Introdution to Accident Investigation Training by ToolBox Topics
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Introdution to Accident Investigation Training by ToolBox Topics
- 1. Accident Investigation Slide 1 INTRODUCTION to ACCIDENT INVESTIGATION for SUPERVISORS
- 2. Accident Investigation Slide 2 TRAINING OBJECTIVES Explain the need for Accident Investigations Explain the benefits of Accident Investigations Provide the information necessary to properly complete Accident Investigations Provide the tools necessary to properly complete Accident Investigations
- 3. Accident Investigation Slide 3 WHAT IS ACCIDENT INVESTIGATION? Process to determine the underlying causes of accidents Causal information used to identify and take preventive action Basic component of loss prevention
- 4. Accident Investigation Slide 4 BENEFITS OF ACCIDENT INVESTIGATION ? GROUP DISCUSSION
- 5. Accident Investigation Slide 5 BENEFITS OF ACCIDENT INVESTIGATION... Prevention of future, similar losses Contribution to the bottom line Reduction of human suffering Continuous improvement process
- 6. Accident Investigation Slide 6 WHY DO ACCIDENT INVESTIGATIONS FAIL ? GROUP DISCUSSION
- 7. Accident Investigation Slide 7 WHY ACCIDENT INVESTIGATIONS FAIL... Lack of time to complete Lack of motivation to complete Lack of accountability Lack of skills & knowledge Investigation stopped short and didn’t reveal all causes of the accident
- 8. Accident Investigation Slide 8 ROLES & RESPONSIBILITIES Branch Management Safety Director Supervisors Task Force / Committee
- 9. Accident Investigation Slide 9 DEFINITION OF KEY WORDS Accident / Incident Frequency / Severity Exposure / Control Illness / Injury Property Damage Near Misses Root Causes Contributory Causes
- 10. Accident Investigation Slide 10 PRE-ACCIDENT PLANNING Clearly defined roles and responsibilities Training of key staff members Communications established Standard procedures established Necessary equipment and forms on hand
- 11. Accident Investigation Slide 11 WHICH ACCIDENTS NEED TO BE INVESTIGATED ? Injury? Illness? Property damage? Near miss? RECORD YOUR ANSWERS !
- 12. Accident Investigation Slide 12 WHICH ACCIDENTS NEED TO BE INVESTIGATED ? Injury? Illness? Property damage? Near miss? ANSWER: ALL OF THE ABOVE !
- 13. Accident Investigation Slide 13 ACCIDENT INVESTIGATION: A 6-STEP PROCESS Collect Information Analyze All Causes Assess Future Accident Potential Develop Corrective Action Report Data and Recommendations Take Corrective Action and Monitor
- 14. Accident Investigation Slide 14 COLLECTING INFORMATION ON-SITE: Securing the scene Investigating at the scene Recording key information Equipment is needed... STEP 1
- 15. Accident Investigation Slide 15 ACCIDENT INVESTIGATION KIT Camera Measuring tape Barricade tape Plastic vials with caps Graph paper Accident investigation forms STEP 1
- 16. Accident Investigation Slide 16 COLLECTING INFORMATION OFF-SITE: Interview key people Assess past accident history Review pertinent records STEP 1
- 17. Accident Investigation Slide 17 INTERVIEWING TIPS Put the person at ease, explain purpose Fact-finding process, don’t assess blame Ask open-ended questions Investigating the accident vs. disciplining the employee STEP 1
- 18. Accident Investigation Slide 18 REVIEWING RECORDS Standard Work Practices Job Safety Analysis Material Safety Data Sheets Employee Personnel Records Maintenance Logs Past Accident History Inspection Records MVRs STEP 1
- 19. Accident Investigation Slide 19 DETERMINING CAUSES The root cause is the most fundamental and direct cause of an accident or incident There may be one or more contributory causes, in addition to the root cause Accident Investigation is ineffective unless all causes are determined and corrected STEP 2
- 20. Accident Investigation Slide 20 CATEGORIES OF ROOT CAUSES Can be classified as: Workplace Factors - Largely a function of Management Practices Employee Factors - Largely a function of Employee Behavior STEP 2
- 21. Accident Investigation Slide 21 CATEGORIES OF ROOT CAUSES Workplace Factors: Examples - Improper Tools & Equipment - Inadequate Maintenance - Lack of Job Procedures - Poor Workstation Set-Up - Poor Housekeeping - Lack of Job Supervision - Lack of Job Training STEP 2
- 22. Accident Investigation Slide 22 CATEGORIES OF ROOT CAUSES Employee Factors: Examples - Failure to Apply Training - Task Exceeds Physical, Mental Capabilities - Risk-Taking Behavior - Fitness for Duty (Substance Abuse, Fatigue, Effects of Medication, Emotional Distress) STEP 2
- 23. Accident Investigation Slide 23 DETERMINING ROOT CAUSES After answering Who, What, Where, When and How initially, this step answers Why and “completes the puzzle” Don’t Stop Short ! STEP 2
