1. ACCIDENT INVESTIGATION 101

2. 2 Course Objectives Understand the need to investigate Understand the need to investigate Know what to investigate Know what to investigate Determine the cause(s) of accidents Determine the cause(s) of accidents Identify the methods of investigations Identify the methods of investigations Understand the need to be thorough and comprehensive Understand the need to be thorough and comprehensive Identify prevention methods Identify prevention methods Identify sources of assistance Identify sources of assistance

3. 3 What is your definition of an “Accident”?

4. 4 What is an Accident - an unplanned event - an unplanned incident involving injury or fatality - a series of events culminating in an unplanned and unforeseen event

5. 5 How do Accidents occur? - Accidents (with or without injuries) occur when a series of unrelated events coincide at a certain time and space. -This can be from a few events to a series of a dozen or more -This can be from a few events to a series of a dozen or more (Because the coincidence of the series of events is a matter of luck, actual accidents only happen infrequently)

6. 6 Unsafe Acts - An unsafe act occurs in approx 85%- 95% of all analyzed accidents with injuries - An unsafe act is usually the last of a series of events before the accident occurs (it could occur at any step of the event) - By stopping or eliminating the unsafe act, we can stop the accident from occurring

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11. 11 Why Investigate Accidents? Prevent a recurrence with corrective action Prevent a recurrence with corrective action Determine the cause Determine the cause Document your Line Office’s version of the incident Document your Line Office’s version of the incident Complete OSHA-required reporting Complete OSHA-required reporting

12. 12 What is an Accident Investigation? A systematic approach to the identification of causal factors and implementation of corrective actions without placing blame on or finding personal fault. The information collected during an investigation is essential to determine trends and taking appropriate steps to prevent future accidents. A systematic approach to the identification of causal factors and implementation of corrective actions without placing blame on or finding personal fault. The information collected during an investigation is essential to determine trends and taking appropriate steps to prevent future accidents.

13. 13 Which Accidents should be Recorded or Reported? ALL accidents (including illnesses) shall be recorded and reported through the established procedures and guidance as provided by NOAA Safety Division

14. 14 Why Investigate Accidents? Determine the cause Determine the cause Develop and implement corrective actions Develop and implement corrective actions Document the events Document the events Meet legal requirements Meet legal requirements Primary Focus: PREVENT REOCCURENCE!!!

15. 15 Who Investigates? Minor accident/incident Minor accident/incident — Supervisor — Safety committee member Major accident/incident Major accident/incident — Supervisor — Safety committee member — Occupational Health & Safety Manager’s (OHS’s/IIC) — Regional Environmental Compliance Officer’s (RECO’s)

16. 16 Investigator’s Qualifications Accident investigation training Accident investigation training Understanding the importance of investigation Understanding the importance of investigation Ability to communicate details Ability to communicate details

17. 17 When to Investigate? Immediately after incident Immediately after incident — Witness memories fade — Equipment and clues are moved Finish investigation quickly Finish investigation quickly

18. 18 Accident vs. Near-Miss Accident : Any undesired, unplanned event arising out of a given work-related task which results in physical injury/ illness or damage to property. Near-Miss : Events which did not result in injury/illness or damage but had the potential to do so.

19. 19 Accident Ratio Study 30 30 1 10 600 6000 Serious or Disabling Minor Injuries Property Damage Accidents with no visible injury or damage Unsafe Acts or Conditions

20. 20 Accident Causes Unsafe Act Unsafe Act - an act by the injured person or another person (or both) which caused the accident, and/or Unsafe Condition Unsafe Condition - some environmental or hazardous situation which caused the accident independent of the employee - some environmental or hazardous situation which caused the accident independent of the employee

21. 21 Accident Causation Model Results of the accident Results of the accident - physical harm - property damage Incident Occurrence Incident Occurrence - contact with - type Immediate causes Immediate causes - practices - conditions Basic causes Basic causes - personal factors - job factors - supervisory performance - management policy and decisions

