1. Accident Investigations Part I
Put up poster number 1 which only has the chalk marks.
This is a TRUE STORY

2. Accident Investigation - Objectives
By the end of this session the participants will:
Understand the importance of the need for effective and thorough investigation of an accident
Demonstrate practical skills required to respond and investigate an incident/accident in a consistent manner
Make meaningful recommendations for preventive actions to reduce potential risks that may contribute to accidents

3. Effective Accident Investigations - Objectives (cont.)
By the end of this session the participants will:
Understand their critical role in the accident investigation and the accident reporting process
Determine the cause(s) of this accident and make recommendations to help prevent a recurrence of this type of incident

5. What is an Accident ?
“An accident is an undesired event that results in physical harm to a person or damage to property.”

6. Purpose of an Accident Investigation
The purpose of an accident investigation is to prevent the recurrence of the accident. The focus should be on the accident , not the injury .

7. Effective Accident Investigations
What to Look for:
Policies/Procedures Equipment Materials
Environment Task People/Operators
Accidents generally have more than one cause

8. Critical Injury Defined
For the purpose of the Act and Regulations, “critically injured” means an injury of serious nature that,
a) places life in jeopardy;
b) produces unconsciousness;
c) results in substantial loss of blood;
d) involves the fracture of a leg or arm but not a finger or toe;
e) involves the amputation of a leg, arm, hand or foot but not a finger or toe;
f) consists of burns to a major portion of the body; or
g) causes the loss of sight in an eye. O. Reg. 714/82 s.1

9. Who Investigates Accidents?
Supervisors
They have a personal interest to protect.
They know their people, the conditions and the job.
They know how to get the information needed.
They will take action in any case.

10. Who Investigates Accidents?
JHSC Representative
They are familiar with the people and workplace.
They have a legal requirement in Critical Injuries
They have been trained in Accident Investigation

11. Who Investigates Accidents?
Government and Business
Ministry of Labour
Ministry of the Environment
Workplace Safety & Insurance Board

12. Before an Accident Occurs…
Create an accident “action plan”
Create an Accident Investigation Policy
Develop Investigation Procedures
Practice
Prepare an investigation tool kit as part of the action plan which might include:
Camera
Tape measure
Hard hat
Disposable nitrile gloves
Safety footwear
Writing pad
Notebook, etc…

13. When To Investigate An Accident
Immediately or ASAP
( If a Critical Injury or Immediately Reportable Accident, secure the scene and advise the MOL )
Accident Investigation Procedures should be in writing to ensure a consistent response to all accidents.

14. At the Accident Scene Control the Scene
People are the first priority; send for help; make sure area is safe; administer first aid
Stop Ongoing Hazards
Get personal protective equipment; provide emergency lighting, power, air, etc.
Collect Evidence
Take notes, pictures, sketches of tools, equipment, layout, etc.

15. At the Accident Scene Contributing Factors: Housekeeping
Floor/surface conditions
Noise
Air quality/temperature
Equipment malfunction
Supervision
Employee morale/attitude/health
Alcohol/drug abuse

16. What Equipment Is Required?
Personal Protective Equipment
Caution Tape
Measuring Tape
Graph Paper
Pencils
Lockout / Tagout
Clipboard
Camera (battery and film)
Flashlight (with batteries)
Emergency Phone Numbers
Accident Investigation Forms
Optional - tape recorder, photo log, flares, etc.

17. Immediate Causes
Contact with - Electricity - Heat or Cold - Radiation - Noise - Caustics - Toxic Substances
Struck By
Struck Against
Caught In, On, Between, or Under
Fall On, In, or From
Scraped / Rubbed Against
Overexertion or Body Strain
These same causes of the accident could also, if still present, be a risk for us as well.

