1. Accident /Incident Investigation Paul Thornton

2. ---==== START ====---
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3. Menu to KLP

4. Key learning points

5. KLP to first slide

6. Why investigate accidents and incidents?
Investigating accidents and incidents
Why investigate accidents and incidents?

7. Course raises awareness
The training yesterday has raised your awareness of the importance of identifying and controlling risks before harm occurs

8. Things may go wrong
However, sometimes things may go wrong. You need to know what to do on these occasions, and how to learn from them

9. DEF: Incident
An incident could be described as an undesired event that doesn’t result in harm, but has the potential to do so

10. DEF: Incident
An undesired event with this result may also be described as a near miss

11. DEF: Accident
An accident is an undesired event that does result in harm and/or property damage

12. Prevent from happening
Accidents and incidents should be investigated to identify the cause so that it can be prevented from happening again

13. Reasons to investigate
Other reasons to investigate accidents and incidents include:
collecting the required information for notifying authorities
collecting information for insurance purposes
determining the cost of an accident

14. Reasons to investigate
Key benefits of investigation:
making a safer work environment
improving worker morale
preventing further business losses from disruption, down-time and lost business
developing useful skills and knowledge that can be applied throughout the organisation

15. Incidents need investigations
Remember: incidents that don’t result in harm or loss still need to be reported and investigated.

16. - might happen again
Remember: incidents that don’t result in harm or loss still need to be reported and investigated.
An incident might result in more serious consequences if it were to happen again

17. How do accidents and incidents happen?

18. ACCIDENT intro

19. - 4:30 - head for fire exit

20. - Speedy forklift

21. - What was the cause?

22. Finding the Cause of Accidents
Accident investigation allows us to find out the cause of an accident or incident. However, accidents and incidents are rarely caused by a single factor – there are usually several contributory factors. Also, these factors will include obvious and immediate causes and less obvious underlying causes.

23. Finding the Cause of Accidents
Immediate causes Are unsafe actions or lack of action (for example, operating equipment with missing guards and bypassing interlocks, using the wrong personal protective equipment) and unsafe conditions (for example, damaged tools and equipment and high noise and low lighting levels).

24. Finding the Cause of Accidents
Underlying Causes Are factors that allow the unsafe actions and conditions to happen. The majority of these are related to the way the organisation manages health and safety and how people perceive risk

25. Finding the Cause of Accidents
Root Causes A root cause is a factor that may cause conditions that could result in an undesirable event. If the problem were corrected, it’d prevent the undesirable event from happening. In other words, a root cause is an event from which all other causes spring.

26. - struck = injury

27. Finding the Root Cause(s)
Work in your groups to identify the Immediate, Underlying and Root Causes of this incident

28. ACCIDENT intro

29. - 4:30 - head for fire exit

30. - Speedy forklift

31. - What was the cause?

32. - tipped + skidded

33. - skid = oil + brake

34. - oil = leak

35. - leak = no supervision

36. - brake = speed + step

37. - speed = rushing + work pressure

38. - governor

39. - governor = no supervision

40. - emergence = poor c&p

41. - causal tree

42. - Immediate, underlying, root

43. - management

44. Remember: immediate
Remember: if you only investigate as far as the immediate causes, there’s a much higher likelihood that it will happen again

45. ---== KLP3: Investigation? ==---
How do you carry out
an investigation?

46. Aftermath of accident

47. 1. Ensure wellbeing
1. Ensure the wellbeing of the injured person

48. 2. Preserve scene
2. Preserve the scene

49. 3. Report
3. Report the accident (or incident)

50. - to whom 3. Report the accident (or incident) senior management
enforcing authority
injured person’s family
owner of assets
insurance company
safety/employee representatives
health and safety and human resources departments

51. - report form
3. Report the accident (or incident)

52. 4. Assemble team
4. Assemble the investigation team

53. - someone familiar 4. Assemble the investigation team
someone familiar with the work location

54. - supervisor 4. Assemble the investigation team
supervisor or manager from work location

55. - senior mgmt 4. Assemble the investigation team
senior manager with authority or influence

56. - h&s expert 4. Assemble the investigation team
health and safety expert

57. - employee rep 4. Assemble the investigation team
employee representative

58. - involved in event 4. Assemble the investigation team
person involved in event (if possible)

59. - technical expert 4. Assemble the investigation team
technical expert (if necessary)

60. The size of the team is determined by the size of the organisation
- Size of team
The size of the team is determined by the size of the organisation

61. - Size of investigation
The level of investigation is determined by the likelihood of recurrence and the potential worst consequences of the undesired event

62. 5. Investigate
5. Investigate using a structured approach

63. - Gather
5. Investigate using a structured approach
Gather information

64. - Gather points 5. Investigate using a structured approach
Gather information
physical
human
documentary

65. - Analyse
5. Investigate using a structured approach
Analyse findings

66. - Risk control 5. Investigate using a structured approach
Review current risk controls

67. - Action plan 5. Investigate using a structured approach
Create an action plan

68. - Investigation report
5. Investigate using a structured approach

69. 6. Handle external
6. Handle external relations

70. - enforcement
6. Handle external relations
Enforcement authorities

71. - media
6. Handle external relations
Media

72. - locals
6. Handle external relations
Local residents and businesses

73. Getting it right Getting it right:
Investigation is about avoiding it happening again, not attributing blame
Having plans in place before an accident will help for an effective investigation
Sharing the findings is as important as ensuring the quality of the investigation

74. KLP Summary Key learning points:
Why investigate accidents and incidents?
How do accidents and incidents happen?
How do you carry out an investigation?

75. Why investigate accidents and incidents?
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Key learning points:
Why investigate accidents and incidents?
How do accidents and incidents happen?
How do you carry out an investigation?

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