22. 22 Results of the Accident Physical Harm Physical Harm - catastrophic (multiple deaths) - single death - disabling - serious - minor Property Damage Property Damage - catastrophic - major - serious - minor

23. 23 Incident Occurrence Type Type - struck by- struck against - slip, trip - fell from - caught on- fell on same level - caught in- overexertion Contact with Contact with - electricity- equipment - noise- vibration - hazmat- heat/cold - radiation- animals/insects

24. 24 Immediate Causes Practices Practices - operating without authority - use equipment improperly - not using PPE when required - correct lifting procedures not established - drinking or drug use - horseplay - equipment not properly secured

25. 25 Immediate Causes (cont’d) Conditions Conditions - ineffective guards - unserviceable tools and equipment - inadequate warning systems - bad housekeeping practices - poor work space illumination - unhealthy work environment

26. 26 Basic Causes Personal Factors Personal Factors - lack of knowledge or skill - improper motivation - physical or mental condition - literacy or ability Job Factors Job Factors - Physical environment - sub-standard equipment - abnormal usage - wear and tear - inadequate standards - design and maintenance

27. 27 Basic Causes (cont’d) Supervisory Performance Supervisory Performance - inadequate instructions - failure of SOPs - rules not enforced - hazards not corrected - devices not provided Management Policy and Decisions Management Policy and Decisions - set measurable standards - measure work in progress - evaluate work vs. standards - correct performance

28. 28 Investigator’s Qualifications Technical knowledge Technical knowledge Objectivity Objectivity Analytical approach Analytical approach Familiarity with the job, process or operation Familiarity with the job, process or operation Tact in communicating Tact in communicating Intellectual honesty Intellectual honesty Inquisitiveness and curiosity Inquisitiveness and curiosity

29. 29 Beginning the Investigation Gather investigation team and kit Gather investigation team and kit Report to the scene Report to the scene Look at the big picture Look at the big picture Record initial observations Record initial observations Take pictures Take pictures

30. 30 What’s Involved? Who was injured? Who was injured? Medication, drugs, or alcohol? Medication, drugs, or alcohol? Was employee ill? Was employee ill? Double shift or rotating shifts? Double shift or rotating shifts?

31. 31 Witnesses Who witnessed the incident? Who witnessed the incident? Was a supervisor or lead person nearby? Was a supervisor or lead person nearby? Where were other employees? Where were other employees? Why didn’t anyone witness the incident? Why didn’t anyone witness the incident?

32. 32 Interviewing Tips Discuss what happened leading up to and after the accident Discuss what happened leading up to and after the accident Encourage witnesses to describe the accident in their own words Encourage witnesses to describe the accident in their own words Don’t be defensive or judgmental Don’t be defensive or judgmental Use open-ended questions Use open-ended questions

33. 33 What Was Involved? Machine, tool, or equipment Machine, tool, or equipment Chemicals Chemicals Environmental conditions Environmental conditions Production schedule Production schedule

34. 34 Severity of Incident (NOAA Safety Policy NAO-209-1) Major Major - Employee fatality, - Employee fatality, - Hospitalization of 3 or more employees, - Hospitalization of 3 or more employees, - Permanent employee disability, - Permanent employee disability, - Five or more lost workdays, - Five or more lost workdays, - Conditions that could pose an imminent and - Conditions that could pose an imminent and threat of serious injury/illness to other employees threat of serious injury/illness to other employees - Property losses in excess of $1 Million - Property losses in excess of $1 Million Minor Minor - All other (less serious) incidents and unsafe - All other (less serious) incidents and unsafe conditions reported by employees conditions reported by employees

