Presentation on theme: "Accident Investigation You Did What…Again? Presented by: John Dietrich, Atkinson, Andelson, Loya, Rudd & Romo LaFaye Platter, Hemet USD Lucy Rebuck, Hemet."— Presentation transcript:
Accident Investigation You Did What…Again? Presented by: John Dietrich, Atkinson, Andelson, Loya, Rudd & Romo LaFaye Platter, Hemet USD Lucy Rebuck, Hemet USD Suzanne Trowbridge, Keenan & Associates
Why Investigate? Prevent future incidents (leading to accidents). Identify and eliminate hazards. Expose deficiencies in process and/or equipment. Reduce injury and worker compensation costs. Maintain employee morale. Meet DOSH rule requirement that you investigate serious accidents.
“You can’t manage risk and change culture from behind a desk” John Dietrich
“Common sense is not so common” Lucy Rebuck
Investigate All Incidents and Accidents Conduct and document an investigation that answers: Who was present? What activities were occurring? What happened? Where and what time? Why did it happen?
How Do You Investigate??
How To Investigate – Main Steps Develop a plan Assemble an investigation kit Investigate all incidents and accidents immediately Collect facts Interview witnesses Write a report
Tips for Developing An Accident Investigation Plan Develop your action plan ahead of time. Your plan might include: Who to notify in the workplace? How to notify outside agencies? Who will conduct the internal investigation?
Tips for Developing a Plan (continued) What level of training is needed? Who receives report? Who decides what corrections will be taken and when? Who writes report and performs follow up?
What Should Be in The “Investigation Kit” Camera Tape recorder Gloves Tape measure Large envelopes High visibility tape Scissors Personal protective equipment First aid kitReport Forms
Root Cause Analysis Direct Cause – Unplanned release of energy or hazardous materials Indirect Cause – Unsafe acts and/or unsafe conditions Root Cause – Policies and decisions, personal factors, environmental factors
The Five Whys Basic Question - Keeping asking “What caused or allowed this condition/practice to occur?” The “five whys” is one of the simplest of the root cause analysis methods.
5 Whys In Action Suzy had an unwitnessed trip and fall accident: 1)Why?She wasn’t looking where she was going 2)Why? She was carrying a box 3) Why? She was wearing inappropriate shoes 4) Why? There was water on the ground 5) Why?
Begin Investigation Immediately It’s crucial to collect evidence and interview witnesses as soon as possible because evidence will disappear and people will forget.
Fact Finding Witnesses and physical evidence Employees/other witnesses Position of tools and equipment Equipment operation logs, charts, records Equipment identification numbers Take notes on environmental conditions, air quality Take samples Note housekeeping and general working environment Note floor or working surface condition Take many pictures Draw the scene
Interview Witnesses Interview promptly after the incident Choose a private place to talk Keep conversations informal Talk to witnesses as equals Ask open ended questions Listen. Don’t blame, just get facts Ask some questions you know the answers to
Write The Report Who What Where When Why – Root Cause Prevention & Action Steps Follow through
Case Study #1 Handout to be provided
Case Study #1 - Findings Morale a result of poor supervision & management
Case Study #2 Eye Injury Investigation results: wasn’t following safety protocol; training provided on correct chemical handling Action steps: – Disciplined employee for failing to follow safety protocols
Case Study #3 Bus Driver Crashes Bus While Texting Investigation: – Employee trained not to text – Employee observed texting on run in the am – Letter of reprimand at end of am shift for texting – Accident in pm while texting
Conclusion Root Cause Analysis Close Loop On Accident Investigation Findings Hold Everyone Accountable for Safety