1. Accident Investigation and Analysis
NOTE TO PRESENTER: Before presenting this information to a group of employees or supervisors, become familiar with the accident investigation procedures of your organization. Due to specific regulatory mandates, you should become familiar with the applicable standards in your area and industry - osha.gov. Thousands of accidents occur throughout the United States every day. The failure of people, equipment, supplies, or surroundings to behave or react as expected causes most of them. Accident investigations determine how and why these failures occur. By using the information gained through an investigation, a similar, or perhaps more disastrous, accident may be prevented. It is important to conduct accident investigations with prevention in mind.

2. Disclaimer This training material presents very important information.
Your organization must do an evaluation of all exposures, applicable codes and regulations and establish proper controls, training and protective measures to effectively control exposures and assure compliance.
This program is neither a determination that the conditions and practices of your organization are safe nor a warranty that reliance upon this program will prevent accidents and losses or satisfy local, state or federal regulations.
All procedures and training, whether required by law or not, should be implemented and reviewed by safety and risk management professionals and legal counsel to assure that all local, state and federal requirements are satisfied.
Conducting accident investigations can, at times, be a very complex set of tasks, depending on the kinds of accidents being investigated. This presentation is intended to provide an overview of key concepts in accident investigation and analysis.

3. Course Outline—Accident Investigation and Analysis
Why Take Accident Investigation and Analysis Training?
Basic Accident Causes
The Investigation Process
Controls
Analysis
Corrective Actions
Summary
This presentation is a basic overview of this important topic and only presents key concepts.

4. Why Take Accident Investigation and Analysis Training?
Why investigate accidents?
Unless the causes of an accident are known, solutions cannot be put into place.
Investigations uncover the root causes of accidents.
Investigations discover solutions that will stop similar accidents from reoccurring.
Investigations help protect people, products, processes and property.
Most accident investigations will determine that multiple possible causes contributed to the accident.

5. Why Take Accident Investigation and Analysis Training?
Purpose of an analysis:
The purpose is not to place blame but to help determine the root causes of the incident, to correct source issues and prevent reoccurrence.
Approaches:
Investigation
Observation
Incident re-creation
Witness interviews
Value adds:
Identify safe and unsafe conditions.
Identify safe and unsafe behaviors.
Identify needed organizational changes.
Provide positive and negative feedback.
Reinforce best practices.
Incident investigations are not conducted to assign blame. They are opportunities for improvement and require the cooperation of everyone involved or knowledgeable about the operation.

6. Basic Accident Causes Most accidents result from multiple causes:
Unsafe acts: An example is texting while driving. Determine what activities contributed to the accident, both in management and front line staff.
Unsafe conditions: Examples include an unguarded machine or liquids on the floor. Determine what material, environmental or equipment conditions contributed to the accident.
Organizational causes: What programs or processes (or lack thereof) contributed to the accident?
NOTE TO PRESENTER: There are many models that can be used to present information about basic causes of incidents and accidents. The approach presented here allows the participant to establish a framework to understand basic concepts.
For example, consider a machine that was left unguarded. This can be due to the following scenarios:
The employee never received training in that area.
The employee received training, but the training on machine guarding was not covered well or adequately.
Supervisors gave tacit approval; they were not concerned if the machine guards were used.
Daily inspection records, follow-up, etc., were inadequate.
The organization had no formal process to inspect machine guarding or no standards in place to assure that machine guards were reviewed before equipment was placed in service.
Stopping at the general category cause level increases the likelihood of a recurrence and tends to place blame on the individual, even if indirectly.

7. Basic Accident Causes Unsafe acts:
Capture unsafe acts that may have contributed to the accident, such as:
Unauthorized equipment operation.
Horseplay, joking, teasing, etc.
Not following the procedures.
Bypassing safety devices.
Not using protective equipment.
Being under the influence of drugs or alcohol.
Taking short-cuts.
Remember, every unsafe behavior has underlying root causes.
For example, work quotas and incentives could result in someone using unauthorized/improper equipment, bypassing a safety device, not using the required PPE, taking short-cuts, etc.

