Accident Investigation WHAT IS AN ACCIDENT What is

Accident Investigation

WHAT IS AN ACCIDENT? • What is an accident? o Any unexpected event o Some may even be good • Does an accident always involve an injury? • Does an injury always involve an accident?

What Is An Accident?

Accidents • Accident o Any unplanned event that results in § Personal injury § Property damage

Accidents • Usual causes o Failure of people, equipment, supplies, or surroundings to behave or react as expected

WHY INVESTIGATE? • Why investigate? o To PREVENT injuries • Investigations should not be witch hunts o If results show need for discipline, fine But. . . o That is not the purpose

INVESTIGATIONS • Include non injury accidents incidents o Proactive o Preventative • Investigating only injuries o Reactive

INJURY PYRAMID Fatality Serious Recordable 1 st Aid Cases Non-injury Accidents

Incident Investigation Plan • Establish parameters • Be aware of other requirements o ADA, EEO, Union, etc. • Establish procedures • Develop forms • Train employees

First Report The “First Report of Injury” sent to Workers’ Compensation Company is NEITHER an accident report NOR an investigation.

Incident Report • Write an incident report o As soon as possible • Start with a supervisor’s report based on information provided by employees o “Employee said. . . ”

Injury Potential • Investigate based on POTENTIAL FOR INJURY • The greater the potential, the more thorough the investigation

The Investigation Avoid a “cold trail”

The Investigation • Be methodical • Gather as much information as possible o Throw out irrelevant information during the analysis step

The Investigation • Beware of preconceived conclusions • Beware of “jumping the gun” o Do not offer solutions before you find the basic cause

The Investigation • • • ASK QUESTIONS When you get an answer, ask “WHY” Then ask “WHY” again And AGAIN And “who? ”, “what? ”, and. . . ”why? ”

Basic Causes Indirect Causes Direct Causes Management Safety Policies & Decisions Personal Factors Environmental Factors Unsafe Act Unsafe Condition Unplanned Release of Energy and/or Hazardous Material Incident

The Investigation • Investigate the scene o Take measurements o Take pictures o Evaluate equipment o Be imaginative

The Investigation • Look for o o o o Guards off Lack of PPE Housekeeping issues Poor work practices Faulty equipment Inadequate training Poorly written procedures Etc.

The 4 “Ps” • • People Position Parts Paper

Interviews • • Interview employee involved Interview witnesses Interview other employees in area Look for similar incidents

Interviews • Explain the purpose of the investigation • • o Accident prevention Put at ease Let speak freely Take notes without distracting Only use a tape recorder with the person’s knowledge and consent. • Interview as soon as possible

Analysis Techniques • • • Change analysis Job Safety Analysis (JSA) Event and Causal Factors Analysis Multi linear Events Sequencing (MES) Project Evaluation Tree (PET) Combination

Report of Investigation • 1. Background information • 2. Detailed account of the incident • 3. Resolution • 4. Corrective actions

RESOLUTION • Discuss ways of preventing future incidents • Solicit ideas from employees & others • Be creative • Make recommendations

Corrective Actions • Corrective actions o Recommendations that are adopted • Inform and train employees and supervisors

Follow-Up • Involve supervisors & employees • Are solutions: o Used? o Effective? • Solicit feedback

Trend Analysis • Evaluate for incident, accident and injury trends in order to focus efforts • Use 300 forms, incident & accident reports, first aid logs, inspection reports, etc. • Analyze by entity, facility, time, job, etc. • Do at least a 3 year comparison

Resource • Ask for help from your workers’ compensation carrier

Sandra A. Mihalik, WSO-CST Safety & Health Specialist Montana Safety & Health Bureau Phone: 406. 444. 6418 E-mail: smihalik@mt. gov