1. Accident Investigations

2. The Purpose of Investigation
Determine the root cause so that steps can be taken to remove causes and prevent recurrence of similar events.
Reporting Evaluating Analyzing

3. Accident Investigation
Incident – A deviation from an acceptable standard (near miss)
Hazard – An incident without adequate controls
Accident- When a hazard results in damage
All accidents come from incidents , but not all incidents result in accidents.

4. Incident - Contact (Accident)
Contact with
electricity
plant & equipment
noise or vibration
hazardous substances
radiation
heat & cold
animals or insects
microbiological agents
struck against
struck by
fall to below
fall on same level
caught on
caught in
caught between
over exertion
chemical contact

5. 94% of All Accidents Result from Human Factors
Unsafe Acts
Any hazard created as a result of a human action or behavior
Unsafe Condition
Any condition of tools, equipment, machinery, materials, products, structures , or other elements in an employees’ work environment that may cause or contribute to an accident.

6. Examples of Unsafe Acts
Lack of adequate training
Poor Attitudes
Lack of required protective equipment
Working outside of normal operating procedures
Unclear safety rules , policies and procedures
Poor leadership and/or supervision

7. Benefits of a Good Accident Investigation
Demonstrates concern for fellow workers
Identifies other unsafe acts or conditions
Exposes inefficient procedures and practices
Reduces operating costs

8. The Victim Death Pain & suffering Permanent disability
Effects on family & dependents
Loss of earnings
Extra expenditure
Inability to resume occupation
Psychological effects
Feeling of uselessness
Fear of further injury
Social effects
Loss of sports or hobby
In Queensland on average one person in 20 will be seriously injured on the job every year
More people DIE of accidents on the job than Stroke, Heart Attack or Cancer

9. The Supervisor loss of trained worker loss of production extra work
investigations & reports
training new employee
loss of prestige by:
management
other workers
effects on promotion
worry (could I have prevented it ?)
Stress
There is a possibility of social stresses taking part also, especially in small work groups where a cross section of levels form social groups, ie
fishing trips
family gatherings
social outings (drinking, darts etc)
There may also be the potential for other workers to identify the supervisor as ineffective or incompetent
Stress takes many forms and all those factors previously mentioned will undoubtedly take an effect as psychological hazard

10. Types of Accident Causes
Immediate Cause
Root (Basic) Cause

11. Immediate Causes (Symptoms)
Standard Practices
operating with authority
use serviceable equipment
use equipment properly
use of PPE where required
correct lifting
no drinking & drugs
no horseplay
secure equipment or warnings
Standard Conditions
effective guards & devices
serviceable tools & equipment
adequate warning systems
good housekeeping
non polluted environment
noise
hazardous substances
good illumination & ventilation
good working, storage & traveling space
Not wise to talk about long lists of unsafe act or unsafe conditions
Terms of standard practices and standard conditions

12. Basic Causes (The Real Problem)
Personal Factors
lack of knowledge or skill
improper motivation
physical or mental conditions
literacy or ability
Job Factors
physical environment
sub-standard equipment
abnormal usage
wear & tear
inadequate maintenance
design & maintenance
purchasing standards
Supervisory Performance
inadequate instructions
failure of SOPs
rules not enforced
hazards not corrected
devices not provided
Management Policy & Decisions
set measurable standards
measure work in progress
evaluate work standards
correct performance
This is the area where most causes can be located and where effective Quality Assurance programs are in place, may of these causes have the potential to be eradicated
Organization policy and procedures should identify and outline specific safety requirements and ensure compliance

13. The Following Statements Are NOT Proper Accident Causes:
Didn’t pay attention
He/She was careless
Poor Housekeeping
Didn’t lift case correctly
Not aware of surroundings
These causes are too general and do not prevent recurrence

14. A Complete Investigation Includes:
All Facts
All Opinions
All Statements
Any Related Information

15. When to do an Investigation
Less physical evidence removed
More details remembered
Memories are clearer
Haven’t had time to be biased by others

16. The Supervisor’s Role
The supervisors attitude determines the success of the investigation and the employee’s return to work experience

17. Can Accidents be Prevented ?
Effective Management & Supervision
Commitment to Accident Prevention
Effective Policy & Procedures
Effective Reporting & Recording
Regular Consultation & “Toolbox” Meetings
Risk Assessments
Specific Training
Culture
Rewards for Good Performance
Setting achievable safety goals at all levels and ensure ownership of specific safety objectives
Commitment must be sought and maintained by all levels within the workplace, but the start must be made by management to ensure continued support
Management must ensure sufficient resources are funded and available and encouragement provided
Safety performance must be measured by using various tools, such as:
workplace audits & inspections
risk assessments
job safety analyses
frequency rates (number of injuries*1,000,000 divided by man hrs worked)
duration rates (working hrs lost divided by number of injuries)
Training and retraining will ensure correctness and consistency as well as a confident level of knowledge, leading to act or react in an informed manner, by recognizing hazards and controlling them before they become a problem
There are a huge variety of books, codes of practice, Australian Standards and a host of other materials that may be called upon to assist, as well as pictorial assistance in the form of posters, brochures and booklets
Safety Incentive Schemes is a large bone of contention in the industry but is worth discussing and evaluating on an individual basis

18. Warning Signs Increases in breaches of safety procedures
Increase in reportable incidents
Technical concerns
Friction or disputes
Introduction of new procedures or equipment
New employees
Long periods of work
Environmental issues

19. Investigation Questions
A Condition
Why did it exist?
Why wasn’t it corrected
What caused it to exist
Where was it?
Where was its source?
When did it occur?
When do similar conditions occur?
Who was responsible?
Who can give me answers?
How should it be correct?
How can it be avoided?
An Action
Why was it being done?
Why was it necessary?
What was its purpose?
What details need elimination?
Where should it be done?
Where else is it being done?
Who can give me answers?
Who can show me what was done?
How is the best way to do it?
How can it be improved?

20. Keys to Supervisor Safety Success
Create Teamwork
Know Thyself
Encourage New Ideas
Listen to Every Complaint
Develop Good Habits
Show Enthusiasm
“Pat on the Back”
Set a Good Example