- 24. Accident Investigation Slide 24 ASSESS FUTURE POTENTIAL Assess Severity - Class A Hazard (Major) - Class B Hazard (Serious) - Class C Hazard (Minor) STEP 3
- 25. Accident Investigation Slide 25 CLASS “A” HAZARD (MAJOR) A condition or practice likely to cause permanent disability, loss of life, body part and/or extensive property loss or damage STEP 3
- 26. Accident Investigation Slide 26 CLASS “B” HAZARD (SERIOUS) A condition or practice likely to cause serious injury or illness (resulting in temporary disability) or property damage that is disruptive, but less severe than Class A STEP 3
- 27. Accident Investigation Slide 27 CLASS “C” HAZARD (MINOR) A condition or practice likely to cause minor (non-disabling) injury or illness or non- disruptive property damage STEP 3
- 28. Accident Investigation Slide 28 CORRECTING THE CAUSES Control(s) must directly address each cause identified Consider short term controls if permanent controls are not readily available More than one control may be needed Use the “Control Hit List” to make sure that the “best” control has been found STEP 4
- 29. Accident Investigation Slide 29 THE CONTROL HIT LIST 1. Eliminate the Hazard 2. Substitute a less hazardous material 3. Use Engineering Controls 4. Use Administrative Controls 5. Personal Protective Equipment (PPE) 6. Training of Employees STEP 4
- 30. Accident Investigation Slide 30 REPORT DATA & RECOMMENDATIONS Document facts only Determine if the corrective action applies to more than one employee, more than one job function, more than one shift, etc. Prioritize corrective actions based on future accident potential Submit both short term and long term solutions, if necessary STEP 5
- 31. Accident Investigation Slide 31 TAKE ACTION & MONITOR Ensure that long term solutions don’t get “lost in the shuffle” Evaluate the effectiveness of implemented controls: - Interview Employees - Job Safety Analysis - Accident / Incident Experience STEP 6
- 32. Accident Investigation Slide 32 WHY ACCIDENT INVESTIGATIONS FAIL... No time to complete No motivation to complete Lack of accountability Lack of skills & knowledge Investigation stopped short and didn’t reveal the root causes of the accident WHICH OF THESE WILL BE AN OBSTACLE FOR YOU?
Notas do Editor
- Welcome supervisors and pass out the note-taking guides. Set the stage for the meeting by thoroughly explaining: - Why are we here - Company or facility goals in establishing an Accident Investigation program - Expectations from the audience during and after the training - Format of the meeting (informal, discussion oriented) - Length of the meeting - Planned breaks, etc. It is important that supervisors recognize the business need for completing and using Accident Investigations (AIs) and that they are the primary resource in this process as they are the level of management that is the closest to the work being performed and determining if established job procedures were being followed prior to an accident. A brief review of facility accident results may be appropriate to emphasize the importance of this topic and the role that each supervisor plays in bringing these losses under control in the future.
- Review the training objectives one by one. Explain that the supervisors will be expected to take this information and tools and complete AIs on accidents or incidents that occur in their respective areas. State that we will come back to this slide at the end of the course and all present will be able to comment on whether each of the objectives was met. TRANSITION: Now we will begin today by defining what we mean by Accident Investigation...
- Accident Investigation is a process that allows management to identify and evaluate the true causes of an accident or incident. This information is used to formulate solutions to the underlying problems so as to avoid or minimize future accidents from the same source. If we choose not to investigate accidents, we are destined to repeat them over and over. Accident Investigation is one of the fundamental principles of Loss Control management. All supervisors need to be aware of the need for and the benefits of an effective AI program. They should also be provided with the skills to consistently and thoroughly investigate workplace accidents and incidents. And that’s why we are here today, to provide the knowledge and tools that will form the foundation of our Accident Investigation program. TRANSITION: Now that we’ve defined Accident Investigation, let’s discuss the benefits associated with an Accident Investigation program...
