet pictures when needed (picture worth 1000 words)
Interview Tips HNeed information - not placing blame. HTry to form open ended, non-judgmental questions. HAsk as many questions as it takes to clarify your understanding.
Begin Your Written Report Gather all of your facts previously obtained, in particular who/what/when/where/how/why, and the cause/root cause of the incident. Additionally, gather written statements, information on similar incidents, and pictures to support your position when needed.
Example of Fact Gathering On July 29, 1999, on or about 10:45 am, Joe Employee was stacking concrete blocks and walked into a piece of steel re-enforcing bar that was protruding out of the end of the pipe storage shelving unit located inside the Project Materials compound, striking him in the face. A 1” cut was received across the middle of Mr. Employee’s forehead. He proceeded directly to the dispensary, where he received 4 sutures to close the laceration, then was released at 11:41am in a full duty status. He went to lunch, then informed his immediate supervisor of the incident upon returning to work at 12:30.
Your Conclusions: Cause: The incident was caused by Joe not paying attention to his surroundings and striking his head on the rebar. Root Cause #1: Somebody didn’t properly store the rebar and left it in a haphazard state that was obviously unsafe. Root Cause #2: The supervisor has not been taking responsibility for his work area by monitoring for unsafe conditions.
So Now What? At this point you have gathered facts, interviews, pictures, and all pertinent information. You have made conclusions and determined what the cause and root cause of the incident was. Question: What do you do with this information?
Corrective Action You take corrective action that would prevent the reoccurrence of this type of injury in the future, such as: 1. You look around for similar things in your work center that would present the same type of hazard and implement corrective action. Examples: pipe storage, lumber storage, conduit storage, etc. 2. You should counsel the work center supervisor on proper storage methods and his responsibilities.
Finish Your Written Report Now write your conclusions (cause & root cause) in your report, and finally wrap up your report by a “Corrective Actions Taken” paragraph. Attach all supporting documentation to the back of the report. You are now done with your written report.
To Recap Your Investigation HWho/what/when/where/how/why HConclusions (cause & root cause) HCorrective Actions Taken
Uses of the Report 1. Toolbox Talks/Departmental Training 2. Use your written report to complete the Supervisor’s Incident Investigation Report
Supervisor’s Incident Investigation Report Now that you have completed your written report, you are finally ready to complete the Supervisor’s Incident Investigation Report. This piece of paper is merely a standardized form to document your incident investigation. Filling out the form before doing an investigation is putting the cart before the horse and does not constitute an investigation.
Why Investigate All Incident and not just Injuries? H Because for every Serious Injury, there are: H Fatality H 10 minor injuries H 30 property damages H 600 near misses HSo where should you be looking?