217 - Accident Investigation Training by niusheng11


   Explain the meaning and impact of
   Identify different types of accident causes
   Know the purpose of accident investigation
   Explain how to conduct an accident
   Know how to document accident
          What is an Accident?
   Unplanned event results in mishap
    (personal injury or property damage).
   Accidents are the result of the failure of
    people, equipment, materials, or
    environment to react as expected.
   All accidents have consequences or
          Purpose of Accident
   Determine the sequences of events leading
    to failure.
   Identify the cause of the accident.
   Find methods to prevent accident from
      Consequences of Accidents
Direct Consequences    Indirect Consequences

1.   Personal injury   1.   Lost income
2.   Property loss     2.   Medical expenses
                       3.   Time to retrain
                            another person
                       4.   Decreased employee
                      Types of Causes
                    Basic Causes
     Poor Management Safety Policy & Decisions
       Personal Factors/Environmental Factors

 Unsafe Act                                 Conditions
                  Indirect Causes

              Unplanned release of energy            ACCIDENT
                   (Direct Cause)                   Personal Injury
                                                   Property Damage
  Examples of Accident Causes
Direct Causes   Indirect Causes   Basic Causes
Struck          Failure to secure No oversight
Falls           Guarding          Poor
Caught          Improper use      Training
Exertion        Unsafe position Policies
Contact with…. Environmental      Stress
Impact (vehicle) Defect           Engineering
                Be Prepared
   Develop a policy for accident investigation
   Routinely audit your policy to:
    - ensure personnel understand their role
    - system is driving corrective actions
    Assign responsibilities to personnel:
    - employee must be trained to investigate
    - investigator should know process
Employee Involvement
   Train employees in incident investigation
       Knowledge and skills
   Employees may act a member of an
    Incident Investigation Team
       Personnel from an area not involved in the
   Interview Employees who perform the
    same job
   Review JHAs, SOPs – recommend
Incident Analysis Team
   Identify                      Membership
    Incident/Accident                 Third Line Supervisors
    Team Lead                         Employees from an
       Control Scope of               area not involved in
        activities by                  the incident
        identifying analysis          Maintenance Services
        to pursue                      and Wage Personnel
   Ensure all team                   Safety Supervisor
    members engaged                   1st Line Supervisor
                                       from affected area
   Communicate Results
                                      Occupational health
    Conducting the Investigation
   Interview witnesses.
   Document the accident scene before any
    changes are made.
   Review all information (procedures,
    equipment manuals).
    Conducting the Investigation
   Make documented observations on:
       Pre-accident conditions
       Accident sequence
       Post-accident conditions
   Document the facts (i.e.: location, witness
    remarks, and contributing factors).
   Determine sequence of events leading to
     Common Problem Solving
   Job Hazard analysis
   Sequence diagrams
   Change analysis
        Job Hazard Analysis
Steps    Hazards   Causes   Control
              Change Analysis
   A change analysis consists of:
       Defining the problem
       Establishing the norm
       Identifying, locating, and describing the
       Identify what was affected and not affected
       List features of change
       Pick likely causes
                              The Five Whys
    Basic Question - Keeping asking “What caused or allowed
     this condition/practice to occur?” until you get to root causes.
    The “five whys” is one of the simplest of the root cause
     analysis methods. It is a question-asking method used to
     explore the cause/effect relationships underlying a particular
     problem. Ultimately, the goal of applying the 5 Whys method
     is to determine a root cause of a defect or problem.
The following example demonstrates the basic process:

My car will not start. (the problem)

1) Why? - The battery is dead. (first why)
2) Why? - The alternator is not functioning. (second why)
3) Why? - The alternator belt has broken. (third why)
4) Why? - The alternator belt was well beyond its useful service life and has never been replaced.
     (fourth why)
5) Why? - I have not been maintaining my car according to the recommended service schedule.
     (fifth why and the root cause)
            Benefit of Asking the Five Whys
Simplicity. It is easy to use and requires no advanced mathematics or tools.
Effectiveness. It truly helps to quickly separate symptoms from causes and
identify the root case of a problem.
Comprehensiveness. It aids in determining the relationships between various
problem causes.
Flexibility. It works well alone and when combined with other quality
improvement and trouble shooting techniques.
Engaging. By its very nature, it fosters and produces teamwork and teaming
within and without the organization.
Inexpensive. It is a guided, team focused exercise. There are no additional

Often the answer to the one “why” uncovers another reason and generates
another “why.” It often takes “five whys” to arrive at the root-cause of the
problem. You will probably find that you ask more or less than “five whys” in
           Witness Interviews
   Interview promptly.
   Establish rapport with witness (treat as
   Get the facts.
   Write down the witness’ statement
   Complete an accident investigation form to
       Personnel information
       Accident information (location, events
        leading to accident, machines involved)
       Causes of the accident
       Recommendation to prevent accident
       Follow up information
   From the accident investigation form and
    witness statements write an accident
    investigation report. The report should
       Background information (where, who)
       Summary (sequence, extent, type, source)
       Analysis (causes)
       Recommendations
    Steps to Accident Investigation
   Survey the scene
   Secure the scene (initiate interim controls)
   Get help for the injured
   Collect evidence
   Analyze data
   Determine causes (scientific methods)
   Follow up (eliminate hazards)

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