18. Basic Causes Lack of preventative maintenance
Servicing, Moving or Live Equipment
Failure To Warn or Secure
Tampering or Removing Safety Devices
Unsafe Working or Travelling Speed
Unsafe Working Posture or Position
Incorrect Equipment or Body Use
Poor or Improper Work Practices

19. Root Causes Personal Factors Job Factors Poor Motivation
Labour Relations
Lack of Skill or Knowledge
Physical and/or Psychological Problems
Job Factors
Poor Purchasing Standards
Poor Work Standards
Poor Maintenance or Design
Abnormal Usage
Excessive Wear and Tear
Lack of Programs and Procedures

20. Equipment or Conditions Involved
Metal Lab cart
Specimen Blender
Metal work counter
electrical appliance
plug-ins (cart & counter)
metal sink
leather shoes
eyeglasses
Conditions
water on floor
damaged equipment
running water
Participants to take a guess as to what happened. They should look at the first poster and identify the items. Reveal afterwards.

21. Accident Scene
Click here to view accident scene
What happened?

22. Flip Chart Layout Who was injured? What happened?
How to prevent a recurrence?
Some of the questions we will need to ask. Have groups try to answer these questions. Give them about 5 to 10 minutes to answer these questions.

23. Accident Investigation Part II
Put up poster number 2, the one with all the photographs.

24. Effective Accident Investigations
What to Look for:
Policies/Procedures Equipment Materials
Environment Task People/Operators
Accidents generally have more than one cause

25. Accident Investigation Process
Response
Assess Scene / Identify Witnesses
Preserve Evidence
Notification
Interview Witnesses
Analysis and Conclusions
Recommendations
Follow up

26. Accident Investigation Forms
Internal Accident Report
Investigator’s Checklist
Witness Interview Form
JHSC Accident Investigation Report
Accident Findings Recommendation Form

27. At the Accident Scene Contributing Factors: Housekeeping
Floor / surface conditions
Noise
Air quality / temperature
Equipment malfunction
Supervision
Employee morale / attitude / health
Alcohol / drug abuse

28. Basic Causes Preventative Maintenance
Servicing Moving or Live Equipment
Failure To Warn or Secure
Tampering or Removing Safety Devices
Unsafe Working or Travelling Speed
Unsafe Working Posture or Position
Incorrect Equipment or Body Use
Poor or Improper Work Practices
Mention that these hazards might still be present

29. Root Causes Personal Factors
Poor motivation and/or labour relationship
Lack of skill or knowledge
Physical and/or psychological problems
Job Factors
Poor purchasing Standards
Poor work standards
Poor maintenance or design
Abnormal usage
Excessive wear and tear
This exercise is important as the participants will likely jump to conclusions without having full knowledge as they had not interviewed the witnesses.

30. Who Are The Witnesses ? Eye Witness
First Person (s) at the scene Witness
Surrounding Events Witness
Person Having Knowledge

31. Interview Process First - Get The Big Picture Separate All Witnesses
Interview Each Witness Alone and In Private
Interview Eye Witnesses First
Interview At Accident Scene (when advisable)

32. Effective Interview Technique
Put person at ease
Explain purpose of accident investigation
Listen to the individual’s version
Ask the right questions at the right time
Repeat the information given back to the individual
Always thank person for their cooperation
Immediately document critical information
Provide drawings and photos where useful
Probe for Basic Causes
Keep the door open for further information

33. Interviewing Questions To Ask
Where were you at the time of the accident ?
What were you doing at the time ?
What did you see, hear ?
What were the environmental conditions ?
What was the injured worker doing at the time ?
In your opinion, what caused the accident ?
How might similar accidents be prevented in the future ?

34. Interviewing Questions to Ask
Ask “WHY” 5 times
“He was lying on the floor” - Why?
“Because there was water on the floor” - Why?
“Because there was a leak in the sink” - Why?
“Because maintenance hadn’t fixed it” - Why?
“Because they’re short-staffed” - Why?
“Because of the hiring freeze”

35. Typical Investigation
Who was injured?
John Doe
Slipped on spill on floor and struck their head.
What happened?
Have the 2 witnesses read their accident investigation sheets at the podium. Audience can ask questions of the witnesses. The witnesses can only answer what they know on their sheet.
Reveal bullets after the witness statements.
We should clean up spills right away or put sign up saying wet floor.
How to prevent a recurrence?
Hot link to poster 2

36. At the Accident Scene Contributing Factors: Housekeeping
Floor/surface conditions
Noise
Air quality/temperature
Equipment malfunction
Supervision
Employee morale/attitude/health
Alcohol/drug abuse
Participants to add to the list previously made.