- Ask the class to name several benefits of accident investigation and record their answers on a flip chart. Keep the responses focused on the true benefits of AI and discourage answers that may jump to conclusions such as, “To uncover Workers’ Compensation fraud” or “To discipline employees who took short-cuts on the job”. Explain that although information may come out during the course of the investigation that requires this type of management intervention, they are separate issues that are handled in a separate process. The next slide provides several possible answers to this question.
- Review the benefits of completing AIs. If your company has a continuous improvement process, discuss how AI would enhance and parallel those efforts. Emphasize that the goal of reducing or preventing recurrence of accidents provides benefits that include both financial and humanitarian rewards. TRANSITION: Let’s discuss why Accident Investigations sometimes fail so that we can avoid these pitfalls ourselves...
- Ask the class why Accident Investigations can sometimes fail, or be less than 100% effective. Record their answers on a flip chart. The next slide provides sample answers to this question.
- Discuss each reason of why AIs fail, one by one. State that these are not the only reasons that AIs may fail or be less than effective, but they are the most common reasons. Ask the supervisors to identify any other reasons they can think of and write their responses on a flipchart. This training session is designed to assist us in avoiding many of these pitfalls ourselves so that we can maximize the benefits from AIs. However, we need to be aware of these pitfalls and continually remind each other of the benefits of completing AIs thoroughly and consistently. TRANSITION: Let’s briefly discuss the issue of accountabilities, roles, and responsibilities relating to Accident Investigation within our facility...
- Discuss the roles in your operation (such as Facility Management supports and manages the overall program, the Safety Coordinator provides training and technical assistance as well as troubleshoots the program, and the supervisors and/or committees actually investigate the accidents and incidents After an Accident Investigation is completed, the supervisor may be accountable for employee training or re-training and implementation of other specified corrective actions. (Upper management may need to approve and carry out certain corrective actions requiring capital expenditures.) None of these parties can carry out the program effectively without the support of the others. Successful implementation requires a teamwork effort including clear communications. Also hand out or discuss specific accountabilities by function within the facility, if available.
- Briefly define the key terms that are useful in understanding AI, particularly accident, Incident, Near Misses, Root Causes, and Contributory Causes. TRANSITION: Let’s discuss several planning activities that must be completed prior to actually investigating an accident for the first time...
- This slide lists additional topics that need to be addressed before a functional Accident Investigation program can be instituted. Discuss each point individually. Again state that this training program is creating part of the the foundation for an AI program. TRANSITION: Many different types of accidents and incidents may occur in our operations. Let’s decide which types will need to be investigated...
- Ask the supervisors which of these incidents needs to be investigated and why. Review the definition of each term if needed. Supervisors can record their own answers in their notes. The next slide answers this question.
- Ideally, all of these situations should be investigated. Certainly an injury, illness and property damage should all be investigated because conditions already existed once to cause a loss and if unchecked, will probably exist again in the future. The existence and identification of a near miss indicates the potential for future loss even though an actual loss has not occurred yet. Sometimes, these situations alert us to very serious loss potential and we would be foolish to ignore these types of incidents. You may wish to discuss the priority order in which these situations fall in relation to each other, i.e. which type of incident would you investigate first, then second, etc. TRANSITION: Now that we all have common background information on Accident Investigations, let’s talk about the actual investigation process itself...
- Accident Investigation can be thought of as a 6 step process, as shown. Review each of the six steps in turn. Emphasize that the failure to properly and thoroughly complete any of the six steps will hinder the overall effectiveness of the investigation. (The following set of slides cover each of the six steps in detail, so the purpose of this slide is merely to give an overview). TRANSITION: Let’s look at each of these steps more closely, beginning with the collection of information...
- Once we have an accident or incident to investigate, several activities will take place at the actual accident scene. If warranted by the circumstances, the scene may need to be barricaded and physically segregated against further injury or merely to preserve the scene for the initial investigation. (Ask the class for examples, such as a chemical spill). Information to be recorded will be largely determined by the nature of the accident. (Examples are helpful here). TRANSITION: It is advisable to have several pieces of equipment set aside for AI purposes...
