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 controlsAccident- When a hazard results in damageAll accidents come from incidents , but not all incidents result in accidents.
4 Incident - Contact (Accident) Contact withelectricityplant & equipmentnoise or vibrationhazardous substancesradiationheat & coldanimals or insectsmicrobiological agentsstruck againststruck byfall to belowfall on same levelcaught oncaught incaught betweenover exertionchemical contact
5 94% of All Accidents Result from Human Factors Unsafe ActsAny hazard created as a result of a human action or behaviorUnsafe ConditionAny 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 trainingPoor AttitudesLack of required protective equipmentWorking outside of normal operating proceduresUnclear safety rules , policies and proceduresPoor leadership and/or supervision
7 Benefits of a Good Accident Investigation Demonstrates concern for fellow workersIdentifies other unsafe acts or conditionsExposes inefficient procedures and practicesReduces operating costs
8 The Victim Death Pain & suffering Permanent disability Effects on family & dependentsLoss of earningsExtra expenditureInability to resume occupationPsychological effectsFeeling of uselessnessFear of further injurySocial effectsLoss of sports or hobbyIn Queensland on average one person in 20 will be seriously injured on the job every yearMore 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 & reportstraining new employeeloss of prestige by:managementother workerseffects on promotionworry (could I have prevented it ?)StressThere is a possibility of social stresses taking part also, especially in small work groups where a cross section of levels form social groups, iefishing tripsfamily gatheringssocial outings (drinking, darts etc)There may also be the potential for other workers to identify the supervisor as ineffective or incompetentStress takes many forms and all those factors previously mentioned will undoubtedly take an effect as psychological hazard
10 Types of Accident Causes Immediate CauseRoot (Basic) Cause
11 Immediate Causes (Symptoms) Standard Practicesoperating with authorityuse serviceable equipmentuse equipment properlyuse of PPE where requiredcorrect liftingno drinking & drugsno horseplaysecure equipment or warningsStandard Conditionseffective guards & devicesserviceable tools & equipmentadequate warning systemsgood housekeepingnon polluted environmentnoisehazardous substancesgood illumination & ventilationgood working, storage & traveling spaceNot wise to talk about long lists of unsafe act or unsafe conditionsTerms of standard practices and standard conditions
12 Basic Causes (The Real Problem) Personal Factorslack of knowledge or skillimproper motivationphysical or mental conditionsliteracy or abilityJob Factorsphysical environmentsub-standard equipmentabnormal usagewear & tearinadequate maintenancedesign & maintenancepurchasing standardsSupervisory Performanceinadequate instructionsfailure of SOPsrules not enforcedhazards not correcteddevices not providedManagement Policy & Decisionsset measurable standardsmeasure work in progressevaluate work standardscorrect performanceThis 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 eradicatedOrganization 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 attentionHe/She was carelessPoor HousekeepingDidn’t lift case correctlyNot aware of surroundingsThese causes are too general and do not prevent recurrence
14 A Complete Investigation Includes: All FactsAll OpinionsAll StatementsAny Related Information
15 When to do an Investigation Less physical evidence removedMore details rememberedMemories are clearerHaven’t had time to be biased by others
16 The Supervisor’s RoleThe supervisors attitude determines the success of the investigation and the employee’s return to work experience
17 Can Accidents be Prevented ? Effective Management & SupervisionCommitment to Accident PreventionEffective Policy & ProceduresEffective Reporting & RecordingRegular Consultation & “Toolbox” MeetingsRisk AssessmentsSpecific TrainingCultureRewards for Good PerformanceSetting achievable safety goals at all levels and ensure ownership of specific safety objectivesCommitment must be sought and maintained by all levels within the workplace, but the start must be made by management to ensure continued supportManagement must ensure sufficient resources are funded and available and encouragement providedSafety performance must be measured by using various tools, such as:workplace audits & inspectionsrisk assessmentsjob safety analysesfrequency 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 problemThere 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 bookletsSafety 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 incidentsTechnical concernsFriction or disputesIntroduction of new procedures or equipmentNew employeesLong periods of workEnvironmental issues
19 Investigation Questions A ConditionWhy did it exist?Why wasn’t it correctedWhat caused it to existWhere 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 ActionWhy 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 TeamworkKnow ThyselfEncourage New IdeasListen to Every ComplaintDevelop Good HabitsShow Enthusiasm“Pat on the Back”Set a Good Example