Accident Investigation 101 Training by Safety and Environmental Compliance Office
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This document provides an overview of accident investigation procedures. It defines what constitutes an accident, discusses causes of accidents including unsafe acts and conditions, and outlines the steps of conducting an accident investigation including securing the scene, interviewing witnesses, analyzing causal factors, and identifying corrective actions to prevent future occurrences. The goal of any investigation is to determine what happened and why, in order to implement solutions that prevent reoccurrence.
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Accident Investigation 101 Training by Safety and Environmental Compliance Office
- 1. ACCIDENT INVESTIGATION 101ACCIDENT INVESTIGATION 101
- 2. 2 Course ObjectivesCourse Objectives Understand the need to investigateUnderstand the need to investigate Know what to investigateKnow what to investigate Determine the cause(s) of accidentsDetermine the cause(s) of accidents Identify the methods of investigationsIdentify the methods of investigations Understand the need to be thoroughUnderstand the need to be thorough and comprehensiveand comprehensive Identify prevention methodsIdentify prevention methods Identify sources of assistanceIdentify sources of assistance
- 3. 3 What is yourWhat is your definition of andefinition of an “Accident”?“Accident”?
- 4. 4 What is an AccidentWhat is an Accident - an unplanned event- an unplanned event - an unplanned incident- an unplanned incident involving injury or fatalityinvolving injury or fatality - a series of events culminating- a series of events culminating in an unplanned andin an unplanned and unforeseen eventunforeseen event
- 5. 5 How do Accidents occur?How do Accidents occur? -- Accidents (with or without injuries)Accidents (with or without injuries) occur when a series of unrelated eventsoccur when a series of unrelated events coincide at a certain time and space.coincide at a certain time and space. -This can be from a few events to a-This can be from a few events to a series of a dozen or moreseries of a dozen or more (Because the coincidence of the series of(Because the coincidence of the series of events is a matter of luck, actualevents is a matter of luck, actual accidents only happen infrequently)accidents only happen infrequently)
- 6. 6 Unsafe ActsUnsafe Acts - An unsafe act occurs in approx 85%-- An unsafe act occurs in approx 85%- 95% of all analyzed accidents with injuries95% of all analyzed accidents with injuries - An unsafe act is usually the last of a- An unsafe act is usually the last of a series of events before the accidentseries of events before the accident occurs (it could occur at any step of theoccurs (it could occur at any step of the event)event) - By stopping or eliminating the unsafe act,- By stopping or eliminating the unsafe act, we can stop the accident from occurringwe can stop the accident from occurring
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- 11. 11 Why Investigate Accidents?Why Investigate Accidents? Prevent a recurrence with correctivePrevent a recurrence with corrective actionaction Determine the causeDetermine the cause Document your Line Office’s version ofDocument your Line Office’s version of the incidentthe incident Complete OSHA-required reportingComplete OSHA-required reporting
- 12. 12 What is an AccidentWhat is an Accident Investigation?Investigation? A systematic approach to the identificationA systematic approach to the identification of causal factors and implementation ofof causal factors and implementation of corrective actionscorrective actions without placingwithout placing blameblame on or finding personal fault. Theon or finding personal fault. The information collected during aninformation collected during an investigation is essential to determineinvestigation is essential to determine trends and taking appropriate steps totrends and taking appropriate steps to prevent future accidents.prevent future accidents.
- 13. 13 Which Accidents should beWhich Accidents should be Recorded or Reported?Recorded or Reported? ALLALL accidentsaccidents (including illnesses) shall(including illnesses) shall be recorded and reportedbe recorded and reported through the establishedthrough the established procedures and guidanceprocedures and guidance as provided byas provided by NOAA Safety DivisionNOAA Safety Division
- 14. 14 Why Investigate Accidents?Why Investigate Accidents? Determine the causeDetermine the cause Develop and implement corrective actionsDevelop and implement corrective actions Document the eventsDocument the events Meet legal requirementsMeet legal requirements Primary Focus: PREVENT REOCCURENCE!!! PREVENT REOCCURENCE!!! PREVENT REOCCURENCE!!!
- 15. 15 Who Investigates?Who Investigates? Minor accident/incidentMinor accident/incident — SupervisorSupervisor — Safety committee memberSafety committee member Major accident/incidentMajor accident/incident — SupervisorSupervisor — Safety committee memberSafety committee member — Occupational Health & Safety Manager’sOccupational Health & Safety Manager’s (OHS’s/IIC)(OHS’s/IIC) — Regional Environmental Compliance Officer’sRegional Environmental Compliance Officer’s (RECO’s)(RECO’s)
- 16. 16 Investigator’s QualificationsInvestigator’s Qualifications Accident investigation trainingAccident investigation training Understanding the importanceUnderstanding the importance of investigationof investigation Ability to communicate detailsAbility to communicate details
- 17. 17 When to Investigate?When to Investigate? Immediately after incidentImmediately after incident — Witness memories fadeWitness memories fade — Equipment and cluesEquipment and clues are movedare moved Finish investigation quicklyFinish investigation quickly
- 18. 18 Accident vs. Near-MissAccident vs. Near-Miss Accident : Any undesired, unplanned event arising out of a given work-related task which results in physical injury/ illness or damage to property. Near-Miss : Events which did not result in injury/illness or damage but had the potential to do so.
