Ch-1 (What is an Accident?) and Ch-2 (An Accident Happens: What Do You Do? How Long Do You Do It?)

• Event or circumstance that produce an accident • Root cause also mean similar • It can be at the basic (worker or equipment) level, intermediate (supervisory) level, and upper management level. • It incorporates root, basic, immediate, lower level, upper level, and management causes. • It answer the question: "What cause this to happen?"

Causal Factors

• Often unreported. • It leads to monetary damage. • How much monetary damage is enough to prompt a response or reporting? • A broken hand tool might not get reported, however a vehicle crash might get reported.

Property Damage and Equipment Damage Accidents

• This is an undesired event • Accident implies human error • There are normal (positive) sequences where there is no accident • There are accident sequences of events which are negative sequence

Accident

• Many companies' accident investigations forms and record-keeping forms are just a documentation tool. • It is not just to take witness statements and documents what happened. • The purpose of an accident investigation is to ask questions, interview, analyze, probe, and discover what happened. • The purpose is to use these forms and tools to investigate and determine the causal factors and prevent these instances from occurring.

Accident Documentation versus Investigation

• Accident investigations determine corrective actions so that future accidents are prevented and the overall safety program is improved.

Goals: Recommend Corrective Actions

• Risk is the amount of probability of occurrence and severity of occurrence that is inherent in everything we do. • There are risky situations that arise every day at the workplace. • Zero accidents is a goal that every company and every person should strive to meet.

Risk and Accidents

• There are instances where a near-miss accident had more potential than an injury accident, however through chance and luck it was just a small accident or a near miss. • Just because the accident was a small one this time, if conditions and acts are not corrected, then a big accident will come later.

Small versus Big Accidents

• Accident investigations must also be performed to complete workers' compensation claims, to comply with legal requirements, and OSHA regulations, and to determine the total costs of accidents.

Why: To Comply with Law and Determine Total Cost of Accident

Many companies even governmental agencies use the term ________ rather than ________ to lessen the impact of human error or fault.

incident accident

According to __________ _________ __________: "The occurrence in the sequence of events that produces unintended injury, death, or property damage"

National Safety Council

• It is an occurrence in a sequence of events that had the potential to produce injury, death, or property damage but did not. • It should be investigated the same way accidents are. • When two aeroplanes almost collide or fly too close to each other, you could say a near hit • Some one says: "You were lucky", "You dodged a bullet on that occasion", "That almost got you that time" • Near misses usually turn into an accident

Near Miss

• It is a structured process to uncover the sequence of events so that causal factors can be determined and corrective actions can be taken. • Steps in accident investigation: analyzing the facts, developing an accident sequence, finding the causes, and recommending corrective action. Analytical technique: first-aid cases, OSHArecordable injuries or illnesses, fatalities, property damage, or near misses.

Accident Investigation

• If near misses are not reported at all or proper procedures are not followed, then they cannot be investigated, thus the potential for an accident still exists. • Praise and recognition for reporting near misses, rather fault-finding accusations, will start a trend in more reporting of near misses, thus sincere effort to fix problems. • How companies react to near misses is key to preventing these hazards.

Accident versus Near Miss

• The difference between an accident and near miss is usually a matter of inches, seconds, luck, chance, severity, or damage. • Prompt reporting of the instance is very important

Accident versus Near Miss

• What do you do? How long do you do it? -these are the two major issues of accident investigation. • First question is simple as you provide emergency response, protect the employees involved from further harm, and try to determine what happened. • Second question is more difficult as it depends on severity of accident. In a perfect world there is no time limituntil the investigator is reasonably certain of what happened and why. • "Accidents do not just happen, but are caused"

Chapter Objectives

• It is the actions taken to prevent recurrence of the accident. • These are the 'fixes' to prevent future accidents. • These fixes should be performed at the appropriate level.

