Accident Investigation

Accident Investigation Steps

1. Analyzing the facts 2. Develop an accident sequence 3. Finding causes 4. Recommending corrective action

Phases of an Investigation

1. Gain knowledge: discover facts about the accident, interview, document 2. Analyze the knowledge: what happened 3. Develop corrective actions: how can we prevent this

classifications of accidents

1. Near miss: potential 2. Minor injury or first aid: no reportable 3. Major injury: recordable 4. Catastrophic level: death, multi major injury, major damage

GW Hienrich

Ancestor/ social environment, fault/ person, unsafe act, unsafe condition, injury

MORT

o Management Oversight and Risk Team - Links causes from worker level up to management

Analysis

o Systematic process used to determine what is unknown about an accident

Haddons Model

o Way to correlate the factors and phases of an incident o Three phases: pre injury, injury, post injury o Three factors: human, equipment, and environment factor

Cause and effect theory

o Way to determine casual factors of an incident o An action or event that will produce another response or action in return

Domino Theory

o illustrates how an accident happens each step at a time, 1: Set the stage start of an accident o Removing at least one domino would prevent the incident

Near-Miss

occurrence of events that had potential to carry injury or cause damage

Accident Investigation

structured process of uncovering the sequence of events that caused or could have caused injury, death, or damage

Risk

the amount of probability of occurrence and severity of occurrence that is inherent in everything we do.

Accident

undesired event that causes injury or property damage

Bird and Germain

Lack of control, basic causes, immediate causes, incident, loss

Layered

Obtains all the casual factors not just the obvious ones

Purpose of an Accident Investigation

- Analyze root causes to obtain a clear sequence of events - Develop solutions to prevent reoccurrence

Root cause

The word root is what is controversial (first or last)

Unsafe act and conditions

o Immediate cause that lead to the loss o Two theories have diverged from each other over time

Epidemiological model

o Factors in who was hurt, what got hurt, and how o Takes from how diseases are tracked and researched o Too narrow to be the only theory in use

Corrective Actions

actions taken to prevent the reoccurrence of the event

Causal Factors

events and circumstances that produce an event

Human error theory

o Allow investigators to determine interactions between human, environment, and equipment

Goals of an accident investigation

o Determine the Accident Sequence without Placing Blame. - Accident investigation determines the accident sequence. - Its purpose is not to find fault or assign blame. - Implement a fair and consistent accountability system. - If necessary, dig deeper into why the program allowed individuals to violate policies and procedures. o Recommend Corrective Action. - Prevent recurrence of the incident. o Update the safety program - Be familiar with the challenges of reporting near-miss incidents; be able to explain how traditional safety incentive programs may affect the reporting of near-miss incidents.

strategic decisions

o Determine the level of investigation - Est a policy defining levels of severity - Same steps no mater what o Who will investigate - Most effective to use a team or individual - Team approach • Best for large or complex incidents • Each person assigned a diff area • Decide how much time has been allotted to the investigation • Determine if additional resources are necessary

Multiple Causation Theory

o Each accident is a cause of multiple unsafe acts and condition o Must use analytical approach when using this