- 19. 19 Accident Ratio StudyAccident Ratio Study 3030 1 10 600 6000 Serious or Disabling Minor Injuries Property Damage Accidents with no visible injury or damage Unsafe Acts or Conditions
- 20. 20 Accident CausesAccident Causes Unsafe ActUnsafe Act - an act by the injured person or- an act by the injured person or another person (or both) whichanother person (or both) which caused the accident,caused the accident, and/orand/or Unsafe ConditionUnsafe Condition - some environmental or hazardous- some environmental or hazardous situation which caused the accidentsituation which caused the accident independent of the employeeindependent of the employee
- 21. 21 Accident Causation ModelAccident Causation Model Results of the accidentResults of the accident - physical harm- physical harm - property damage- property damage Incident OccurrenceIncident Occurrence - contact with- contact with - type- type Immediate causesImmediate causes - practices- practices - conditions- conditions Basic causesBasic causes - personal factors- personal factors - job factors- job factors - supervisory performance- supervisory performance - management policy and- management policy and decisionsdecisions
- 22. 22 Results of the AccidentResults of the Accident Physical HarmPhysical Harm - catastrophic (multiple deaths)- catastrophic (multiple deaths) - single death- single death - disabling- disabling - serious- serious - minor- minor Property DamageProperty Damage - catastrophic- catastrophic - major- major - serious- serious - minor- minor
- 23. 23 Incident OccurrenceIncident Occurrence TypeType - struck by- struck by - struck against- struck against - slip, trip- slip, trip - fell from- fell from - caught on- caught on - fell on same level- fell on same level - caught in- caught in - overexertion- overexertion Contact withContact with - electricity- electricity - equipment- equipment - noise- noise - vibration- vibration - hazmat- hazmat - heat/cold- heat/cold - radiation- radiation - animals/insects- animals/insects
- 24. 24 Immediate CausesImmediate Causes PracticesPractices - operating without- operating without authorityauthority - use equipment- use equipment improperlyimproperly - not using PPE when- not using PPE when requiredrequired - correct lifting- correct lifting procedures notprocedures not establishedestablished - drinking or drug use- drinking or drug use - horseplay- horseplay - equipment not- equipment not properly securedproperly secured
- 25. 25 Immediate CausesImmediate Causes (cont’d)(cont’d) ConditionsConditions - ineffective guards- ineffective guards - unserviceable tools and- unserviceable tools and equipmentequipment - inadequate warning- inadequate warning systemssystems - bad housekeeping- bad housekeeping practicespractices - poor work space- poor work space illuminationillumination - unhealthy work- unhealthy work environmentenvironment
- 26. 26 Basic CausesBasic Causes Personal FactorsPersonal Factors - lack of knowledge or skill- lack of knowledge or skill - improper motivation- improper motivation - physical or mental condition- physical or mental condition - literacy or ability- literacy or ability Job FactorsJob Factors - Physical environment- Physical environment - sub-standard equipment- sub-standard equipment - abnormal usage- abnormal usage - wear and tear- wear and tear - inadequate standards- inadequate standards - design and maintenance- design and maintenance
- 27. 27 Basic CausesBasic Causes (cont’d)(cont’d) SupervisorySupervisory PerformancePerformance - inadequate instructions- inadequate instructions - failure of SOPs- failure of SOPs - rules not enforced- rules not enforced - hazards not corrected- hazards not corrected - devices not provided- devices not provided Management PolicyManagement Policy and Decisionsand Decisions - set measurable- set measurable standardsstandards - measure work in- measure work in progressprogress - evaluate work vs.- evaluate work vs. standardsstandards - correct performance- correct performance
- 28. 28 Investigator’s QualificationsInvestigator’s Qualifications Technical knowledgeTechnical knowledge ObjectivityObjectivity Analytical approachAnalytical approach Familiarity with the job, process or operationFamiliarity with the job, process or operation Tact in communicatingTact in communicating Intellectual honestyIntellectual honesty Inquisitiveness and curiosityInquisitiveness and curiosity
- 29. 29 Beginning the InvestigationBeginning the Investigation Gather investigationGather investigation team and kitteam and kit Report to the sceneReport to the scene Look at the bigLook at the big picturepicture Record initialRecord initial observationsobservations Take picturesTake pictures
- 30. 30 What’s Involved?What’s Involved? Who was injured?Who was injured? Medication, drugs,Medication, drugs, or alcohol?or alcohol? Was employee ill?Was employee ill? Double shift orDouble shift or rotating shifts?rotating shifts?
- 31. 31 WitnessesWitnesses Who witnessed theWho witnessed the incident?incident? Was a supervisor orWas a supervisor or lead person nearby?lead person nearby? Where were otherWhere were other employees?employees? Why didn’t anyoneWhy didn’t anyone witness the incident?witness the incident?
