1. First Alert!! A key part of an accident investigation.

2.  Response  Investigation  Incident Report  Prevention  Follow-up STEPS

3.  Response  Investigation  Incident Report  Prevention  Follow-up STEPS

4. ACCIDENT INVESTIGATION  An accident is an undesired event or sequence of events causing (or with the potential to cause) injury, ill- health, or damage.

5. CASE STUDY  A one ton concrete block is being moved by means of an overhead crane, and the sling breaks. The following could result: The block hits a pile of sand, there is no damage or injury. The block hits an item of equipment, resulting in damage, but no injury. When the block hits the ground, a piece breaks off and hits a person working in the area. This is an injury accident. It may be a DART or the injuries may only require first aid. If the person was working directly under the block when the sling failed there could be a fatality.  A one ton concrete block is being moved by means of an overhead crane, and the sling breaks. The following could result: The block hits a pile of sand, there is no damage or injury. The block hits an item of equipment, resulting in damage, but no injury. When the block hits the ground, a piece breaks off and hits a person working in the area. This is an injury accident. It may be a DART or the injuries may only require first aid. If the person was working directly under the block when the sling failed there could be a fatality.

6. RESPONSE  How you handle the situation is critical.  Contact a First Aid responder if necessary.  If necessary, contact Asset Protection for an ambulance or other emergency personnel.  How you handle the situation is critical.  Contact a First Aid responder if necessary.  If necessary, contact Asset Protection for an ambulance or other emergency personnel.

7. STEPS  Response  Investigation  Incident Report  Prevention  Follow-up  Response  Investigation  Incident Report  Prevention  Follow-up

8.  The aim of an accident investigation is: To find out what happened and determine immediate and underlying causes To reappraise existing risk assessments To introduce measures to prevent a reoccurrence and To establish training needs.  The aim is not to assign blame.  The aim of an accident investigation is: To find out what happened and determine immediate and underlying causes To reappraise existing risk assessments To introduce measures to prevent a reoccurrence and To establish training needs.  The aim is not to assign blame. ACCIDENT INVESTIGATION

9. EQUIPMENT  What you will need: Pens and a notebook Measuring tape A camera with date Copies of the accident report forms and Personal Protective equipment.  What you will need: Pens and a notebook Measuring tape A camera with date Copies of the accident report forms and Personal Protective equipment.

10. WHEN TO INVESTIGATE  Immediately after the accident. Team member and witness memories fade and stories can change. Equipment is moved. Details and clues are lost.  Immediately after the accident. Team member and witness memories fade and stories can change. Equipment is moved. Details and clues are lost.

11. THE ACCIDENT OCCURS  Leave the accident scene intact.  Look for witnesses.  Safeguard the evidence and try to establish what happened.  Contact SPM, a FM, or I/O if you need help with the investigation.  Determine the facts of the accident.  Leave the accident scene intact.  Look for witnesses.  Safeguard the evidence and try to establish what happened.  Contact SPM, a FM, or I/O if you need help with the investigation.  Determine the facts of the accident.

12. BEGINNING THE INVESTIGATION  Report to the scene.  Look at the big picture.  Record initial observations.  Take pictures.  Report to the scene.  Look at the big picture.  Record initial observations.  Take pictures.

13. STEPS  Response  Investigation  Incident Report  Prevention  Follow-up  Response  Investigation  Incident Report  Prevention  Follow-up

14. WHAT TO RECORD  Date/time of accident.  Exact place of accident. Equipment used.  The injured person.  PPE.  Date/time of accident.  Exact place of accident. Equipment used.  The injured person.  PPE.

15. WHAT’S INVOLVED  Who?  What?  When?  Where?  Why and How?  Influencing factors; fatigue, medicines, illness?  Who?  What?  When?  Where?  Why and How?  Influencing factors; fatigue, medicines, illness?

16. TIME OF ACCIDENT  Normal shift?  Date and time?  Was the Team Member farmed out to another area?  Did the TM come off a vacation or return from a weekend?  Normal shift?  Date and time?  Was the Team Member farmed out to another area?  Did the TM come off a vacation or return from a weekend?

17. ACCIDENT LOCATION  Determine specific details of the location.  What specific job task was the TM performing?  Did the job task place the TM on, under, in, or near equipment?  Was TM performing normal job duties?  Determine specific details of the location.  What specific job task was the TM performing?  Did the job task place the TM on, under, in, or near equipment?  Was TM performing normal job duties?