37. Investigation Begins
Individual shots of accident scene
Click link(s)
Lab cart - first view
Lab cart - second view
Plug
Water
Feet

38. Effective Investigation
Examples…
Immediate Causes?
Basic Causes?
Immediate causes: contact with electricity, fall to floor, struck head
Basic causes: tampering / removal of safety device (3 prong & insulating rubber feet)
water on floor
Root causes: poor maintenance/ housekeeping
labour relations poor
poor health
Root Causes?

39. Effective Investigation
Examples…
Contact with live equipment
Fall to the floor
Struck head
Immediate Causes?
Tampering / removal of safety device (3 prong & insulating rubber feet
Water on floor
Basic Causes?
Immediate causes: contact with electricity, fall to floor, struck head
Basic causes: tampering / removal of safety device (3 prong & insulating rubber feet)
water on floor
Root causes: poor maintenance/ housekeeping
labour relations poor
poor health
Poor maintenance / housekeeping
Poor labour relations
Poor health
Root Causes?

40. Accident Scene Re-visited
Click here to view accident scene
What really happened?

41. Recommendations & Follow - Up
Have intermediate control measures been implemented prior to final corrective measure ?
Have the intermediate or final corrective measures resulted in further hazards?
How adequate are the control measures ?
How effective are the control measures ?
Has there been follow-up and an analysis of the corrective measures to ensure they have been implemented and are effective ?
The accident:
John Doe was pushing the metal cart. The end of the metal cart hit the plug which was missing a ground pin. The plug was also not all the way into socket at the end of the counter. At that point the metal cart became live. For whatever reason John Doe was not grounded. But as soon as he went to touch the tap he became grounded. The electricity passing through him created a complete circuit so his posture became frozen. He could not move to break the circuit. The supervisor entered the room. She slipped on the floor and kicked the cart which broke the circuit. John Doe then collapsed and struck his head on the ice machine.
bump on the head and electrocution killed him.
Coroner considered underlying medical condition, seizures, hw would he have survived with this condition.
The shoes played no role
The water and the condensation from the sink drain were contributing factors
Bottom line…
The machine on the cart used to have rubberized feet which were no longer there.
The plug on the machine no longer had a ground pin as it had been broken off.
The receptacle on the cabinet did not have the orange plug inserted all the way. The cart touched the metal contact on the plug which energized it. There was no GFIC present.
The electrocution occurred because the worker touched the energized cart and the sink which cause a path to ground through his upper body and his arms.
Click to advance to optional Accident Scene

42. Thank You

43. OPTIONAL SCENARIO: OFFICE ACCIDENT

44. OPTIONAL SCENARIO: OFFICE ACCIDENT

45. OFFICE ACCIDENT Contributing Factors:
Policies/Procedures Equipment Materials
Environment Task People/Operators

46. Office Accident Investigation
Immediate Causes?
Basic Causes?
Immediate causes: contact with electricity, fall to floor, struck head
Basic causes: tampering / removal of safety device (3 prong & insulating rubber feet)
water on floor
Root causes: poor maintenance/ housekeeping
labour relations poor
poor health
Root Causes?

47. Office Accident Investigation
Fall to the floor
Struck back
Immediate Causes?
Using improper procedure / equipment
Standing on cabinet
Basic Causes?
Immediate causes: contact with electricity, fall to floor, struck head
Basic causes: tampering / removal of safety device (3 prong & insulating rubber feet)
water on floor
Root causes: poor maintenance/ housekeeping
labour relations poor
poor health
Working alone
Training
Root Causes?

48. OFFICE ACCIDENT CONCLUSION
Accidents generally have more than one cause
Keep asking WHY until you determine the root cause

49. Thank You