- 32. 32 Interviewing TipsInterviewing Tips Discuss what happened leadingDiscuss what happened leading up to and after the accidentup to and after the accident Encourage witnesses to describeEncourage witnesses to describe the accident in their own wordsthe accident in their own words Don’t be defensive or judgmentalDon’t be defensive or judgmental Use open-ended questionsUse open-ended questions
- 33. 33 What Was Involved?What Was Involved? Machine, tool,Machine, tool, or equipmentor equipment ChemicalsChemicals EnvironmentalEnvironmental conditionsconditions ProductionProduction scheduleschedule
- 34. 34 Severity of IncidentSeverity of Incident (NOAA Safety Policy NAO-209-1)(NOAA Safety Policy NAO-209-1) MajorMajor - Employee fatality,- Employee fatality, - Hospitalization of 3 or more employees,- Hospitalization of 3 or more employees, - Permanent employee disability,- Permanent employee disability, - Five or more lost workdays,- Five or more lost workdays, - Conditions that could pose an imminent and- Conditions that could pose an imminent and threat of serious injury/illness to otherthreat of serious injury/illness to other employeesemployees - Property losses in excess of $1 Million- Property losses in excess of $1 Million MinorMinor - All other (less serious) incidents and unsafe- All other (less serious) incidents and unsafe conditions reported by employeesconditions reported by employees
- 35. 35 Who Investigates?Who Investigates? Major AccidentsMajor Accidents - NOAA GO TEAM Investigation Team- NOAA GO TEAM Investigation Team - LO Representative- LO Representative - Other agencies such as NTSB, USCG, OSHA- Other agencies such as NTSB, USCG, OSHA Minor AccidentsMinor Accidents - First-Line Supervisor- First-Line Supervisor - Site Director or Manager- Site Director or Manager - Site Safety Representative- Site Safety Representative - SECO (if needed)- SECO (if needed)
- 36. 36 When to Investigate?When to Investigate? Immediately after incidentImmediately after incident Witness memories fadeWitness memories fade Equipment and cluesEquipment and clues are movedare moved Finish investigation quicklyFinish investigation quickly
- 37. 37 What to Investigate?What to Investigate? All accidents and near-missesAll accidents and near-misses - Conduct investigation upon first- Conduct investigation upon first notificationnotification - Keeping the scene in-tact and- Keeping the scene in-tact and recording witnesses statementsrecording witnesses statements early is key to a successfulearly is key to a successful investigationinvestigation
- 38. 38 Accident Investigation KitAccident Investigation Kit May Include:May Include: Digital CameraDigital Camera Report forms, clipboard, pensReport forms, clipboard, pens Barricade tapeBarricade tape FlashlightFlashlight Tape measureTape measure Tape recorderTape recorder Personal Protective Equipment (as appropriate)Personal Protective Equipment (as appropriate)
- 39. 39 The Accident OccursThe Accident Occurs Employee or co-worker immediately reportsEmployee or co-worker immediately reports the accident to a supervisorthe accident to a supervisor Supervisor secures/assesses the scene toSupervisor secures/assesses the scene to prevent additional injuries to otherprevent additional injuries to other employees, before assisting the injuredemployees, before assisting the injured employeeemployee Supervisor treats the injury or seeksSupervisor treats the injury or seeks medical treatment for the injuredmedical treatment for the injured The accident scene is left intactThe accident scene is left intact Site safety rep is contacted to assist theSite safety rep is contacted to assist the supervisor in the investigation of thesupervisor in the investigation of the accident.accident.
- 40. 40 Beginning the InvestigationBeginning the Investigation Gather investigationGather investigation members and kitmembers and kit Report to the sceneReport to the scene Look at the bigLook at the big picturepicture Record initialRecord initial observationsobservations Take picturesTake pictures
- 41. 41 What’s Involved?What’s Involved? Who was injured?Who was injured? Medication, drugs,Medication, drugs, or alcohol?or alcohol? Was employee ill orWas employee ill or fatigued?fatigued? Environmental conditions?Environmental conditions?
- 42. 42 WitnessesWitnesses Who witnessed theWho witnessed the accident?accident? Was a supervisor orWas a supervisor or Team Lead nearby?Team Lead nearby? Where were otherWhere were other employees?employees? Why didn’t anyoneWhy didn’t anyone witness the accidentwitness the accident (working alone, remote areas)?(working alone, remote areas)?
- 43. 43 Interviewing TipsInterviewing Tips Discuss what happened leadingDiscuss what happened leading up to and after the accidentup to and after the accident Encourage witnesses to describeEncourage witnesses to describe the accident in their own wordsthe accident in their own words Don’t be defensive or judgmentalDon’t be defensive or judgmental Use open-ended questionsUse open-ended questions Do not interrupt the witnessDo not interrupt the witness
- 44. 44 What was Involved?What was Involved? Machine, tool, orMachine, tool, or equipmentequipment ChemicalsChemicals EnvironmentalEnvironmental conditionsconditions Field season prepField season prep operationsoperations
- 45. 45 Date and time?Date and time? Normal shift orNormal shift or working hours?working hours? Employee comingEmployee coming off a vacation?off a vacation? Time of AccidentTime of Accident
- 46. 46 Accident LocationAccident Location Work areaWork area On, under, in, nearOn, under, in, near Off-site addressOff-site address Doing normal jobDoing normal job dutiesduties Performing non-Performing non- routine or routineroutine or routine tasks (i.e., properlytasks (i.e., properly trained)trained)
- 47. 47 Employee’s ActivityEmployee’s Activity Motion conductedMotion conducted at time of accidentat time of accident Repetitive motion?Repetitive motion? Type of materialType of material being handledbeing handled
- 48. 48 Accident NarrativeAccident Narrative Describe the details so the readerDescribe the details so the reader can clearly picture the accidentcan clearly picture the accident Specific body parts affectedSpecific body parts affected Specific motionsSpecific motions of injured employeeof injured employee just before,just before, during, andduring, and after accidentafter accident
- 49. 49 Causal FactorsCausal Factors Try not to accept single cause theoryTry not to accept single cause theory Identify underlying causes (root)Identify underlying causes (root) Primary causePrimary cause Secondary causesSecondary causes Contributing causesContributing causes EffectsEffects
- 50. 50 Corrective Actions TakenCorrective Actions Taken Include immediate interim controlsInclude immediate interim controls implemented at the time of accidentimplemented at the time of accident Recommended corrective actionsRecommended corrective actions Employee trainingEmployee training Preventive maintenance activitiesPreventive maintenance activities Better operating proceduresBetter operating procedures Hazard recognition (ORM)Hazard recognition (ORM) Management awareness of risks involvedManagement awareness of risks involved
- 51. 51 Immediate NotificationImmediate Notification Supervisor shall complete the NOAASupervisor shall complete the NOAA Accident Reporting Form (web-based) andAccident Reporting Form (web-based) and submit within 24 hours of incidentsubmit within 24 hours of incident occurrence.occurrence.