- This equipment is typically kept on hand for AI purposes. Keeping the equipment in a central location in a kit arrangement may be useful as well. Not all of this equipment will be needed in every investigation, but since all equipment will probably be needed at some time, it is advisable to organize and keep within easy access. The camera is used to record and document the accident location and the physical placement and physical relationship of evidence within the scene. A measuring tape can be used to measure distances at the scene. Barricade tape will help to cordon off the area for protection against disturbing the evidence and protecting passers-by from additional injury. Plastic bags and vials are useful to collect solid or liquid evidence for later evaluation or identification, such as laboratory analysis of an unknown liquid on the floor. Graph paper will assist in drawing a scaled diagram of the scene while an appropriate number of blank accident investigation forms should always be kept on hand. TRANSITION: Once we have gathered the necessary information from the scene itself, we can turn to several activities that will probably occur away from the accident scene...
- Regarding point #1, ask the class who they would consider interviewing to collect more information about an accident (initially, the injured person and any eye-witnesses. Depending on the accident, we may want to also interview others, such as the personnel manager, maintenance foreman, other supervisors and employees, etc.). Eye-witnesses can provide critical information about an accident as far as describing the activities and events that led up to the accident itself. The interview process should include the injured employee, if possible. Do not ask the employee to re-enact the accident. Ask why (because a second accident is possible through the re-enactment process). Determining past accident history with a particular operation, machine or work activity is valuable to evaluating future accident potential. However, this is not the only piece of information to be considered. A series of near misses in a particular area will not show up as past accidents, but may represent a potential for a serious future loss if left unchecked. TRANSITION: Next, let’s discuss the technique of interviewing key personnel in order to obtain additional information about the accident...
- It is important to initially put the witness at ease by carefully explaining the purpose of the investigation itself. This process is fact-finding in nature and not a means to assess blame or discipline employees. Although there may be disciplinary action as the result of the accident, that process is distinctly different than the investigation process which seeks to obtain the root causes of an accident and propose solutions to identified problems. A good questioning technique in this process is to ask open-ended questions, that is, questions that cannot be answered with just a one word response. This technique often provides the investigator with more information than questions that are not open-ended. TRANSITION: In all likelihood, the information we have now discovered will have raised a new set of questions about how and why the accident occurred. Let’s take a look at additional sources of information available to us as we move closer to determining the root cause of the accident...
- Here is a partial list of additional sources of information. Review each point and ask for any more sources that may occur to the class. TRANSITION: At this point in the Accident Investigation process, we have gathered evidence at the scene, obtained historical information on the accident history of the job or work process, and have interviewed any injured parties as well as eye-witnesses and other key personnel. We have also obtained a variety of secondary information from the sources listed on this slide. Now it’s time to bring all of this information together and find the root causes of the accident...
- As we discussed earlier, the root cause is the most fundamental and direct cause of an accident or incident. In all likelihood, there are also secondary, or contributing causes that played some part in the accident. However, the root cause is the one event or condition that precipitated the accident. The key is that if we were to remove the root cause, the accident would not have occurred. If we removed the contributory causes, the accident still may have occurred, although the severity of the accident may have been less. In any case, the AI is in effective until we determine and correct all of the causes. TRANSITION: Let’s take a look at some common types of root causes so that we maty all understand this important point better...
- Root causes can generally be grouped as either being Workplace Factors or Employee Factors. Workplace Factors are largely under the control of management and Employee Factors are under the control of the individual employee. TRANSITION: Let’s take a look at some of the possible root causes for a Workers’ Compensation injury under the first category of Workplace Factors...
- Review each point in turn. Note that all of these points are preceded by descriptions such as “Improper, Lack of, and Poor”. TRANSITION: Let’s now turn to sample Employee Factors...
- Review each point individually. Note that the employer may make every effort to properly train the employee to safely perform the job, but if the employee decides to take inappropriate risks anyway, the root cause will be classified as an Employee Factor and not a Workplace Factor. Similarly, if a supervisor directs an employee to lift an item that is too heavy to be safely handled by one person alone, the root cause falls under the Workplace Factors category since it is under the direct control of management. If, however, the employee decides on his/her own to lift the same item, and had been instructed by management to get help in this situation, then the root cause would fall under the class of Employee Factors.
- Introduce the class to two techniques contained in their reference guide, the “Five Why's” and the “Key Question”. The “Five Why's” is a useful tool in getting down to the root causes of an accident so that our corrective action is not merely treating the symptoms of an accident. After the “Five Whys” have been asked and answered, The “Key Question” is simply a screening tool that tells us if we have indeed gotten to the root cause level. The fundamental here is not to stop short of obtaining the root cause. The “Five Whys” and the “Key Question” help us avoid this pitfall of Accident Investigations. Walk the class through the examples in the reference guide for each of these two techniques. TRANSITION: When we are satisfied that we are at the root cause level, it is time to propose corrective actions so the accident is not likely to recur...
