ACCIDENT INVESTIGATION

ACCIDENT INVESTIGATION Accident investigation is required activity by Washington State Administrative code. It is also required by the City’s safety committees for review of the results of the investigations and follow-up recommendations. This chapter provides some insight to the philosophy and process of investigating accidents and incidents. The Accident Worksheet is found in Appendix FA-3 and is also referred to in Chapter A-3, Safety Committees. The key to preventing a reoccurrence It is the position of the City of Spokane that all accidents can be prevented, not just theoretically, but realistically. A key step in this prevention program is accident investigation and then the corrective actions that follow. Accident Investigation It is critical that accident investigation be entered into knowing that we can make a difference if we can find the true causes of the accident. This means dropping any assumptions that there is nothing that can be done - “it is an accident.” Now that you have dropped this assumption, 1 2 9 30 0 A5.1 CITY OF SPOKANE RISK MANAGEMENT & SAFETY MANUAL Chapter A-5: Accident Investigation Created: September 2000 realize that we should investigate all accidents formally, and the near miss accidents in an informal investigation. Heinrich’s Accident triangle shows us this. A study of accidents was done. What it revealed on the average is: that out of 330 times in an identical situation, there would be 300 near miss accidents, or opportunities to see an accident coming. 29 times there would be a minor accident, and 1 out of the 330 would result in a serious accident. For example: I could stumble on a crack in the sidewalk 300 times, I might fall and sustain a scrape or bruise 29 times, and one time I could perhaps fall with a baby in my arms and the child would be severely injured. Since this is a statistical model, we don’t know which time will be the serious injury. It could be the first stumble, the last, or anywhere in the middle of the 330. This is why we investigate all accidents and near miss opportunities. Accidents Have Multiple Causes All accidents have multiple causes that intersect in time and space. If we can deduce the causes and eliminate anyone of them, we can prevent a repeat of the exact same accident from happening again. Many times eliminating one of the causes also Primary Cause Secondary Cause Contributing Causes CITY OF SPOKANE RISK MANAGEMENT & SAFETY MANUAL Chapter A-5: Accident Investigation Created: September 2000 A5.2 eliminates future accidents that might have occurred with other elements as well. The key is to investigate until the true causes of the accident are discovered. Fortunately there is a technique for doing this type of accident investigation. It is called the Why Method of Accident Investigation. The Why Method of Accident Investigation This method starts out very simply by stating the name of the injured party, the injury, and the element that caused the injury. These are the apparent facts that we have to begin with. Then we start with the Cause of Injury and ask the question why? Why was the person injured by: whatever it was. Then repeat by asking why to the answer of that question until there is a series of questions and answers. From that list, select the Primary Cause that is most likely. Now you can take the original question or any question in the primary cause list and ask once again, why? There should be a different answer and we start descending down the secondary cause list repetitively asking the question, why? CITY OF SPOKANE RISK MANAGEMENT & SAFETY MANUAL Chapter A-5: Accident Investigation Created: September 2000 A5.3 Note that there Accident Injury Cause of Injury are two styles of asking the Why ? Why ? question. One in a descending order with each answer Why ? Why ? Why ? resulting in another question - why? And the second style is to keep asking the same question way over and over getting different answers each time. The Typical Results of an Investigation 15% Condition The typical results of an investigation reveal that 85% of the causes are “actions”, something that someone did. 15% of the causes of accidents 85% Personal Action exist in the workplace. are “physical conditions” that In the majority of controlled environments this will hold true. The fortunate result of this is that most accidents can be remediated through either training or an engineering control. We are only looking for one or the other. CITY OF SPOKANE RISK MANAGEMENT & SAFETY MANUAL Chapter A-5: Accident Investigation Created: September 2000 A5.4 It is important that we stay objective with employees. Just because 85% of accidents are caused by something someone did, it does not mean that they wanted to be involved in an accident. No one wants to be injured. Accident investigation should not be punitive, but should be presented as a caring function of management – making the work environment safer. Investigative Tools and Skills The supervisor or manager filling out the injury report should also be the one to do the accident investigation. Presumably they are close to the worker and know the job best. If the supervisor starts the investigation immediately, they will be closest to the fresh facts. Furthermore they should have the ability to come to a logical conclusion and effect positive change. We must reiterate that the accident investigation must begin immediately and that the person doing the accident investigation should go to the scene of the accident. Important details come from the accident scene. We want to get there before causal factors are removed and we want the opportunity to interview witnesses. Waiting is not acceptable and the accident investigation is due with the accident report, which should be completed before the end of that shift. CITY OF SPOKANE RISK MANAGEMENT & SAFETY MANUAL Chapter A-5: Accident Investigation Created: September 2000 