- 52. 52 SummarySummary Investigate accidents immediatelyInvestigate accidents immediately Determine who was involved andDetermine who was involved and who witnessed itwho witnessed it Ascertain what items or equipmentAscertain what items or equipment were involvedwere involved Record detailed descriptionRecord detailed description Determine causal factorsDetermine causal factors Conduct corrective actionsConduct corrective actions
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- 55. 55 1.1. What is an Accident Investigation?What is an Accident Investigation? a.a. A systematic approach to the identification of causalA systematic approach to the identification of causal factors and implementation of corrective actions.factors and implementation of corrective actions. b.b. Finding personal fault and placing blame.Finding personal fault and placing blame. c.c. The appropriate steps to prevent future actions.The appropriate steps to prevent future actions. d.d. The essential step to determine trends and takingThe essential step to determine trends and taking action against person or persons at fault.action against person or persons at fault.
- 56. 56 2.2. Which Accidents should be Recorded orWhich Accidents should be Recorded or Reported?Reported? a.a. Only on the job accidents.Only on the job accidents. b.b. ALL accidents (including illnesses) shall beALL accidents (including illnesses) shall be recorded and reported.recorded and reported. c.c. Only on the job accidents on illnesses that occur onOnly on the job accidents on illnesses that occur on the job and reported within 8 hours.the job and reported within 8 hours. d.d. All accidents shall be recorded and reported.All accidents shall be recorded and reported.
- 57. 57 3.3. Why Investigate Accidents?Why Investigate Accidents? a.a. To develop and implement corrective actions.To develop and implement corrective actions. b.b. To document the events.To document the events. c.c. The Primary Focus is to PREVENTThe Primary Focus is to PREVENT REOCCURENCE!!!REOCCURENCE!!! d.d. To determine the cause.To determine the cause.
- 58. 58 4.4. Accident vs. Near-Miss?Accident vs. Near-Miss? a.a. AnyAny unplanned events arising out of work vs. Any events which did not result in injury. b. Any unsafe work habit vs. Any Hazardous working conditions. c. Any events which warns us a problem vs. Any circumstances that result in injury or property damage.
- 59. 59 5.5. Which of the following are the basicWhich of the following are the basic areas that are looked at in an Accidentareas that are looked at in an Accident Investigation.Investigation. a.a. Policies.Policies. b.b. Equipment.Equipment. c.c. Training.Training. d.d. All of the above.All of the above.
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- 61. 61 QuizQuiz 1.1. It is best to interview witnesses all together inIt is best to interview witnesses all together in order to save time.order to save time. True or FalseTrue or False 2.2. Name two environmental factors that may beName two environmental factors that may be involved in an accident: ______________ andinvolved in an accident: ______________ and ______________.______________. 3.3. Define a “minor” accident according toDefine a “minor” accident according to investigation procedures:investigation procedures: __________________________________.__________________________________. 4.4. The main reason for investigatingThe main reason for investigating accidents is to fix the blame somewhere.accidents is to fix the blame somewhere. True or FalseTrue or False 5.5. Employees need to report injuries only if theyEmployees need to report injuries only if they think they need to see a doctor.think they need to see a doctor. True or FalseTrue or False
- 62. 62 QuizQuiz (cont.)(cont.) 6.6. Prior to arriving at the accident scene, one teamPrior to arriving at the accident scene, one team member should have taken the __________________.member should have taken the __________________. 7.7. Describe at least two factors to investigate about theDescribe at least two factors to investigate about the injured employee: ______________ andinjured employee: ______________ and _____________._____________. 8.8. How could the time of the accident be consideredHow could the time of the accident be considered a causal factor?a causal factor? 9.9. Describing the general accident locationDescribing the general accident location is adequate for the report.is adequate for the report. True or FalseTrue or False 10.10. Describe at least two factors to investigate whenDescribe at least two factors to investigate when equipment is involved: ____________ and ___________.equipment is involved: ____________ and ___________.
