Accident Causation and Investigation Techniques

Investigation Procedure

1. Secure the scene of the accident 2. Provide care to the injured 3. Isolate the scene of the accident 4. Lead investigator selects team, assigning specific tasks to each member 5. Briefing to investigative team 6. Inspect the accident site 7. Interview victims and eyewitnesses 8. Determine most likely causes 9. Implement corrective actions

Multilinear events sequencing method

An integrated body of concepts and procedures for investigating and analyzing a wide range of desired and undesired processes before or after they happen

Safety management error, safety program defect, management/command error, system defect, operating error, mishap, result

Avenues for initiating countermeasures

Safety program defect countermeasures

Revise information collection, analysis, implementation

Ishikawa

Root cause analysis method that relies upon creation of a graphical "fishbone" diagram showing the influencing factors in the causation of an incident

System defect countermeasures

SOP's, regulations, policy letters, statements

Energy Release Theory

Theory that portrays accidents in terms of energy and transference where large amounts of energy can disrupt people and the environment and cause injuries.

combination theory

the actual cause of an accident may be explained by combining many models

Petersen's Accident/Incident Theory

theory that says that their are three ways accidents happen, either by overload, ergonomic traps, or decision to err

Operating errors countermeasures

training and motivation

Mishap countermeasures

PPE, barriers, separation

Gross Hazard Analysis

Performed to get a rough assessment of the risks involved in performing a task. Typically takes the form of a diagram or table

Systems Theory

Theory that explains that accidents are related to the relationship between man, machines, and the environment

2, 10, 88

% of unavoidable accidents, % of unsafe conditions, % of unsafe acts

Job Safety Analysis

A process through which all the various steps in a job are identified and listed in order.

Result countermeasures

Containment, firefighting, rescue, evacuation, first aid

Heinrich's Three E's

Engineering, Education, and Enforcement

Near-miss relationship

For every disabling injury, there are 29 minor injuries and 300 close calls

Epidemiological Theory

Studies the relationship between environmental factors and disease. 1. Predisposition Characteristics - Tendencies may predispose worker to certain actions 2. Situational Characteristics - Peer pressure, poor attitude, risk taking

Modern Causation Model

Theory that describes injuries as results and accidents as mishaps.

Safety management error and Command error defect countermeasures

Training, education, motivation task design

operating error

Unsafe position, unstable stacks, poor housekeeping, removing a guard

Failure modes and effects analysis

a procedure for identifying and correcting potential safety problems inherent to product or process designs

Fault Tree Analysis

a visual method for analyzing the interrelationships among failures

Heinrich Domino Theory

an accident is one factor in a sequence that may lead to an injury. An accident occurs only as a result of a personal or mechanical hazard. Personal and mechanical hazards exist only through the fault of careless persons or poorly designed or improperly maintained equipment. Faults of persons are inherited or acquired as a result of their social environment or acquired by ancestry. The environment is where and how a person was raised and educated.

Human Factors Theory

attributes accidents to a chain of events ultimately caused by human error

behavior-based safety

identifying the worker behaviors that contribute to accidents and then training workers to avoid these behaviors

system defects

improper assignment of responsibility, climate of motivation, training, education, equipment, supplies, allocation of funds

safety program defect

ineffective information collection, weak causation analysis, poor countermeasures, inadequate implementation and controls