35. 35 Who Investigates? Major Accidents Major Accidents - NOAA GO TEAM Investigation Team - NOAA GO TEAM Investigation Team - LO Representative - LO Representative - Other agencies such as NTSB, USCG, OSHA - Other agencies such as NTSB, USCG, OSHA Minor Accidents Minor Accidents - First-Line Supervisor - First-Line Supervisor - Site Director or Manager - Site Director or Manager - Site Safety Representative - Site Safety Representative - SECO (if needed) - SECO (if needed)

36. 36 When to Investigate? Immediately after incident Immediately after incident Witness memories fade Witness memories fade Equipment and clues are moved Equipment and clues are moved Finish investigation quickly Finish investigation quickly

37. 37 What to Investigate? All accidents and near-misses All accidents and near-misses - Conduct investigation upon first notification notification - Keeping the scene in-tact and recording witnesses statements recording witnesses statements early is key to a successful early is key to a successful investigation investigation

38. 38 Accident Investigation Kit May Include: Digital Camera Digital Camera Report forms, clipboard, pens Report forms, clipboard, pens Barricade tape Barricade tape Flashlight Flashlight Tape measure Tape measure Tape recorder Tape recorder Personal Protective Equipment (as appropriate) Personal Protective Equipment (as appropriate)

39. 39 The Accident Occurs Employee or co-worker immediately reports the accident to a supervisor Employee or co-worker immediately reports the accident to a supervisor Supervisor secures/assesses the scene to prevent additional injuries to other employees, before assisting the injured employee Supervisor secures/assesses the scene to prevent additional injuries to other employees, before assisting the injured employee Supervisor treats the injury or seeks medical treatment for the injured Supervisor treats the injury or seeks medical treatment for the injured The accident scene is left intact The accident scene is left intact Site safety rep is contacted to assist the supervisor in the investigation of the accident. Site safety rep is contacted to assist the supervisor in the investigation of the accident.

40. 40 Beginning the Investigation Gather investigation members and kit Gather investigation members and kit Report to the scene Report to the scene Look at the big picture Look at the big picture Record initial observations Record initial observations Take pictures Take pictures

41. 41 What’s Involved? Who was injured? Who was injured? Medication, drugs, or alcohol? Medication, drugs, or alcohol? Was employee ill or Was employee ill or fatigued? fatigued? Environmental conditions? Environmental conditions?

42. 42 Witnesses Who witnessed the Who witnessed the accident? accident? Was a supervisor or Was a supervisor or Team Lead nearby? Team Lead nearby? Where were other Where were other employees? employees? Why didn’t anyone Why didn’t anyone witness the accident witness the accident (working alone, remote areas)? (working alone, remote areas)?

43. 43 Interviewing Tips Discuss what happened leading up to and after the accident Discuss what happened leading up to and after the accident Encourage witnesses to describe the accident in their own words Encourage witnesses to describe the accident in their own words Don’t be defensive or judgmental Don’t be defensive or judgmental Use open-ended questions Use open-ended questions Do not interrupt the witness Do not interrupt the witness

44. 44 What was Involved? Machine, tool, or equipment Machine, tool, or equipment Chemicals Chemicals Environmental conditions Environmental conditions Field season prep operations Field season prep operations

45. 45 Date and time? Date and time? Normal shift or Normal shift or working hours? working hours? Employee coming off a vacation? Employee coming off a vacation? Time of Accident

46. 46 Accident Location Work area Work area On, under, in, near On, under, in, near Off-site address Off-site address Doing normal job duties Doing normal job duties Performing non- routine or routine tasks (i.e., properly trained) Performing non- routine or routine tasks (i.e., properly trained)

47. 47 Employee’s Activity Motion conducted at time of accident Motion conducted at time of accident Repetitive motion? Repetitive motion? Type of material being handled Type of material being handled

48. 48 Accident Narrative Describe the details so the reader can clearly picture the accident Describe the details so the reader can clearly picture the accident Specific body parts affected Specific body parts affected Specific motions Specific motions of injured employee of injured employee just before, just before, during, and during, and after accident after accident