- 63. 63 Quiz AnswersQuiz Answers 1.1. False. Witnesses should be interviewedFalse. Witnesses should be interviewed separately.separately. 2.2. Wet floor, poor lighting, cold or hot day, noise.Wet floor, poor lighting, cold or hot day, noise. 3.3. A “minor” accident is when the injured employeeA “minor” accident is when the injured employee does not require outside medical attention.does not require outside medical attention. 4.4. False. Accidents are investigated so correctiveFalse. Accidents are investigated so corrective actions can be taken to prevent anotheractions can be taken to prevent another accident.accident. 5.5. False. Employees need to report all injuries, noFalse. Employees need to report all injuries, no matter how small, and near-miss incidents.matter how small, and near-miss incidents.
- 64. 64 Quiz AnswersQuiz Answers (cont.)(cont.) 6.6. Investigation kit.Investigation kit. 7.7. Alcohol or drugs, medication, illness, tired,Alcohol or drugs, medication, illness, tired, extra shift, eyesight.extra shift, eyesight. 8.8. Early morning accident related to tired,Early morning accident related to tired, inattentive employee. Late afternooninattentive employee. Late afternoon accident related to fatigue of a full day ofaccident related to fatigue of a full day of work.work. 99.. False. The report requires very specificFalse. The report requires very specific details of the location of an accident.details of the location of an accident. 10.10. Equipment malfunction, employee trainingEquipment malfunction, employee training and skill level, amount of supervision.and skill level, amount of supervision.
Editor's Notes
- I.Background Information: Prior to conducting the class, you need to determine who will be investigating accidents. Supervisors, Safety Committee Members, Managers, etc., may all be involved in accident investigations. These are the folks who need to participate in accident investigation training. Make sure you have defined the roles of your accident investigation team. Who will lead the investigation? Who will write up the report? Who will follow up on recommendations? Do you have written accident investigation and reporting procedures that describe the responsibilities of employees, management and supervisors, and the investigation team? Does your plan also incident investigation report forms and instructions on how to complete the forms? II.Speaker’s Notes: All of you have been selected to participate in the investigation of accidents. Not all of you will participate in every investigation; however, at some point you may be involved, so it is important that you understand your role in that investigation. Today we will discuss the importance of immediately investigating an accident/incident, why an accident/incident should be investigated in the first place, what needs to be investigated, and how to investigate an incident.
- Review the training objectives one by one. Explain that the participants 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...
- 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.
- I.Background Information: Stress the importance of investigating incidents. Your investigation team must understand that their job can save the company a lot of money and can help prevent a similar accident from occurring in the future. The input of every member of the investigation team is vital to a thorough and successful investigation report. II.Speaker’s Notes: Why should we investigate accidents? To prevent future accidents from occurring is the number one reason. Also, accident investigations will usually bring out “hidden” safety issues that can be addressed in other work areas to prevent accidents in those areas. Determining the cause is not a reason to place blame. Usually there are multiple causes or contributing factors. Digging into the root or main cause may take time, because it may be hidden under a number of easy or apparent causes. We also need to document the company’s version of the incident for reporting to the Occupational Safety and Health Administration (OSHA) and so the workers’ compensation claim can be managed correctly.
- 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...
- I.Background Information: Stress the importance of investigating incidents. Your investigation team must understand that their job can save the organization a lot of money and help prevent a similar accident from occurring in the future. The input of every member of the investigation team is vital to a thorough and successful investigation report. II.Speaker’s Notes: Why should we investigate accidents? To prevent future accidents from occurring is the number one reason. Also, accident investigations will usually bring out “hidden” safety issues that can be addressed in other work areas to prevent accidents in those areas. Determining the cause is not a reason to place blame. Usually there are multiple causes or contributing factors. Digging into the root or main cause may take time, because it may be hidden under a number of easy or apparent causes. We also need to document the NMFS version of the incident for reporting to the Occupational Safety and Health Administration (OSHA) and so the workers’ compensation claim can be managed correctly.
- I.Background Information: Your company’s accident investigation and reporting procedures should explain who is responsible for investigating the different types of accidents. This is just an example of which employees might be on the investigation team. Please make the appropriate changes so the information coincides with your company’s accident investigation and reporting procedures. How does your company’s accident investigation and reporting procedures define “minor” and “major” accidents? Make sure the definitions in the Speaker’s Notes match the description in your company’s plan. II.Speaker’s Notes: A “minor” accident is one in which no injury occurs or the most severe injury only requires first aid, not a visit to the doctor. This type of accident or near miss can easily be handled by the injured employee’s supervisor and a member of the safety committee. The chosen safety committee member should work in a different department so he or she can look at the situation from a fresh perspective. A “major” accident is one in which the injury is severe enough that a doctor’s visit is required. Again, the supervisor will be involved, along with at least one member (possibly more) of the safety committee. The safety manager and production manager will also be involved. The assembled investigation team decides who will lead the investigation and who will be responsible for writing the report.
- I.Background Information: The employees in this class will have the basis to become qualified trainers just by their participation in this class. Once they understand the importance of the investigation and learn how to find and communicate details, they will be effective members of an investigation team. II.Speaker’s Notes: Not everyone is permitted to investigate accidents. Obviously, you are on yourway due to your participation in this class. By the end of this session, you will understand the proper way to investigate accidents. You should also understand the importance of conducting an investigation. If you don’t take the investigation process seriously, or just go through the motions, the investigation will not be valid. A thorough investigation requires the ability to seek out hidden details and to communicate those details successfully so that others reading the investigation report will be able to picture exactly what happened.