- Step 3 in the six step Accident Investigation process is to Assess future Loss Potential. Why do you think this step is important? (It helps to assign priority to the Corrective Actions that we will recommend and it helps us “sell” the need for improvements to upper management. We can think of loss severity in three classes, Class A represents the potential for major Injuries or damage, Class B for serious injuries or damage, and Class C for minor Injuries or damage. TRANSITION: Let’s define each of these in more detail...
- A Class A Hazard represents a condition or practice that is likely to cause permanent disability, a loss of life, body part and/or extensive property damage. Ask the class for examples of hazards that fall into this class. Possible answers include an unguarded machine with the potential to amputate a finger or hand, am unprotected floor opening that could lead to a fall from an elevation greater than 10 feet, and badly worn brakes on a motor vehicle that could lead to an intersection collision.
- A Class B Hazard represents a condition or practice that could cause serious injury or illness such as a temporary disability, or property damage that is serious but less severe than those under Class A. Ask the class for examples of hazards that fall into this class. Possible answers include an unguarded floor opening that may lead to a fall from an elevation of less than 10 feet, unguarded pinch points in a machine that may lead to serious bruises or broken bones but not amputations, and work procedures that allow an employee to move 55 gallon drums with no assistance.
- A Class C Hazard is minor in nature and is likely to cause non-disabling injuries or illnesses or non-disruptive property damage. Ask the class for examples of Class C Hazards. Possible answers may be the use of a chemical that may cause dermatitis without the practice of using gloves or barrier creams, a process that creates dust but work practices do not call for the use of ventilation or the wearing of eye goggles, etc. TRANSITION: Now that we’ve completed the first three steps of Accident Investigation, it is time to move on to Step Four, determining the corrective actions needed...
- In order to make the corrective action successful, we need to have a corrective action for each and every root cause we have identified. However, more than one control may be needed for each root cause depending on the circumstances. If our corrective actions are not likely to be implemented right away (because of such things as a large expenditure of money, a re-design of a workstation or purchase of different equipment or machinery), it is advantageous to propose and implement short term solutions that will minimize the immediate risk (give an example). The “Control Hit List” is a simple tool that spells out for us the desired levels of controls available so that we may select the “best” type of control as our first choice and so that we consider all of the possible controls without just reaching for the most obvious one. The “Force Field Analysis” is simply a visual tool that helps us to realize that for every restraining force, we must identify and implement an opposing counteracting force. Walk the class through the force field analysis using the Reference Guide and use the next slide to discuss the control hit list.
- This is the Control Hit List and the description and use of this tool is contained within your Reference Guide. It helps us to think of controls in six categories because some categories have proven more effective than others. These six major categories of controls are listed in priority order, with the most effective control at the top and the least effective control at the bottom. Ask supervisors to give an example of every control on the list. Assist them as needed. Then give an example of a hazard and ask the class if they think the most effective way is to eliminate the hazard (choice #1) or only train the workers that the hazard exists and do nothing else (choice #6). Remind the supervisors that more than one control can be used for each identified hazard. Remind supervisors that this information is contained in their reference guide. Once the causes have been found, the key is to always consider controls at the top of this list and work their way down. Although it may be somewhat rare to actually eliminate the hazard, it is essential to always start with this possibility. It is not unusual to combine more than one control for the same hazard, particularly when the controls chosen are low on this list (for example, combine employee training with the use of personal protective equipment).
- Review each point in turn and then ask for an example of a short term control versus a long term control ( If employees are exposed to an excessive vapor concentration, a short term control may be the wearing of PPE, while the long term control may be installing a ventilation system). Take time to review your company’s accident investigation form and procedures for completion.
- Step 5 is to actually implement the corrective action identified and recommended through the Accident Investigation process. It is essential that long term solutions do not get lost in the shuffle and get implemented as originally planned. Over time, the effectiveness of the controls we have chosen can be assessed through such means as employee interviews, job safety analysis and finally, the presence or lack of additional accidents and incidents from the same causes.
- Lead a final discussion and attempt to remove or resolve any barriers that may still be present that might interfere or hamper the effectiveness of an AI program. Thank all for attending and participating.