1. Accident Investigation HU151_Lect 9 Fall 2012/13

2. HU 151, Lecture9, Accident Investigation 2 OUTLINE Accident/Incident Investigation Outcome Investigation Steps Three Types of Causes Example

3. HU 151, Lecture9, Accident Investigation 3 What Is An Accident? An unplanned, unwanted, but controllable event which disrupts the work process and causes personal injury and/or in property damage.

4. HU 151, Lecture9, Accident Investigation 4 BP's Deepwater Horizon oil well explosion last year - killed 11 workers and caused the biggest offshore spill in US history. According to BP's September 2010 report, the accident started with a "well integrity failure". This was followed by a loss of control of the pressure of the fluid in the well. The "blowout preventer", a device which should automatically seal the well in the event of such a loss of control, failed to engage. Hydrocarbons shot up the well at an uncontrollable rate and ignited, causing a series of explosions on the rig.BP's September 2010 report http://www.bp.com/liveassets/bp_internet/globalbp/globalbp_uk_english/incident_response/STAGING/local_assets/downloads_pdfs/Deepwater_Horizon_Accident_Investigation_Report.pdf

5. HU 151, Lecture9, Accident Investigation 5 What Is An Incident? An unplanned and unwanted event which disrupts the work process and has the potential of resulting in injury, harm, or damage to persons or property.

6. HU 151, Lecture9, Accident Investigation 6 Incident Investigation Incidents should be investigated as well, since they are potential “accidents ”. Criteria for investigating an incident: - What is reasonably the worst outcome, equipment damage, or injury to the worker? - What might the severity of the worst outcome have been? - If it would have resulted in significant property loss or a serious injury, then the incident should be investigated with the same thoroughness as an accident investigation.

7. HU 151, Lecture9, Accident Investigation 7 Accident Investigation Will determine 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.

8. HU 151, Lecture9, Accident Investigation 8 Investigation Outcome 1. Prevent future incidents (leading to accidents). 2. Identify and eliminate hazards. 3. Expose deficiencies in process and/or equipment. 4. Reduce injury and worker compensation costs. 5. Maintain workers’ morale. 6. Meet regulations.

9. HU 151, Lecture9, Accident Investigation 9 Main Steps 1. Develop a plan 2.Assemble an investigation kit 3.Investigate all incidents and accidents immediately 4.Collect facts 5.Interview witnesses 6.Write a report

10. HU 151, Lecture9, Accident Investigation 10 Begin Investigation Immediately It’s crucial to collect evidence and interview witnesses as soon as possible because evidence will disappear and people will forget.

11. HU 151, Lecture9, Accident Investigation 11 CAUSES  Direct Cause – the actual energy (movement or source) that caused injury to employee. If this energy wasn’t present, the injury would not have occurred.  Indirect Causes – any unsafe acts or conditions that contribute to the injury occurring.  Basic Causes – policies, procedures, environment or personal factors that contribute to the injury occurring.

12. HU 151, Lecture9, Accident Investigation 12 The Three Basic Causes Poor Management Safety Policy & Decisions Personal Factors Environmental Factors Unsafe Act Unsafe Condition Unplanned release of energy and/or Hazardous material Basic Causes Indirect Causes Direct Causes ACCIDENT Personal Injury Property Damage

13. HU 151, Lecture9, Accident Investigation 13 Preparing for the Investigation Develop contingency plans prior to the accident. Designate an investigator  This person should only be responsible for investigating.  Should have a good working knowledge of operating procedures. Be equipped with the right tools to do the job thoroughly.

14. HU 151, Lecture9, Accident Investigation 14 Record the Facts Interview witnesses as soon as possible. Document the accident scene before any changes are made.  Take photos  Draw scaled sketches  Record measurements Gather support documents such as maintenance records, reports, production schedules or process diagrams.

15. HU 151, Lecture9, Accident Investigation 15 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, machinery, energy sources and other contributing factors.

16. HU 151, Lecture9, Accident Investigation 16 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.

17. HU 151, Lecture9, Accident Investigation 17 Interviewing Excellent source of first hand knowledge. May present pitfalls in the form of:  Bias  Perception  Exaggeration It is important to maintain a clear thought process and control of the interview.

18. HU 151, Lecture9, Accident Investigation 18 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.

19. HU 151, Lecture9, Accident Investigation 19 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.

20. HU 151, Lecture9, Accident Investigation 20 Interviewing Word each question carefully and be sure the witness understands. Identify the qualifications of each witness (name, address, occupation, years of experience, etc.). Supply each witness with a copy of their statements (signed statements are desirable).