- I.Background Information: How does your company notify or assemble the investigation team? Is the safety manager or production manager contacted and then the members of the investigation team? II.Speaker’s Notes: Ideally, the investigation should begin immediately. The investigation team should be assembled, and the process should begin even while the injured employee is still being treated. The memories of the injured employee and witnesses are affected by time. They may elaborate on the story or forget important details if they are not questioned immediately. Potential causal factors might be removed. For example, the equipment involved may be moved, the slippery floor cleaned up, the broken ladder repaired. Investigators want to arrive at the scene before anything is changed. If the investigation team cannot arrive at the scene immediately, they should make it a priority to arrive as soon as possible. Waiting a day or two is just not acceptable. By then, you have lost important information, and the investigation will not be complete. Recommendations from the investigation may not be valid because they are based on inaccurate information.
- I.Background Information: The employees in this class will have the basis to become qualified trainers just by their participation in this class. Once they understand the importance of the investigation and learn how to find and communicate details, they will be effective members of an investigation team. II.Speaker’s Notes: Not everyone is permitted to investigate accidents. Obviously, you are on yourway due to your participation in this class. By the end of this session you will understand the proper way to investigate accidents. You should also understand the importance of conducting an investigation. If you don’t take the investigation process seriously, or just go through the motions, the investigation will not be valid. A thorough investigation requires the ability to seek out hidden details and to communicate those details successfully so that others reading the investigation report will be able to picture exactly what happened.
- I.Background Information: How does your company call for an investigation team to gather? Who determines the members of a particular investigation team? Who retrieves the investigation kit? Pass out accident investigation forms. II.Speaker’s Notes: Once the team has gathered at the scene, decide who will be the team leader. Step back from the scene to look at the big picture. Do you observe anything that is unusual or out of place? Record your initial observations. Try not to record what you think may have happened; just record what you see. Take pictures or a video.
- I.Background Information: Does your company have any kind of postaccident drug-screen requirement? If so, you will find out later if the injured employee was on alcohol or illegal drugs. Most of the information contained in this slide will have to be taken from the employee’s statement. The employee may not think to include all of this information, so make sure the employee is thoroughly interviewed. II.Speaker’s Notes: Write down the complete name of the injured employee(s) the department the employee works in, and the name of his or her supervisor. Have the injured employee complete his or her account of the incident. Was the injured employee taking any medication, either prescription or non-prescription, such as pain medicine, allergy medicine, aspirin, etc.? Is the employee diabetic or subject to seizures? Is there any evidence of use of alcohol or illegal drugs? Was the employee feeling ill lately (if so, the employee may have been taking medication)? Did the employee have symptoms of drowsiness, upset stomach, headaches, etc.? Was the injured employee working a double shift or rotating shifts? Fatigue or the adjustment in work hours may have contributed to the incident. When interviewing the injured employee, do not come across as trying to find the employee at fault for the accident. Just tell the employee that these questions on the form are standard questions that have to be answered.
- I.Speaker’s Notes: Write down the name(s) of the witness(es), the departments in which they work, and the names of their supervisors. Interview witnesses separately and write down or record their statements. Some questions to ask witnesses include: Were there any unsafe acts on the part of the person involved that precipitated the incident (i.e., horseplay or not following proper safety procedures)? Do you know of any personal factor on the part of the individual involved that may have induced an unsafe condition (i.e., inexperience, alcohol use or fatigue)? If supervisors or leads were nearby, was the employee being directly supervised? Where was the supervisor at the time of the accident? Use a facility map or draw a picture of where other employees, including witnesses, were located when the accident occurred. What were they doing? If there were no witnesses, why not? Was the injured employee working alone? If not, why had the other employees left the injured employee alone? Was the fact that the employee was alone a contributing factor?
- I.Background Information: If time allows, have the employees conduct some mock interviews to get them comfortable with the process. II.Speaker’s Notes: When interviewing, avoid using domineering or patronizing mannerisms or speech. The interviewee will probably not respond well to this attitude. Convey your sincere concern for the safety of employees at your company, and let them know that you are trying to find ways to fix the cause of this accident. Do not interrupt the interviewee; take detailed notes. Review your notes with the interviewee at the end of the interview to avoid any misunderstanding.
- I.Speaker’s Notes: Was the injured employee operating a machine, tool, or piece of equipment that may have contributed to the incident? Was there a malfunction? Was the employee trained to use the equipment? How much experience did the employee have with the equipment? Was the employee being directly supervised while using the equipment? Was the employee wearing proper personal protective equipment (PPE), if required? Was the employee using a chemical at the time of the incident? If so, was the employee properly trained, experienced, or supervised? Was the employee wearing appropriate PPE? Environmental factors include: slippery floor, inadequate lighting, crowded work space, noise, stress, etc. The production schedule can be a factor if the production level was increased well above normal levels. Did this increase cause the injured employee to bypass safety procedures in order to speed up production? Were safety hazards ignored because production had to be finished?
