Accident Investigation

Conklin 3 Layers of organization

- individual worker - organizational -performance expectations set up by management

Training 5 Intentions

-Builds Foundations -Creates Dialogue -Prioritize Ideas -Forms Attitudes -Practice

Conklin Types of Failures

-Individual -Organization -System

APOLLO Heigharchy

-Inherent Safety -Passive (doesn't have any moving parts) -Active (valve) Administrative

What would you find in an Accident Investigation Kit???

-Tape -Cones -Gloves -Camera -Notepad

What to do if an accident occurs?

-provide emergency response -protect employees from further harm -determine accident sequence

3 types of Accident Situations

1. Accident Free 2. Plant Procedures 3. Ideal

4 parts of an Accident Program

1. Accident Policy 2. Emergency Training 3. Accident Invest Kit 4. Accident Invest Training

3 Types of Cause and Effect Analysis

1. Apollo 2. Fishbone 3. 5- Why

TAP ROOT 3 Standards Corrective Actions

1. Discipline 2. Training 3. Procedures

5 Types of Analysis

1. Events and Causal Factors 2. Change Analysis 3. Barrier Analysis 4. Analytical Trees 5. Cause and Effect

Example of Unsafe Act

1. Failure to use PPE 2. Improper lifting/loading 3. Horseplay

2 Types of Trees

1. Fault 2. Analytical

TAP ROOT Steps=

1. Identify Events 2. Causal Factors 3. Root Causes 4. Corrective Actions

3 Phases of Investigation

1. Investigation 2. Analyze 3. Recommendation

4 Types of Evidence

1. Paper 2.Physical 3. People 4.Photo

APOLLO 7 Elements of a Management System

1. Policy/Program 2. Define responsibility 3. Specification of Approvals 4. Required training 5. Measure of Protection 6. System of Documentation 7. Verification

TAP ROOT Human Error=

1. Procedures 2. Training 3. QC 4. Management

Example of Unsafe Condition

1. Temperature Extremes 2. Noise 3. Poor House Keeping

Conklin Types of Managers:

1. Were Different 2. Already know this stuff 3. flavor of the month 4. i am too busy

Levels of Accountability

1. Worker 2. Supervisor 3. Management 4. Coorporate

APOLLO 7 Causes of Equipment Failure

1. design 2. Material of Construction 3. Fabrication 4. Maintenance Error 5. Operator 6. Unattended Operation 7. Assembly and Installation

APOLLO RCI Methodology

1. identify Problem 2. Cause and Effect Chart 3. ID Effective Solutions 4. Implement and track effective solutions

Heinrich's Pyramid

300=near misses 29=minor 1=major

Bird's Pyramid

600=near misses 30=property damage 10=minor 1=major

APOLLO Evidence Types Sensed= Inferred=

=5 senses =lab analysis, procedures, logs

Incident

An unintentional event may cause personal harm or other damage **removes human blame

How should you ask investigative questions??

Ask opened ended questions, directly after accident

APOLLO Root Causes

At least 2= 1 action + 1 Condition strong solutions= root causes

BCA

Barrier and Control Analysis

Difference between Near Miss and an Accident

Chance/Luck

Conklin 3 Parts of failure

Context Consequence Retrospective

ETBA

Energy Trace Barrier Analysis

2 Types of Barriers

Engineer=Hard Administrative=Soft 1. Machine Gaurds 1. Procedures 2. PPE 2. Training 3. Fall Protection 3. Supervision

Causal Factors

Events that cause the accident *root causes *basic *immediate

FTA= LTA= FMEA=

Fault Tree Analysis Less Than Adequate Failure Modes and Effect Analysis

HBT

Hazard Barrier Target

What is included in an Accident report??

Injury Accident Description Causal Factors Corrective Actions

MORT

Management Oversight Risk Tree

APOLLO

Randy Keller

Conklin Safety Definition

Safety is not the absence of events; safety is the presence of defenses

Failure

Something that goes with the personnel, equipment, or environment

APOLLO Problem Definition

What=Primary Block(Effect)=Problem Why=caused by Where?? When??

TAP ROOT Event=

Who does what 1 action per event frequency x consequence

TAP ROOT Condition=

amply events

Steps following corrective actions=

develop corrective actions, track corrective, follow up

Root Causes

different meanings to everyone *1st cause *Last Cause * caused the accident

TAP ROOT Causal=

event or condition we can do something about and prevent incident

TAP ROOT corrective action=

lower frequency and consequence

Goal of accident investigation

reoccurance of the accident

Accident

sequence of events that produces unwanted injury, illness, death , or property

TAP ROOT Accident=

something happens that wasn't supposed to

Hazard

something that has the potential to cause injury

TAP ROOT Incident=

worst thing that could have or would have happened