A5.5 Investigative skills include interviewing both the injured individual and any witnesses. It is important that we be sincere and caring during the accident investigation. Remember and convey that our goal is to prevent future injuries, not punish employees. The classic investigative questions of “who, what, why, when, where, and how” must be answered. Hidden and often human action type details must be uncovered. These are not in the physical evidence realm, and therefore are more difficult to uncover. The supervisor filling out the accident report should be able to spot an unsafe act or unsafe condition quickly and then be able to communicate a clear picture to secondary audiences. It helps to ask open-ended questions that require more then a yes or no answer. Use of the “awkward minute,” allows 60 seconds of silence for the interviewee to formulate and respond to a question. It is important that we do not interrupt the interviewee once they have started. It is OK to clarify information, but wait until they have finished speaking. Our job in the investigative stage is to take detailed notes and complete the paper work immediately. If the investigation does not yield apparent causes, we might want to question things like policies, procedures and training. This includes looking at who was near by, or who should have been near by. Were there any unsafe acts, unsafe conditions, equipment or chemicals? What CITY OF SPOKANE RISK MANAGEMENT & SAFETY MANUAL Chapter A-5: Accident Investigation Created: September 2000 A5.6 personal factors might have come into play? Has there been any change in productivity demands? The deeper we question the more likely we are to come to realistic causes of the accident. Then we are most likely to be solving root causes instead of symptoms. Often an Accident Investigation Tool Box can be helpful. You might want to include things like a camera to take accident photos with; or, a micro cassette recorder to record statements with; or, flashlight to explore dark or dimly lit accident scenes. You definitely want to have the accident report and investigation forms and perhaps a clipboard to write on. We also recommend gloves in case there is hazardous debris to handle or blood borne pathogens. Having a roll of barrier tape might also be a consideration if we need to keep employees out of an accident site, or if we need to block off the area during the investigation and until we get it cleaned up and back to a point of productivity. EFFECTING CHANGE (Our Tool Box for Correcting Unsafe Actions or Conditions) There are six techniques that are widely accepted by safety professionals for effective accident prevention. These are:  The Domino Theory  Industrial Hygiene Techniques CITY OF SPOKANE RISK MANAGEMENT & SAFETY MANUAL Chapter A-5: Accident Investigation Created: September 2000 A5.7  The Energy Release Theory  The Technique of Operations Review  System Safety Schematics  Antecedents, Behaviors & Consequences Different methods are more applicable to certain situations, so we will cover all six. The Domino Theory H.W. Heinrich, a leading Industrial Safety Engineer, developed the Domino theory. He believed that all accidents could be modeled with a chain of five factors. They were: o Ancestry and social environment o The fault of a person o An unsafe act and/or physical hazard o An accident o The resulting injury If the chain could be broken before the accident, injuries could be eliminated. He believed that the easiest place to break the chain was by eliminating an unsafe act or physical hazard. This theory is the corner stone of our accident investigation program because it simplifies our search to the two basic elements of prevention – the unsafe act or physical condition that can be commonly found in all accidents. This CITY OF SPOKANE RISK MANAGEMENT & SAFETY MANUAL Chapter A-5: Accident Investigation Created: September 2000 A5.8 also simplifies corrective activity that can be categorized in two groups, education and training, or change of a physical hazard. Industrial Hygiene Methods These are eleven basic methods developed by hygienists and engineers over the years for controlling work processes. It is the plan that we use to make processes safer. They are: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Substitute a less harmful material Alter process to reduce worker contact Isolate or enclose a process Use wet methods to reduce particulates Ventilate to disperse contaminates Dilution ventilation Maintain good housekeeping Monitor & control exposure Personal Protective Equipment (PPE) Implement baseline & detection programs Educate and train employees The Energy-Release Theory The Energy-Release Theory is credited to Dr. William Haddon Jr. of the Insurance Institute for Highway Safety and was developed in the 1970s. There are ten basic principals that are used widely wherever energyrelease is seen. They are: 1. 2. Prevent the marshaling of energy Reduce the amount of energy A5.9 CITY OF SPOKANE RISK MANAGEMENT & SAFETY MANUAL Chapter A-5: Accident Investigation Created: September 2000 3. 4. 5. 6. 7. 8. 9. 