- I.Background Information: Your accident investigation and reporting procedures should explain who is responsible for investigating the different types of accidents. This is just an example of which employees might be on the investigation team. Please make the appropriate changes so the information coincides with your company’s accident investigation and reporting procedures. How NOAA’s accident investigation and reporting procedures define “minor” and “major” accidents? Make sure the definitions in the Speaker’s Notes: match the description in your company’s plan. II.Speaker’s Notes: A “minor” accident is one in which no injury occurs or the most severe injury only requires first-aid, not a visit to the doctor. This type of accident or near miss can easily be handled by the injured employee’s supervisor and a member of the safety committee. The chosen safety committee member should work in a different department so he or she can look at the situation from a fresh perspective. A “major” accident is one in which the injury is severe enough that a doctor’s visit is required. Again the supervisor will be involved, along with at least one member (possibly more) of the safety committee. The safety manager and production manager will also be involved. The assembled investigation team decides who leads the investigation and who will be responsible for writing the report.
- I.Background Information: How do you notify or assemble the investigation team? Is the SECO or safety focal point contacted, and then they contact members of the investigation team? II.Speaker’s Notes: Ideally, the investigation should begin immediately. The investigation team should be assembled and the process should begin even while the injured employee is still being treated. The memories of the injured employee and witnesses are affected by time. They may elaborate on the story or forget important details if they are not questioned immediately. Potential causal factors might be removed. For example, the equipment involved may be moved, the slippery floor cleaned up, the broken ladder repaired. Investigators want to arrive at the scene before anything is changed. If the investigation team cannot arrive at the scene immediately, they should make it a priority to arrive as soon as possible. Waiting a day or two is just not acceptable. By then you have lost important information, and the investigation will not be complete. Recommendations from the investigation may not be valid because they are based on inaccurate information.
- I.Background Information: Do you have an accident investigation kit made up? If so, where is it located? Who has access to the kit? Who is responsible for obtaining the kit when the investigation team is called? All of this information should be explained in your accident investigation and reporting procedures. II.Speaker’s Notes: This slide lists the essential elements of an investigation kit. Pictures can be taken and used as evidence or to help supplement the report. Having the report forms will help make sure details are not overlooked while conducting the investigation. Barricade tape is used to block off the accident scene until the investigation is complete. A flashlight may be needed to look for those hidden details A tape measure records the height of fall, etc. A tape recorder can be used by all team members to record witnesses’ statements or investigator’s observations. Work gloves are needed because equipment or debris may need to be moved.
- I.Background Information: Your employees should already understand the importance of immediately reporting all incidents, including near misses. This is stressed in the “New Employee Safety Orientation” training session. Do your supervisors understand how to handle an injured employee? Have they been trained in first-aid/CPR? Do they take the injured worker to the doctor if necessary? Does the supervisor know how to initiate an incident investigation? Do they understand the importance of leaving the incident scene intact for the investigators? Make sure the supervisor understands that the employee should complete the employee account of incident form as soon as possible. II.Speaker’s Notes: Employees are responsible for immediately reporting all injuries, near miss incidents, and facility-damaging accidents. Remember, as a supervisor, you are responsible for ensuring all injured personnel receive proper treatment. Do not touch the incident scene until the investigation team arrives, unless something presents an immediate danger to other personnel, until the investigation team arrives. Contact the incident investigation team and have the injured employee complete the employee account of the incident form.
- I.Background Information: How does NMFS call for an investigation team to gather? Who determines the members of a particular investigation team? Who retrieves the investigation kit? Pass out Accident Investigation forms. II.Speaker’s Notes: Once the team has gathered at the scene, decide who will be the team leader. Step back from the scene to look at the big picture. Do you observe anything that is unusual or out of place? Record your initial observations. Try not to record what you think may have happened; just record what you see. Take pictures or a video.
- I.Background Information: Does NMFS have any kind of post-accident drug screen requirement? If so, you will find out later if the injured employee was on alcohol or illegal drugs. Most of the information contained in this slide will have to be taken from the employee’s statement. The employee may not think to include all of this information, so make sure the employee is thoroughly interviewed. II.Speaker’s Notes: Write down the complete name of the injured employee(s). What department do they work in? Who is the supervisor? Have the injured employee complete his or her account of the incident. Was the injured employee taking any medication, either prescription or non-prescription, such as pain medicine, allergy medicine, aspirin, etc.? Is the employee diabetic or subject to seizures? Is there any evidence of use of alcohol or illegal drugs? Was the employee feeling ill lately (if so, the employee may have been taking medication)? Did the employee have symptoms of drowsiness, upset stomach, headaches, etc.? Was the injured employee working a double shift or rotating shifts? Fatigue or the adjustment in work hours may have contributed to the incident. When interviewing the injured employee, do not come across as trying to find the employee at fault for the accident. Just tell the employee that these are standard questions on the form that have to be answered.
- I.Speaker’s Notes: Write down the name(s) of the witness(es), the departments in which they work, and the names of their supervisors. Interview witnesses separately and write down or record their statements. Some questions to ask witnesses include: Were there any unsafe acts on the part of the person involved that precipitated the incident (i.e., horseplay or not following proper safety procedures). Do you know of any personal factor on the part of the individual involved that may have induced an unsafe condition (i.e., inexperience, alcohol use or fatigue). If supervisors were nearby, was the employee being directly supervised? Where was the supervisor at the time of the accident? Use a facility map or draw a picture of where other employees, including witnesses, were located when the accident occurred. What were they doing? If there were no witnesses, why not? Was the injured employee working alone? If not, why had the other employees left the injured employee alone? Was the fact that the employee was alone a contributing factor?