8. Unsafe conditions are often a result of unsafe acts.
Basic Accident Causes
Unsafe conditions:
Capture unsafe conditions that may have contributed to the accident, such as:
Ergonomic hazards: Repeated lifting, bending, leaning or deviated postures in wrists and hands, arm and shoulder positions.
Environmental hazards: Chemical, noise, heat or other exposures.
Improper storage or housekeeping, i.e., material storage, cluttered walkways, debris or liquids on floors.
Improper or damaged personal protective equipment such as gloves, face and eye protection.
Inadequate machine guarding.
Uneven or slick walking surfaces.
The result of taking a unsafe behavior (e.g., a short-cut) may result in an unsafe condition (e.g., a tripping hazard).
For example, when employees were finished using a hose, they pushed the hose to the side of the walkway rather than placing it back on the hose rack as instructed. This resulting in a trip hazard (an unsafe condition).
Unsafe conditions are often a result of unsafe acts.

9. Basic Accident Causes Organizational causes:
Capture organizational causes that may have contributed to the accident, such as:
Inadequate employee training.
Inadequate supervision of employees.
Poor hiring procedures.
Inadequate safety programs or procedures.
Lack of preventative maintenance.
Inadequate communication in the organization.
Lack of resources or equipment.
Organizational causes, also known as “management system failures,” directly lead to the condition or behavior that was allowed to occur—these are often referred to as “root causes.”
Once a management system failure is defined (e.g., a lack of personal protective equipment, inadequate procedures, a design flaw, etc.), accurate root cause determination is possible using behavioral and conditional incident information.

10. The Investigation Process
Four-step investigation process:
To assure that nothing is missed and that the best results are obtained, you must:
Control the scene.
Gather all data.
Analyze all data.
Document the results and the recommendations for corrective action.
This slide presents a model for carrying out the steps of an effective investigation.

11. The Investigation Process
Control the scene:
First aid:
Provide medical care to the injured.
Control existing hazards:
Conduct an on-scene evaluation.
Prevent further injuries.
Contain the situation.
Get more help if needed.
Preserve all evidence.
The initial response to an incident scene can be chaotic. Planning the response is key to assuring that critical steps in the incident investigation process are not missed.
Remember, assisting the injured and assuring that no one else becomes injured are the primary goals of the initial response. Containing a chemical spill would prevent additional injuries and be a primary goal of the initial response team.

12. The Investigation Process
Gather the data:
Gathering data is the most important part of the investigation. Everything is based on what is discovered.
Photograph details of the scene.
Interview all witnesses.
Take measurements and make sketches.
Get all the facts, including the following:
The people involved
Date, time, location
Activities at time of accident
Existing safety processes
Equipment involved
List of witnesses
Witness Statements
Scene Review
Safety Process Review
Investigators often fail to get thorough and adequate information.

13. The Investigation Process
Gather the data (continued):
Interview the witnesses:
Conduct interviews in private.
Conduct interviews near the scene.
Plan your questions ahead of time.
Allow the witnesses to tell their entire story in a comfortable manner, and ask follow up questions.
Ask who, what, when, why, where and how questions.
Gather objective facts while making no judgments.
Keep an open mind.
Do not offer your own opinion.

14. The Investigation Process
Gather the data (continued):
Types of questions:
What is the established procedure for the activities occurring at the time of the accident?
What, if anything, was different at the time of the accident?
What was being done immediately prior to the accident?
What type of training did the people involved in the accident have?
What might have caused the accident?
What might have prevented the accident?

15. The Investigation Process
Analyze the data:
Gather photographs, sketches, interview materials and other information from the scene.
Identify the primary and contributory causes of the accident, such as:
The employee bypassed a guard and placed a hand in the machine.
A lack of safety training.
Improper preventative maintenance.
Poor hiring practices.
Reaching below the waist to lift 80 pounds.
Improper personal protective equipment (PPE).
Insufficient job requirements.
Inadequate warning labels.
Interpret results to get a clear picture of what happened.
Depending on the type of incident, many tools can be employed to assist with incident analyses, including, but not limited to, fault-free analysis, failure mode and effects analyses and causal factor charting. Becoming skilled in these methodologies will require extensive training.
In all cases, the more information investigators gather, the better equipped they are at determining root causes.

16. Controls What controls failed?
Identify the specific controls that failed and how those failures contributed to the accident.
Consider the following:
Engineering controls
Administrative controls
Training controls
What steps specified in the Job Hazard Analysis (JHA) were not followed? 16

17. Controls Engineering controls:
These controls were developed to eliminate the hazard. Examples include machine guarding, safety controls and lock out/tag out, etc.
When engineering controls are feasible, they can often be the most effective control approach.
Engineering controls remove a hazard or place a barrier between the worker and the hazard. They include controls such as machine guards that prevent employee contact with moving machine parts or a local ventilation system that removes hazardous vapors from the employees’ work areas.

