3 A Hazard and Exposure Incidents and accidents What’s the definition of an accident?Identify two key conditions that must be present for any accident to occur.A Hazard and Exposure
4 What’s the difference between accident investigation and Analysis? The basicsWhat’s the difference between accident investigation and Analysis?What's the purpose of an OSHA investigation?First - determine what happened to see if the employer violated safety rules.To gain the greatest benefit, why does the employer conduct accident analysis?First - determine what happened to see safety management system weaknesses exist.
5 The process Step 1 - Secure the accident scene What are the basic steps in doing the accident investigation and report?Step 1 - Secure the accident sceneStep 2 - Collect facts about what happenedStep 3 - Determine the sequence of eventsStep 4 - Determine the causesStep 5 - Recommend improvementsStep 6 - Write the report
6 Step 1: Secure the SceneWhen is it appropriate to begin the investigation?What are effective methods to secure an accident scene?
7 Step 2: Collect facts about what happened List methods to document the scene and collect data about what happened.What documents will you be interested in reviewing?Why?
8 Interviewing When is it best to interview? Why? Who should we interview? Why?Where should we conduct the interview?
9 Cooperate, don’t intimidate What are are effective interviewing techniques?Always say this Why?Always do this Why?Never say this… Why?Never do this Why?
10 Team Exercise: Cooperation is the Key Instructions. Your instructor has had an accident. Your team and the instructor are located at the scene of the accident (classroom) and your job now is to ask initial and follow-up questions to gather information about the accident.
11 Step 3: Develop the sequence of events Each event in the unplanned accident process describes one:Actor - The, object, person that is initiating action.Action- The thing being done, behavior“Dale slipped on a banana.”“As Dale lay on the floor, a brick fell on his head .”“Larry discovered Dale unconscious on the floor and immediately began initial first aid procedures.”
12 Team Exercise: Develop the sequence Instructions. Use the information in the interview summaries below to construct a sequence of events listing the events prior to, during and after the accident they describe.1. Determine the “injury event.”2. List the events that led up to the injury.
13 Step 4: Determine the causes W. H. Heinrich's domino Theory"The occurrence of an injury invariably results from a completed sequence of factors, the last one of these being the accident itself."Dan Petersen's Multiple Cause Theory"Behind every accident there are many contributing factors, causes, and subcauses. These factors combine in a random fashion causing accidents."What may be the cause(s) of the accident according to the multiple causation theory?What might be the solutions to prevent the accident from recurring?
15 The causes of Injury, Illness and Accidents 1. Direct Cause of Injury2. Surface Causes of the Accident3. Root Causes of the AccidentSteps in root cause analysis1. Injury cause analysis2. Surface Cause analysis3. Root Causes analysisAccident Causes
16 Team Exercise: “Getting to the roots by asking why, why, why, why” 1. Analyze the injury event to identify and describe the direct cause of injury.a. Describe the injury and it’s cause.b. Identify the accident type.
17 -1 -2 -3 -4 -5 -6 -7 -8 The guard slows work No one is disciplined Corrective MX, blade is brokenOthers use the unguarded sawReplace bladeBlade cuts BobBob decides to ignore missing guardRalph removes guardInjuryBob saws woodRalph doesn’t replace guardBob behind scheduleRalph directed to stop and fix chipperDoesn’t want to make boss madWood shipment arrives lateHigh priority emergency repair
18 Exercise: Digging up the roots 1. Enter the direct cause of injury within the circle below.2. List one hazardous condition and unsafe behavior from the sequence of events your group developed.3. Determine contributing surface causes for the hazardous condition and unsafe behavior.4. Determine implementation and design root causes for contributing surface causes.
19 Step 5: Recommend corrective actions and improvements Use control strategies to make corrective actionsEngineering Controls. Eliminate/reduce hazards through equipment redesign, replacement, substitution, etc.Management Controls. Eliminate/reduce exposure to hazards by controlling employee behaviors.Interim Measures. These include strategies that are used as a temporary fix while permanent controls are being developed.
20 Team Exercise: Recommending Corrective actions Purpose: In this exercise you’ll develop and recommend immediate actions to correct the surface causes of an accident.Instructions. Using the control strategies as a guide, determine corrective actions that will eliminate or reduce one of the hazardous conditions or unsafe behaviors identified in the previous exercise. Write your recommendation below.
21 Recommend system improvements Make improvements to policies, programs, plans, processes, and procedures within one or more of the following elements of the safety management system.Management commitmentAccountabilityEmployee involvementHazard identification and controlIncident and accident analysisEducation and trainingSystem evaluation
22 Making system improvements might include some of the following: Including "safety" in a mission statement.Improving safety policy so that it clearly establishes responsibility and accountability.Changing a training plan to include using checklists.Revising purchasing policy to include safety considerations as well as cost.Changing the safety inspection process to include all supervisors and employees.
23 Team Exercise: ”Fix the system...not the blame" Purpose: In this exercise you’ll develop and recommend one improvement to make sure the case study accident does not recur.Instructions. Develop and write a recommendation to improve one or more policies, plans, programs, processes, procedures, and practices identified as design weaknesses.
24 Step 6: Write the report SECTION I. BACKGROUND SECTION II. DESCRIPTION OFACCIDENTSECTION III. FINDINGSSECTION IV. RECOMMENDATIONSSECTION V: SUMMARYSECTION VI: FOLLOW-UP: ACTIONSSECTION VII: COMMENTS/ATTACHMENTS:
25 The report is an open document until all actions are complete! Take Corrective ActionConduct follow-up evaluationConduct annual review of reports