- I.Background Information: If time allows, have the employees conduct some mock interviews to get them comfortable with the process. II.Speaker’s Notes: When interviewing, avoid using domineering or patronizing mannerisms or speech. The interviewee will probably not respond well to this attitude. Convey your sincere concern for the safety of employees at your facility and let them know that you are trying to find ways to fix the cause of this accident. Do not interrupt the interviewee; take detailed notes. Review your notes at the end of the interview to avoid any misunderstanding.
- I.Speaker’s Notes: Was the injured employee operating a machine, tool, or piece of equipment that may have contributed to the incident? Was there a malfunction? Was the employee trained to use the equipment? How much experience did the employee have with the equipment? Was the employee being directly supervised while using the equipment? Was the employee wearing proper PPE, if required? Was the employee using a chemical at the time of the incident? If so, was the employee properly trained, experienced, or supervised? Was the employee wearing appropriate PPE? Environmental factors include: slippery floor, inadequate lighting, crowded work space, noise, stress, etc. The work schedule can be a factor if the work level was increased well above normal levels. Did this increase cause the injured employee to bypass safety procedures in order to speed up production? Were safety hazards ignored because “production had to be finished”?
- I.Speaker’s Notes: Note the date and exact time of the incident. Was this just before or after a break? Did the injury occur early Monday morning, when the employee may have been tired from a busy weekend? Was the employee working his or her normal shift and performing a normal job function? If not, why was the employee doing work that was outside of the normal work functions? Was the employee coming off of a vacation or sick leave? Is it possible that the employee was daydreaming about the vacation he or she planned to start the next day?
- I.Speaker’s Notes: The incident location needs to be specific. Start with the main work area such as: the northwest corner of the maintenance shop, lobby of the main office, main deck of the vessel. Now get specific: Was the employee on something such as a ladder, a machine, a platform, a chair, a staircase, etc.? Was the injured employee under a overhead load, workbench, a machine, etc.? Was the employee in a forklift, manlift, confined space, etc.? If the accident occurred off-site, make sure the address of the accident site is noted along with these details. Was the injured employee doing work that is part of his or her normal job functions? If not, was the employee properly trained to do the work?
- I.Speaker’s Notes: What type of motion was the injured employee conducting at the time of the accident? Examples include: walking, running, bending over, squatting, climbing, operating a lever, pushing a broom, using a scalpel, turning a valve, turning a wrench, pounding a hammer, etc. Were the motions repetitive? Were they handling heavy or light material? Was it big and bulky? Did they have help, or were they using appropriate material handling equipment, such as a pallet jack or truck dollies?
- I.Background Information: Detailed description is important for claims management. Should the employee later claim that he also injured his knee in the accident, you have a detailed account in which no one witnessed his holding a knee or limping after the accident to indicate that the knee was also injured. II.Speaker’s Notes: The incident should be described on the report in such detail that any reader can clearly picture what happened. For example: The injured employee was walking east down the main aisle, staying to the north side of the aisle, in building #4. He was carrying two boxes of samples with a combined weight of 35 pounds; however, the boxes did come up to his chin and limited his field of vision. The employee did not see the 6-foot, 1/2-inch-diameter extension cord that was laying on the floor and protruding 18 inches into the aisle right next to the newly installed U-Make-It machine. The injured employee stepped on the cord with his left foot, which then rolled forward. Body parts: The employee fell onto his left side and did not have time to break his fall, so his left elbow squarely struck the ground. The boxes were released upon impact. Three of the sample containers broke, spilling approximately 1.5 liters of 10% formalin. Motions after the incident. The employee rolled to his back, sat up and held his left elbow in his right hand. He sat in this position for about a minute before being helped to his feet.
- I.Speaker’s Notes: There are almost always multiple causes that contribute to an accident. Try not to settle on a single cause theory, because there are usually contributing factors. What are all the possible underlying causes or contributing factors. In the example described on the last slide: The employee was carrying a load that partially blocked his vision, the cord should not have protruded out to the aisle. Other considerations: Was the aisle properly lighted? Was there a noise or something that distracted the injured worker from looking down, etc.? Once the list of potential causes or contributing factors has been compiled, try to determine the primary cause, or the cause that appears to have contributed the most to the accident. This is the cause that, if removed, the accident probably would have been prevented. Other causes will be considered as secondary potential causes. All causes should be investigated for corrective actions; however, the primary cause should be the focus of corrective actions.
- I.Background Information: Does NMFS accident investigation and reporting procedures have a form for documenting and recommending corrective actions to management? II.Speaker’s Notes: Immediate corrective actions are those that are done right after the investigation is complete. These will remove a danger and prevent a repeat of the accident until formal, or long-term, corrective actions can be completed. These do not need a recommendation form, because they are implemented immediately by the supervisor or the investigation team. For example, put the extension cord back in its proper storage location before someone else slips on it. Once the investigation team has compiled the investigation report, they can make a number of recommendations to management. Recommendations might include retraining employees on lifting and carrying techniques and material handling equipment, retraining maintenance on putting material away when the job is finished, or maybe improving the lighting in that area of the facility.
- I. Speaker’s Notes: To summarize, these are the steps you should follow when an accident occurs.
- I.Background Information: Remind employees that the quiz is to encourage further discussion and to help you, the trainer, ensure that everyone understands what was discussed in the training session.