Accident Investigation Accident Investigation Learning from our Mistakes

Accident Investigation

Accident Investigation Learning from our Mistakes Bureau Veritas Presentation 2

Accident Investigation Course Introduction • Instructor • Schedule • Participants • Materials • Objectives Bureau Veritas Presentation Incident Investigation 3

Accident Investigation Course Objectives • Understand the critical importance of investigation and reporting • Use tools presented in the course to arrive at the root causes of accidents • Understand the importance of follow-up Bureau Veritas Presentation 4

Accident Investigation Why Investigate? • To determine root causes and prevent recurrence of similar accidents • To demonstrate to employees that management cares Bureau Veritas Presentation 5

Accident Investigation What to Investigate? Everything Serious Injuries 29 1 300 Minor Injuries Non-injury Incidents 350, 000 Chances Bureau Veritas Presentation 6

Accident Investigation Why don’t employees report everything? I said report EVERYTHING!! Bureau Veritas Presentation 7

Accident Investigation What Happened? Resources to find out include: • People • Accident Scene • Records “PAR for the course” Bureau Veritas Presentation 8

Accident Investigation Bureau Veritas Presentation Accident Immediate Causes Basic Causes Safety System Accident Sequence 9

Accident Investigation Causes Sy s Fa tem ilur es The Work System ic Bas s se u a C Bureau Veritas Presentation Immediate Causes The Employee 10

Accident Investigation Workshop • Case #1 - How do you spell relief? • Case #2 – Back to the Grind Danger - High Pressure Bureau Veritas Presentation 11

Accident Investigation Follow-Up The Report The Repair The Review Bureau Veritas Presentation 12

Accident Investigation Summary • Understand the critical importance of investigation and reporting • Use tools presented in the course to arrive at the root causes of accidents • Understand the importance of follow-up Bureau Veritas Presentation 13

Accident Investigation Summary • We investigate to show we care and prevent recurrence • We investigate everything a little to see where we need to investigate a lot • We use people, the accident scene and records (PAR) to find out what happened • We use the Accident Analysis Flow Chart and ask “Why” to help find out why the accident occurred and realize it’s almost always rooted in the management system • We report, repair and review to make sure that the actions necessary to prevent recurrence are completed Bureau Veritas Presentation 14

Accident Investigation Closing Bureau Veritas Presentation 15