18. Controls Administrative controls:
Monitoring for safe practices and environments
Periodic inspections and recordkeeping
Labels and signs
Procedures
Training controls:
New hire safety orientation
Job specific safety training
Periodic refresher training and review
Administrative controls are used where hazards are not particularly well controlled. These can be less effective and require effort by the affected workers and their supervisors and managers.
Examples of administrative controls:
PPE
Rotating workers through hazardous or noisy environments
These practices may reduce the exposures of employees to an effective level in these hazardous environments. However, they:
Should only be considered when engineering controls are not feasible or fail to adequately reduce or eliminate the risk.
Require diligent oversight and employee compliance to be effective long-term.

19. Analysis
Objective:
Seek to identify the root causes of the accident and which actions are necessary to eliminate the causes.
Seek to identify contributory factors.
If only the obvious causes are identified and eliminated, there is a high probability that the problem will return.
Again, most accident investigations will determine multiple possible causes that have contributed to the accident. 19

20. Analysis Common misconceptions:
Every accident has only one true cause and one right solution.
Only breaking rules causes accidents.
Someone needs to be blamed.
Given the same set of facts, everyone will come to the same conclusion.
Most incidents have multiple causes.
Purposely circumventing rules (or the “bad apple” employee cause) occurs very infrequently and should be avoided as an easy root cause.
Blaming someone misses the opportunity to make systematic changes that are capable of making a real difference. Employee behaviors and workplace conditions are most likely the result of management system control failures in which everyone shares.
The incident team make-up is critical to the proper evaluation of facts. A process engineer will view data differently than a process operator. Both are necessary. 20

21. Analysis Analysis guidelines:
Determine internal procedures for investigating serious accidents and near misses.
Obtain design information, diagrams, safety data sheets, operation and maintenance procedures and other necessary information.
Include individuals from different departments, such as safety, engineering, operations, maintenance, industrial hygiene, etc.
Resolve concerns among staff and allow people to freely voice their observations and opinions.
All incidents and near misses should be evaluated and documented.
Using a risk or potential outcome matrix to define the investigation team make-up and effort may prove helpful where resources are limited. 21

22. Analysis Analysis guidelines (continued):
Discuss all aspects of the accident, including the processes, product, etc.
Be open-minded to creative ideas.
Try to put yourself in the other person’s shoes. Why did the injured person respond that way?
Avoid blaming someone.
Implement corrective actions immediately.
Follow-up to determine the effectiveness of the new controls.
It is important to remember that investigations should not be done in a vacuum. Seek out the ideas of employees and managers for potential solutions to eliminating the hazards associated with accident causes.

23. Analysis Analysis benefits an organization by:
Preventing accidents, injuries, and incidents.
Reducing direct and indirect accident costs.
Improving efficiency, productivity and profitability.
Enhancing product quality and public image.
Providing continuous improvement.
Improving workplace morale.
Knowledge directly and indirectly imparted to incident investigation team members impacts company operations and can drive improvement initiatives. 23

24. Corrective Actions Following through:
Identify what corrections are needed.
Specify who is responsible to carry out each correction.
Agree to a reasonable date for completion.
Enact the corrective procedures.
Update the Job Hazard Analysis.
Be sure that additional training occurs for all affected employees.
Follow-up to evaluate the effectiveness of the changes.
The key to accident investigation is sharing what has been learned through organization communication channels and assuring that there is a process for implementing corrective action. Assure that as corrective actions are being implemented they are tracked and they do not remain “open,” instead eventually being “closed.” All corrections need to be tracked until closure is reached. 24

25. Summary
Careful and comprehensive investigations are essential to determine the causes of the accident and to implement corrective actions that prevent the accident from reoccurring.
Most accidents result from multiple causes.
The investigation process is comprised of the following steps: control the scene, gather data, analyze data and document the results and recommendations for corrective action.
Identify specific controls that failed and how those failures may have contributed to the accident: engineering controls, administrative controls and training controls.
Analyze the root causes and immediately implement control changes based on that evaluation. Determine if there is a need to create new program, policy, training, job safety procedures, etc.

26. Accident Investigation and Analysis
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