18. WITNESSES  Have witnesses complete a written statement.  Interview witnesses separately, take detailed notes.  Who witnessed the incident?  Was another FM or FL nearby?  Where were other team members?  Why didn’t anyone witness the incident?  Did security cameras record anything?  Have witnesses complete a written statement.  Interview witnesses separately, take detailed notes.  Who witnessed the incident?  Was another FM or FL nearby?  Where were other team members?  Why didn’t anyone witness the incident?  Did security cameras record anything?

19. INTERVIEWING  Discuss what happened leading up to and after the accident.  Encourage the TM and witnesses to describe the accident in their own words.  Don’t be defensive or judgmental.  Don’t be subjective.  Use lots of open-ended questions.  Discuss what happened leading up to and after the accident.  Encourage the TM and witnesses to describe the accident in their own words.  Don’t be defensive or judgmental.  Don’t be subjective.  Use lots of open-ended questions.

20. ACCIDENT ACTIVITIES  What motion was conducted at time of incident - i.e.: walking, running, squatting, bending, operating a machine, lifting?  Were proper tools for the job being used?  What type of material was being handled?  Details of the materials - i.e. WIC# or tote ID, weight, cases dimensions, location, type of material handling equipment used.  What were the root causes of the accident?  What motion was conducted at time of incident - i.e.: walking, running, squatting, bending, operating a machine, lifting?  Were proper tools for the job being used?  What type of material was being handled?  Details of the materials - i.e. WIC# or tote ID, weight, cases dimensions, location, type of material handling equipment used.  What were the root causes of the accident?

21. INCIDENT DESCRIPTION  Details, Details, Details!!!!  Write report so the reader can clearly picture the incident and understand even if they knows little to nothing about our environment.  Details, Details, Details!!!!  Write report so the reader can clearly picture the incident and understand even if they knows little to nothing about our environment.

22. CASE STUDY  On a chemical site there was a release of flammable material when a team of 2 fitters slackened the bolts on the wrong flange of a double-bodied valve. This caused the valve to fall apart and release the material. The supervisor's investigation showed that the people involved were unfamiliar with the type of valve. The remedial action taken was to verbally reprimand the fitters to 'take more care'.

23. CASE STUDY  Further investigation by an independent person indicated that the fitters had, in fact, been retrained as part of a multi-skilling exercise and their original expertise was in electrical engineering. The internal investigation had been content to blame the fitters and to look no further. The investigation needed to examine: The adequacy of the training given. The way jobs were allocated so that they were only given to those who were competent. The operation of the permit-to-work system which should have ensured that the pipe work was isolated and drained before work started.  Further investigation by an independent person indicated that the fitters had, in fact, been retrained as part of a multi-skilling exercise and their original expertise was in electrical engineering. The internal investigation had been content to blame the fitters and to look no further. The investigation needed to examine: The adequacy of the training given. The way jobs were allocated so that they were only given to those who were competent. The operation of the permit-to-work system which should have ensured that the pipe work was isolated and drained before work started.

24. POINTS TO REMEMBER  The difficulty in achieving objectivity and accuracy without bias.  That the investigator's behavior and questions will determine the availability and quality of evidence and influence the outcome of the investigation.  The need for varying levels of detail and accuracy depending on circumstances.  Personal limitations on expertise and the need for appropriate technical assistance in certain circumstances.  The need to record information and evidence in an appropriate manner.  The difficulty in achieving objectivity and accuracy without bias.  That the investigator's behavior and questions will determine the availability and quality of evidence and influence the outcome of the investigation.  The need for varying levels of detail and accuracy depending on circumstances.  Personal limitations on expertise and the need for appropriate technical assistance in certain circumstances.  The need to record information and evidence in an appropriate manner.

25. POINTS TO REMEMBER  Documents vary in their relevance, usefulness and reliability.  That different people will give different versions of the same events.  The need to distinguish fact from opinion and point of view.  That personal accounts may differ from what is known to have happened.  That attitude and circumstances may influence individual interpretation of events.  Documents vary in their relevance, usefulness and reliability.  That different people will give different versions of the same events.  The need to distinguish fact from opinion and point of view.  That personal accounts may differ from what is known to have happened.  That attitude and circumstances may influence individual interpretation of events.

