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Wednesday, 21 September 2016

Accident investigation

Welcome to
ACCIDENT INVESTIGATION



Objective


Objective 


What is the need for investigating accidents?



The investigation



The Team



Aids Required



Responsiblities of Team



Environment



Records



Structuring the investigation



The Initial Response



Identification of Evidence



Evidence



Recording Evidence



Recording Evidence



Recording Evidence



Recording Evidence



Recording Evidence



Recording Evidence



Recording Evidence



Interviewing skills



Interviewing skills



Interviewing skills



Interviewing skills



Interviewing skills



Interviewing skills



Interviewing skills



Information Preparation



Root cause analysis


Accident Causation


 .

Accident Investigation Models



.

Change and change Analysis



Change and change Analysis



Fault tree analysis



Fault tree analysis



Fault tree analysis



Report Writing



Report writing



Report writing



Summary



Thank you.






Welcome to 
ACCIDENT INVESTIGATION

OBJECTIVES

žTo understand Accident Investigation process in order to conduct more effective accident investigations at work place.
žUnderstanding of various techniques in Accident Investigation Process

žTo identify root causes and recommend preventive measures.

WHAT IS THE NEED FOR INVESTIGATING ACCIDENTS?

THE INVESTIGATION

THE TEAM

Should consist of:
žThe Health and Safety Officer
žThe local Manager/Supervisor
žThe local Safety Rep/Responsible Person
žAn expert in a particular field (if needed)

žWho else – discuss!
Aids Required

Toolkit list:
žCamera, including films etc
žLighting/Torch
žTape recorder/Personal dictaphone
žMobile Telephone
žThermometer
žTape measure
žClipboard/Pens etc
žColoured chalk
žBarrier Tape
žKeep out signs
žPPE
žProtective Gloves/latex
žAbsorbent Cloths/tissue

žPlastic Bags - waterproof
Responsibilities of Team

žTake the control of the accident scene
žPrevent further injury/damage/loss
žPreserve evidence
žLog/measure facts
žNote environmental evidence
žIsolate/interview genuine witnesses/staff/persons in the vicinity
žCheck relevant documentation
žCommunicate/liase with other team members/mgt
žCo-ordinate ongoing investigation information
žDetermine causes
žPrepare/complete accident investigation report
žInfluence changes necessary to prevent recurrence

Environment

Measurements
žTemperature
žLighting conditions
žNoise/vibrations
žSpace constraints
žCondition of flooring
žCeiling
žWet/slippery conditions
žObstructions
žTraffic
žWeather
žAccess/egress
RECORDS

žReports
žMOMs
žRisk Assessments
žTraining Records
žMonitoring Procedures

STRUCTURING THE INVESTIGATION

THE INITIAL RESPONSE

Take control at the scene
žMake sure you don’t injure yourself
žPrevent secondary accidents
žCall for a first aider/emergency services
žCall for Accident Investigation team
žPreserve accident scene

IDENTIFICATION OF EVIDENCE

Critical in any investigation identify
žSequence of events
žOutcome   (Near misses, Major injuries or Fatal)
žCauses

EVIDENCE

Evidence must be factual
žit may be something tangible
žit may be the environmental conditions which prevailed at accident time

RECORDING EVIDENCE

Recording surroundings:
žIsolate the area /deal with any injured person(s) first
žObserve position of injured person(s)
žTime of day/Date
žEnvironment conditions
žPhotographs/Film

Recording surroundings:
žIsolate the area /deal with any injured person(s) first
žObserve position of injured person(s)
žTime of day/Date
žEnvironment conditions
žPhotographs/Film

Injured Person
žName/ D.O.B
žEmployment details
žTraining received
žExperience/knowledge
The Injury
lNature of injury
lTreatment

Four key areas:
žWitnesses
žReports
žEquipment, Plant etc
žDocuments and Procedural Manuals

Witnesses
Care must be exercised when taking any statements or when handling witnesses

Site Accident Summary Reports:
žMedical Department
žSupervisor
žSafety Advisor

Equipment
žModel/make of
žSerial number
žAge
žIntended/actual use
žAny modifications
žMaintenance records
žGuarding
žInterlocks
žSafety Checklists

Documents and Procedural manuals including:
žRisk assessments
žTechnical instructions
žPermits to work
žMethod statements
žRecords of training
žRecords of previous problems/accidents
All documentation must be accessible, evidence used must be recorded, numbered, cross-referenced and signed by originators

INTERVIEWING SKILLS

Successful Investigative Interviews:
žA two-way process
žNeed not be an interrogation
žEstablishment of  Trust
Examples of witnesses:
žThe Injured
žWitnesses to accidents / events (visual & aural)
žManagers and Supervisors

Key Points
žQuestioning should be open-ended to encourage witnesses to give evidence
žUseful to have visual aids
  though do not put suggestions forward to interviewee
žStatements should be written and signed with date and time of the interview
Personal needs
People need to feel:
žvalued
žappreciated
žlistened to
žunderstood

Practical needs
žReasons for the interview
žImmediate & underlying causes can be established
žFacts accounted for/evaluated
žAgreement on actions to be taken
Improved techniques:
žListen and respond with empathy
žAsk for help and encourage involvement
žExplain and ask for explanations
žAlways be truthful

INFORMATION PREPARATION

ROOT CAUSE ANALYSIS

ACCIDENT CAUSATION

Accident Domino Theory


Accidents happen as a result of a sequence of events, the theory is, that if you interfere at any stage, the accident will not occur, and therefore there will be no loss or injury.

žChange and Change Analysis
žFault Tree Analysis

ACCIDENT INVESTIGATION MODELS

Change and Change Analysis

Change and Change Analysis

Fault Tree Analysis

žCan prevent investigator bias.
žAdvantages:
Identifies possible paths from basic cause;
Shows relationships, system deficiencies;
Considers ‘hardware’ and human failings;
Clear record of analytical path followed;
Rational basis for decision making.


REPORT WRITING

Should consider:
1. What is the purpose of the report
2. Who will need it
3. Report structure
4. Style
5. Presentation

3. Report Structure
žMain body first
žConclusions & recommendations
žIntroduction
žFinal stage: appendices/refs etc

4. Style
‘Simplicity’
No ambiguous sentences
Exaggeration
Overuse of adjectives etc
Conclusions - brief, to the point

5. Presentation
check layout
check content
check words used i.e punctuation/grammar

name & date

Once the draft report is completed ensure that the following is covered:
žCoherent description of the events leading up to the accident
žRational view of what should be done in the way of remedial actions

SUMMARY

A successful accident investigation process should incorporate:
žA causal model representing a ‘system based approach
žInvolvement of key, relevant individuals
žProcedures/protocols to structure and support the investigation
žIdentification of both immediate and underlying causes
žDevelopment of recommendations that address the latter
žImplementation of these recommendations and update of relevant risk assessments
žFollow up to ensure, actions taken are successful
žFeedback to relevant parties to share learning
žDevelopment of an accessible database

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