21. HU 151, Lecture9, Accident Investigation 21 Problem Solving Techniques Change Analysis This technique emphasizes change to correct the problem. Examination of deviations from the norm are scrutinized. Consider all problems to result from some unanticipated change. Analyze the changes to determine its cause.

22. HU 151, Lecture9, Accident Investigation 22 Problem Solving Techniques Change 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 and what was not affected.  Identify the distinctive features of the change.  List the possible causes.  Select the most likely causes.

23. HU 151, Lecture9, Accident Investigation 23 Problem Solving Techniques Job Safety Analysis Job safety analysis (JSA) is part of many existing accident prevention programs. In general, JSA breaks a job into basic steps, and identifies the hazards associated with each step as well as prescribing controls for each hazard. A JSA is a chart listing these steps, hazards, and controls. Review the JSA during the investigation if a JSA has been conducted for the job involved in an accident. Perform a JSA if one is not available to determine the events and conditions that led to the accident.

24. HU 151, Lecture9, Accident Investigation 24 Problem Solving Techniques Job Safety Analysis

25. HU 151, Lecture9, Accident Investigation 25 Investigation Report An accident investigation is not complete until a report is prepared and submitted to the proper authorities. Suggestion of items to include in your report.

26. HU 151, Lecture9, Accident Investigation 26 Investigation Report Background Information  Where and when the accident occurred  Who and what were involved  Operating personnel and other witnesses Account of the Accident (What happened?)  Sequence of events  Extent of damage  Accident type  Agency or source (of energy or hazardous material)

27. HU 151, Lecture9, Accident Investigation 27 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)

28. HU 151, Lecture9, Accident Investigation 28 Investigation Report Recommendations (to prevent a recurrence) for immediate and long-range action to remedy:  Basic causes  Indirect causes  Direct causes (such as reduced quantities or protective equipment or structures)

29. HU 151, Lecture9, Accident Investigation 29 CASE STUDY - Bus Accident Description: “I was checking the steering fluid in bus engine. I had to climb up on the front tire and when I was getting down, I felt my left knee pop.”

30. HU 151, Lecture9, Accident Investigation 30 QUESTIONS TO UNCOVER CAUSES  Why did employee have to stand on the tire?  Are there other ways of checking fluids?  What is the process for getting down?  What type of training did you receive for checking fluids? By who?  What is the distance between tire and first step to get down?  Each additional step?  Tell me what you did from the time you arrived at work?  What was going on/happening around you at the time you were getting down?  What type of shoes were you wearing?  Have there been similar incidents? Explain.  What was the weather?

31. HU 151, Lecture9, Accident Investigation 31 Investigation Findings – Bus  Driver was not trained how to check fluids on this type of bus.  There are two step ladders available, but none close by.  No process or procedures in place for checking fluids.  Ladder use is covered in Accident Prevention Program but there was no training specific to ladder use provided to drivers.  Distance from tire to the peg step is 90 cm, step to ground is 50 cm.  Driver had washed bus prior to checking fluids and area around the bus was still wet.  Shoes being worn did not have good tread on soles to prevent slipping.  Another driver came up and started talking as driver was getting down.

32. HU 151, Lecture9, Accident Investigation 32 Accident Causes – Bus Direct causes  Improper body movement Indirect causes  Failure to use proper equipment - step ladder  Wearing inappropriate footwear  Lack of step ladders available and not close by  Employee was distracted Basic causes  Inadequate training in pre-trip procedures for all types of buses  No designated bus wash area

33. HU 151, Lecture9, Accident Investigation 33 CORRECTIVE ACTION PLAN CAUSESCORRECTIVE ACTIONSTIME SCALE Improper body movementDevelop procedures and train drivers on procedures Immediately Mr. Y. Failure to use proper equipment – step ladder Enforce safety rules/discipline policy Immediately Mr. X Wearing inappropriate footwear Develop, implement and enforce safety procedures 6 Months Ms R Lack of step ladders available and not close by Ensure adequate number of step ladders and ensure they are readily available 6 Months Mr. F Employee was distractedSafety awareness trainingImmediate, Ongoing Mr. T Inadequate training in pre-trip inspections for all types of buses Train staff on use of all equipment and procedures 1 Year Mr. J No designated bus wash areaDesignate bus wash area2 Years Mr. V

34. HU 151, Lecture9, Accident Investigation 34 ?