26. THE REPORT  Consider who will have to read it.  Start with a brief summary.  State facts – not opinions.  State your conclusions.  Make any necessary recommendations.  Consider who will have to read it.  Start with a brief summary.  State facts – not opinions.  State your conclusions.  Make any necessary recommendations.

27. CASE STUDY  Video  Be prepared to write a First Alert based on what you see.  Video  Be prepared to write a First Alert based on what you see.

28. FIRST ALERT  Name of TM?  Approximate time and exact location in the building where the person was injured or had an incident?  What were they doing at the time of the injury or incident? (If equipment is involved include type and number of equipment.)  If they lifted something, what was it (Description & WIC), where was it located, what is the approximate weight?  Body part harmed (if applicable)?  Possible cause of the injury or incident?  What did you do to correct the situation?  Did they seek treatment - what kind (first aid responder, St. Luke's North, St. Luke's Hospital, etc...)?  Name of TM?  Approximate time and exact location in the building where the person was injured or had an incident?  What were they doing at the time of the injury or incident? (If equipment is involved include type and number of equipment.)  If they lifted something, what was it (Description & WIC), where was it located, what is the approximate weight?  Body part harmed (if applicable)?  Possible cause of the injury or incident?  What did you do to correct the situation?  Did they seek treatment - what kind (first aid responder, St. Luke's North, St. Luke's Hospital, etc...)?

29. FIRST ALERT  If equipment was involved always answer the following questions.  Was there an impact alarm, Yes or No?  Describe in detail any damage.  Was damage over or under $100?  If damage is under $100 which of the steps below have been or will be completed?  A. Receive a "1 Minute Coach" by a Certified Trainer or FM.  B. View equipment video/Pass quiz with a score of 70% or better.  C. Complete a floor observation by a Certified Trainer.  (In many cases all that is needed is step A, but if you do step B, you need to do step A, and if you do step C, you need to do A & B)  If over $100, were they removed from equipment and sent for a Drug Screen?  If equipment was involved always answer the following questions.  Was there an impact alarm, Yes or No?  Describe in detail any damage.  Was damage over or under $100?  If damage is under $100 which of the steps below have been or will be completed?  A. Receive a "1 Minute Coach" by a Certified Trainer or FM.  B. View equipment video/Pass quiz with a score of 70% or better.  C. Complete a floor observation by a Certified Trainer.  (In many cases all that is needed is step A, but if you do step B, you need to do step A, and if you do step C, you need to do A & B)  If over $100, were they removed from equipment and sent for a Drug Screen?

30. STEPS  Response  Investigation  Incident Report  Prevention  Follow-up  Response  Investigation  Incident Report  Prevention  Follow-up

31. PREVENTION  A thorough investigation includes a method of prevention.

32. ACCIDENT CAUSES  Immediate causes. Usually due to the acts or omissions of individuals.  Underlying causes. Usually a failure of management.  Both are important and must be investigated.  Never waste an accident – the next one could be much worse.  Immediate causes. Usually due to the acts or omissions of individuals.  Underlying causes. Usually a failure of management.  Both are important and must be investigated.  Never waste an accident – the next one could be much worse.

33. CAUSAL FACTORS  Identifying Causal Factors and Corrective Actions.

34. CASE STUDY  The sinking of the Herald of Free Enterprise.

35. STEPS  Response  Investigation  Incident Report  Prevention  Follow-up  Response  Investigation  Incident Report  Prevention  Follow-up

36. ACCIDENT FOLLOW-UP  How you follow-up is just as important as getting the proper information.  Keep others informed (witnesses, department, etc) with your results.  Complete a work order if necessary.  The goal is to prevent recurrences.  How you follow-up is just as important as getting the proper information.  Keep others informed (witnesses, department, etc) with your results.  Complete a work order if necessary.  The goal is to prevent recurrences.

37. STEPS  Response  Investigation  Incident Report  Prevention  Follow-up  Response  Investigation  Incident Report  Prevention  Follow-up

38. SUMMARY  Investigate all accidents immediately.  Determine who was involved and any witnesses.  Ascertain what items or equipment was involved.  Record a detailed and objective description.  Determine causal factors.  Conduct corrective actions.  Investigate all accidents immediately.  Determine who was involved and any witnesses.  Ascertain what items or equipment was involved.  Record a detailed and objective description.  Determine causal factors.  Conduct corrective actions.

39. THANK YOU!