2. Accident Investigation

3. WHAT IS AN ACCIDENT? What is an accident? o Any unexpected event o Some may even be good Does an accident always involve an injury? Does an injury always involve an accident?

4. What Is An Accident?

5. Accidents Accident o Any unplanned event that results in  Personal injury  Property damage

7. Accidents Usual causes o Failure of people, equipment, supplies, or surroundings to behave or react as expected

9. WHY INVESTIGATE? Why investigate? o To PREVENT injuries Investigations should not be witch hunts o If results show need for discipline, fine But..... o That is not the purpose

10. INVESTIGATIONS Include non injury accidents incidents o Proactive o Preventative Investigating only injuries o Reactive

11. INJURY PYRAMID Non-injury Accidents 1st Aid Cases Recordable Serious Recordable Fatality

12. Incident Investigation Plan Establish parameters Be aware of other requirements o ADA, EEO, Union, etc. Establish procedures Develop forms Train employees

13. First Report The “First Report of Injury” sent to Workers’ Compensation Company is NEITHER an accident report NOR an investigation.

14. Incident Report Write an incident report o As soon as possible Start with a supervisor’s report based on information provided by employees o “Employee said......”

15. Injury Potential Investigate based on POTENTIAL FOR INJURY The greater the potential, the more thorough the investigation

17. The Investigation Avoid a “cold trail”

18. The Investigation Be methodical Gather as much information as possible o Throw out irrelevant information during the analysis step

19. The Investigation Beware of preconceived conclusions Beware of “jumping the gun” o Do not offer solutions before you find the basic cause

20. The Investigation ASK QUESTIONS When you get an answer, ask “WHY” Then ask “WHY” again And AGAIN And “who?”, “what?”, and...”why?”

21. Basic Causes Management Safety Policies & Decisions Personal Factors Environmental Factors Indirect Causes Unsafe Act Unsafe Condition Direct Causes Unplanned Release of Energy and/or Hazardous Material Incident

22. The Investigation Investigate the scene o Take measurements o Take pictures o Evaluate equipment o Be imaginative

23. The Investigation Look for o Guards off o Lack of PPE o Housekeeping issues o Poor work practices o Faulty equipment o Inadequate training o Poorly written procedures o Etc.

26. The 4 “Ps” People Position Parts Paper

27. Interviews Interview employee involved Interview witnesses Interview other employees in area Look for similar incidents

28. Interviews Explain the purpose of the investigation o Accident prevention Put at ease Let speak freely Take notes without distracting Only use a tape recorder with the person’s knowledge and consent. Interview as soon as possible

29. Analysis Techniques Change analysis Job Safety Analysis (JSA) Event and Causal Factors Analysis Multi linear Events Sequencing (MES) Project Evaluation Tree (PET) Combination

30. Report of Investigation 1. Background information 2. Detailed account of the incident 3. Resolution 4. Corrective actions

31. RESOLUTION Discuss ways of preventing future incidents Solicit ideas from employees & others Be creative Make recommendations

32. Corrective Actions Corrective actions o Recommendations that are adopted Inform and train employees and supervisors

33. Follow-Up Involve supervisors & employees Are solutions: o Used? o Effective? Solicit feedback

34. Trend Analysis Evaluate for incident, accident and injury trends in order to focus efforts Use 300 forms, incident & accident reports, first aid logs, inspection reports, etc. Analyze by entity, facility, time, job, etc. Do at least a 3 year comparison

35. Resource Ask for help from your workers’ compensation carrier

37. Sandra A. Mihalik, WSO-CST Safety & Health Specialist Montana Safety & Health Bureau Phone: 406.444.6418 E-mail: smihalik@mt.gov