Corrective Actions

• This is a difficult decision. • Company should allow enough time to find out what happened and determine how to prevent it from recurring. • A first-aid case or an OSHA-recordable case will take a few days. • A major injury, fatality, or other complex accident may take anywhere from a couple of days to a month. • Catastrophies with multiple fatalities and involving complex systems (plant explosions, plane crashes etc.) usually take from a month to several years. • Time needed depends on: amount of data collected, number of interviews, number of people helping with the investigation, the analytical methods used, complexity of the system, length of final report or form.

Decision: Decide How Much Time will be Allotted to the Investigation

• Who (an individual or a team) should do the investigation? • The key is to choose the person(s) who is in the best position to discover what really happened and determine how to prevent it from happening again. • Foremen and supervisors are excellent choices if they are able to look beyond their departments to systemic causes (overall system safety management). • They usually understand the worker's jobs and the roles supervisors should play. • Safety professionals can do investigations, but usually they do not fully understand all of the workers' job functions and sequences. • A more useful role for safety professionals is providing assistance to accident investigators, since they are trained to analyze causes.

Decision: Decide Who Will Investigate

• Consultants (subject matter experts, medical doctors, lawyers) or special equipment (testing equipment, external testing, laboratory work, computer software) may be needed. • Coordinating these resources will extend the time needed to perform an investigation.

Decision: Determine Whether Additional Resources will be Needed

• Levels of accidents and levels of accident investigations mean how an investigations will be conducted: how much detail and how long should take. • The more serious an accident is, the more detailed the investigation will be and the longer it will take. • Whether an accident is minor or catastrophic, the investigation process should follow the same steps- develop the accident sequence, analyze it, determine causal factors, and recommend corrective actions.

Decision: Determine the Level of Investigation

• More information can be analyzed by team. • Appoint a team leader. • Team leader must assign each subject matter expert to work in his or her area of expertise for complex issues to uncover. • Area to focus on: technical/engineering issue, training, management systems, supervision, emergency response etc. • Team leader coordinates all of the efforts and ensures that all of the subject matter experts are working toward a common goal - finding out what happened and how to prevent it.

Decision: The Team Approach

• Purpose of Accident investigation is not to find fault or assign blame. • How not to blame someone when s/he disregards safety policy? • The answer comes with: Why s/he violated safety policy? Why supervisors did not enforce the rule? • It is imperative for companies to correct problems with their safety programs to keep accidents from happening.

Goals: Determine the Accident Sequence without Placing Blame

• By identifying hazards from the worker level up to the management systems level, the safety program can be updated and improved. • An accident is an opportunity to find and fix problems with the safety program

Goals: Update the Overall Safety Program

• Employee fear losing their incentives for accident reporting - which do not improve safety programs. • Reporting accidents and near misses, finding causal factors, and determining corrective actions, however will improve them. • Reporting accidents and near misses should be rewarded, and incentive programs should be designed to reward the reporting of all accidents and near misses

Incentive Programs Must Reward Accident Reporting

According to National Safety Council: "an incident is an unintentional event that may cause personal harm or other damage" Other companies use the concept of an incident as more of property or equipment damage.

Incident

• Accidents cannot be investigated properly, if they are not properly reported. • Company policy and employee training must spell out how to properly and consistently report accidents, near misses, and property damage. • Individuals must have no fear of repercussions (accusation of fault or blame) for informing the company or the safety departments of an accident or near miss.

Thorough Accident Reporting is Necessary

• As expensive as an accident may be, the resulting investigation can ultimately save money by helping to prevent future accidents and update safety programs. • Future savings will be found in identifying systematic problems in safety program and correcting them.

Why: To Avoid Spending Money on Accidents in the Future

• An accident investigation cannot do anything for the person already injured, the machine already damaged, or the product already destroyed. • Its value is in preventing future accidents. • Although investigations are performed reactively, they allow companies to be proactive in improving their safety programs.

Why: To Prevent Future Accidents