49. 49 Causal Factors Try not to accept single cause theory Try not to accept single cause theory Identify underlying causes (root) Identify underlying causes (root) Primary cause Primary cause Secondary causes Secondary causes Contributing causes Contributing causes Effects Effects

50. 50 Corrective Actions Taken Include immediate interim controls implemented at the time of accident Include immediate interim controls implemented at the time of accident Recommended corrective actions Recommended corrective actions Employee training Employee training Preventive maintenance activities Preventive maintenance activities Better operating procedures Better operating procedures Hazard recognition (ORM) Hazard recognition (ORM) Management awareness of risks involved Management awareness of risks involved

51. 51 Immediate Notification Supervisor shall complete the NOAA Accident Reporting Form (web-based) and submit within 24 hours of incident occurrence. Supervisor shall complete the NOAA Accident Reporting Form (web-based) and submit within 24 hours of incident occurrence.

52. 52 Summary Investigate accidents immediately Investigate accidents immediately Determine who was involved and who witnessed it Determine who was involved and who witnessed it Ascertain what items or equipment were involved Ascertain what items or equipment were involved Record detailed description Record detailed description Determine causal factors Determine causal factors Conduct corrective actions Conduct corrective actions

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55. 55 1. What is an Accident Investigation? a. A systematic approach to the identification of causal factors and implementation of corrective actions. b. Finding personal fault and placing blame. c. The appropriate steps to prevent future actions. d. The essential step to determine trends and taking action against person or persons at fault.

56. 56 2. Which Accidents should be Recorded or Reported? a. Only on the job accidents. b. ALL accidents (including illnesses) shall be recorded and reported. c. Only on the job accidents on illnesses that occur on the job and reported within 8 hours. d. All accidents shall be recorded and reported.

57. 57 3. Why Investigate Accidents? a. To develop and implement corrective actions. b. To document the events. c. The Primary Focus is to PREVENT REOCCURENCE!!! d. To determine the cause.

58. 58 4. Accident vs. Near-Miss? a. Any a. Any unplanned events arising out of work vs. Any events which did not result in injury. b. b. Any unsafe work habit vs. Any Hazardous working conditions. c. c. Any events which warns us a problem vs. Any circumstances that result in injury or property damage.

59. 59 5. Which of the following are the basic areas that are looked at in an Accident Investigation. a. Policies. b. Equipment. c. Training. d. All of the above.

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61. 61 Quiz 1. It is best to interview witnesses all together in order to save time. True or False 2. Name two environmental factors that may be involved in an accident: ______________ and ______________. 3. Define a “minor” accident according to investigation procedures: __________________________________. 4. The main reason for investigating accidents is to fix the blame somewhere. True or False 5. Employees need to report injuries only if they think they need to see a doctor.True or False

62. 62 Quiz (cont.) 6.Prior to arriving at the accident scene, one team member should have taken the __________________. 7.Describe at least two factors to investigate about the injured employee: ______________ and _____________. 8.How could the time of the accident be considered a causal factor? 9.Describing the general accident location is adequate for the report.True or False 10.Describe at least two factors to investigate when equipment is involved: ____________ and ___________.

63. 63 Quiz Answers 1.False. Witnesses should be interviewed separately. 2.Wet floor, poor lighting, cold or hot day, noise. 3.A “minor” accident is when the injured employee does not require outside medical attention. 4.False. Accidents are investigated so corrective actions can be taken to prevent another accident. 5.False. Employees need to report all injuries, no matter how small, and near-miss incidents.

64. 64 Quiz Answers (cont.) 6.Investigation kit. 7.Alcohol or drugs, medication, illness, tired, extra shift, eyesight. 8.Early morning accident related to tired, inattentive employee. Late afternoon accident related to fatigue of a full day of work. 9.False. The report requires very specific details of the location of an accident. 10.Equipment malfunction, employee training and skill level, amount of supervision.

65. 65 The End