10. Prevent the release of built-up energy Modify the rate or distribution of release Separate energy in space or time Create a physical barrier Modify the contact surface to absorb Strengthen the contact surface Detection, evaluation & counter measures Take long-term action It is important to remember that this is applicable wherever energy is released, including gravity. Think of hardhat situations! The Technique of Operations Review The Technique of Operations Review is a specific look at management practices that is attributed to D.A. Weaver. He believed that all accidents are a result of the failure of management and that it was critical for management to be accountable in resolving issues that cause accidents. This technique is very critical of management, but it often yields truth that cannot be found in the other techniques - if we can objectively evaluate ourselves. Inadequate Coaching –Failure to coach w/ new process –Lack of instruction to situation –Failure to see a need for training –Inadequate instruction / explanation –Failure to listen to the employee Failure To Take Responsibility –Duties responsibility or tasks are not clear –Conflicting goals / responsibilities exist –Time / task pressures –Accountability issues –Inadequate job descriptions CITY OF SPOKANE RISK MANAGEMENT & SAFETY MANUAL Chapter A-5: Accident Investigation Created: September 2000 A5.10 Unclear Authority –By passing or conflicting direction –Incorrect decision or authority –Evasion of decisions –Unclear direction –Subordinate fails to exercise decisions Inadequate Supervision –Low moral, tension, insecurity –Poor conduct examples –Failure to see problems & exert influence –Lack of credibility –Lack of leadership skills Workplace Disorder –Insufficient or hazardous layout –Failure to inspect and understand hazards –Insufficiently maintained –Cluttered or over crowded –Willing to live with disorder Inadequate Planning/Organization –Not preplanning work –Work space problems –New or unusual tasks –Size of workforce –Lack of job / worker match –Poor coordination between stakeholders Personal Deficiencies –Poor health or physical ability –Limited intelligence or knowledge –Substance abuse –Dysfunctional personality traits –Poor habits –Unsuitable assignments \ CITY OF SPOKANE RISK MANAGEMENT & SAFETY MANUAL Chapter A-5: Accident Investigation Created: September 2000 A5.11 Poor Organizational Structure/Planning –Failure to set policy –Unclear goals - follow-through –Lack of accountability –Overburdened functional areas –Lack of human resources development –Failure to encourage and support decisions System Safety System Safety is based on the thought that we can take complex systems and break them down into smaller interrelated systems with relationships. With the chunks of the system in smaller pieces and the relationships diagramed, we can more effectively deal with problems. System safety is usually used in very complex or important situations that deserve detailed evaluation. An example of this is how they found the o-ring that caused the explosion in the space shuttle Challenger. System safety takes on many different forms and can be quite elaborate, but they all share four basic points. They identify potential hazards Incorporate safety into design Evaluate the designs early on And, monitor all safety aspects throughout the life of the system. Some of the common forms of System Safety are:       Change Analysis Energy Flow Analysis Prototype Analysis Job Safety Analysis Scenario Analysis Cost Benefit Analysis      Criticality Analysis PERT Analysis Fault Tree Analysis Failure Mode & Effect Technique of Human Error Rate Prediction (THERP) CITY OF SPOKANE RISK MANAGEMENT & SAFETY MANUAL Chapter A-5: Accident Investigation Created: September 2000 A5.12 Antecedents, Behaviors & Consequences The ABCs of Safety is a very trendy program that is getting a lot of attention. Its value is quite strong in that it helps us to ferret out the reasons people behave unsafely. The concept itself is quite simple. When unsafe behavior is exhibited, we look at the antecedents or behavior triggers to reveal the motivations for that behavior. Once the antecedents are consequences for the motivate a safer behavior. Consequences can be thought of in two ways. Intrinsic, the very natural, consistent and reoccurring consequences that is similar to burning yourself on a hot stove. Every time you touch it, the burner is hot. The feedback is immediate and consistent. Extrinsic consequences are much more inconsistent. For example we may not see an employee without their hardhat on nine out of ten times. Even though we may be consistent in calling them on it on the tenth, the feedback is inconsistent and not naturally occurring as in the intrinsic consequences. Extrinsic consequences can also be positive or negative. Positive extrinsic consequences are rewards or recognition when people do things right. They are synonymous with building a competent and loyal work force. On the other hand, negative extrinsic consequences are punitive and punishing in nature. It is suggested that if we are using negative extrinsic consequences on more than an occasional basis that the management technique is flawed and we should return to the Technique of Operations Review to examine our own strengths and weaknesses. It is key to remember that extrinsic consequences take constant effort to maintain and regular focus on safety as a value must be embraced. This technique’s main strengths lie in the discovery of the basis of behavior and the modification opportunities that are revealed. CITY OF SPOKANE RISK MANAGEMENT & SAFETY MANUAL Chapter A-5: Accident Investigation Created: September 2000 A5.13 established, then the behavior can be adjusted to Empowerment Essential to the theory of Accident Investigation is empowerment. The very reason we do accident investigation and take all the time to discover the primary causes is so that we can take action to effect safe change. That goal can only be accomplished if you realize that you make a difference every time a safety cause is championed. Some changes will not come about immediately. Many changes require significant effort. However, each step towards a safer work environment pays multiple dividends. You can create a safer environment that will cause less physical pain to others. You may save a life. You can prevent significant financial losses through workers’ compensation, lost productivity and material loss. You will help us to comply with the safety regulations and laws that are there to protect our employees. Your efforts make a difference. CITY OF SPOKANE RISK MANAGEMENT & SAFETY MANUAL Chapter A-5: Accident Investigation Created: September 2000 A5.14