Accident Investigation

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					    HU 151_Lect 7




  Accident
Investigation
                OUTLINE
   Accident/Incident
   Investigation Outcome
   Investigation Steps
   Three Types of Causes
    Example




                HU 151, Lecture 7, Accident Investigation   2
       What Is An Accident?
An unplanned, unwanted, but controllable event
which disrupts the work process and causes personal
injury and/or in property damage.




                HU 151, Lecture 7, Accident Investigation   3
   BP's Deepwater Horizon oil well explosion
    last year - killed 11 workers and
   caused the biggest offshore spill in US history.

  According to BP's September 2010
  report, the accident started with a
  "well integrity failure". This was
  followed by a loss of control of the
  pressure of the fluid in the well. The
  "blowout preventer", a device which
  should automatically seal the well in
  the event of such a loss of control,
  failed to engage. Hydrocarbons shot
  up the well at an uncontrollable rate
  and ignited, causing a series of
  explosions on the rig.
http://www.bp.com/liveassets/bp_internet/globalbp/globalbp_uk_english/incident_response/STAGING/local_assets/downloads_pdfs/Deepwater_Horizon_Accident_Investigation_Report.pdf




                                                            HU 151, Lecture 7, Accident Investigation                                                                4
        What Is An Incident?
An unplanned and unwanted event which disrupts the
work process and has the potential of resulting in
injury, harm, or damage to persons or property.




               HU 151, Lecture 7, Accident Investigation   5
    Incident Investigation
     Incidents should be investigated as well, since
     they are potential “accidents”.


Criteria for investigating an incident:

- What is reasonably the worst outcome, equipment damage,
or injury to the worker?
- What might the severity of the worst outcome have been?
- If it would have resulted in significant property loss or a
serious injury, then the incident should be investigated with the
same thoroughness as an accident investigation.

                      HU 151, Lecture 7, Accident Investigation   6
Accident Investigation

   Will determine how and why of failures.
   Examine possible corrective action.
   Aid in the accident prevention and elimination
    of a clearly identified hazard.
   Most important -Investigation                             is not
    intended to place blame.


                  HU 151, Lecture 7, Accident Investigation            7
         Investigation Outcome
1. Prevent future incidents (leading to accidents).
2. Identify and eliminate hazards.
3. Expose deficiencies in process and/or
   equipment.
4. Reduce injury and worker compensation costs.
5. Maintain workers’ morale.
6. Meet regulations.

                  HU 151, Lecture 7, Accident Investigation   8
              Main Steps
1.   Develop a plan
2.   Assemble an investigation kit
3.   Investigate all incidents and
     accidents immediately
4.   Collect facts
5.   Interview witnesses
6.   Write a report

            HU 151, Lecture 7, Accident Investigation   9
Begin Investigation Immediately

   It’s crucial to collect evidence and interview
    witnesses as soon as possible because
    evidence will disappear and people will
    forget.




                HU 151, Lecture 7, Accident Investigation   10
                  CAUSES
   Direct Cause – the actual energy (movement or
    source) that caused injury to employee. If this
    energy wasn’t present, the injury would not have
    occurred.
   Indirect Causes – any unsafe acts or conditions
    that contribute to the injury occurring.
   Basic Causes – policies, procedures,
    environment or personal factors that contribute to
    the injury occurring.


                   HU 151, Lecture 7, Accident Investigation   11
The Three Basic Causes
    Poor Management Safety Policy & Decisions
               Personal Factors                                     Basic Causes
             Environmental Factors




                                                        Unsafe
Unsafe Act       Indirect Causes                       Condition

             Unplanned release of energy                             ACCIDENT
                      and/or
                                                                    Personal Injury
                Hazardous material
                                                                   Property Damage

                       HU 151, Lecture 7, Accident Investigation                   12
Preparing for the Investigation

   Develop contingency plans prior to the
    accident.
   Designate an investigator
       This person should only be responsible for
        investigating.
       Should have a good working knowledge of
        operating procedures.
   Be equipped with the right tools to do the job
    thoroughly.

                      HU 151, Lecture 7, Accident Investigation   13
Record the Facts

   Interview witnesses as soon as possible.
   Document the accident scene before any
    changes are made.
       Take photos
       Draw scaled sketches
       Record measurements
   Gather support documents such as
    maintenance records, reports, production
    schedules or process diagrams.
                    HU 151, Lecture 7, Accident Investigation   14
Record the Facts

   Keep all notes and remarks in a bound
    notebook or three ring binder.
   Record:
       Pre-accident conditions
       Accident sequence
       Post-accident conditions
   Document victim location, witnesses,
    machinery, energy sources and other
    contributing factors.
                      HU 151, Lecture 7, Accident Investigation   15
Record the Facts

   Even the most insignificant detail may be
    useful.
   Document and then document some more.
   The investigator should be concentrating
    solely on the investigation at hand.




                 HU 151, Lecture 7, Accident Investigation   16
Interviewing

   Excellent source of first hand knowledge.
   May present pitfalls in the form of:
       Bias
       Perception
       Exaggeration
   It is important to maintain a clear thought
    process and control of the interview.



                       HU 151, Lecture 7, Accident Investigation   17
Interviewing

   Get preliminary statements as soon as
    possible from all witnesses.
   Locate the position of each witness on a
    master chart (including the direction of view)
   Explain the purpose of the investigation
    (accident prevention) and put each witness at
    ease.



                  HU 151, Lecture 7, Accident Investigation   18
Interviewing
   Let each witness speak freely and take notes
    without distracting the witness (use a tape
    recorder only with consent of the witness).
   Use sketches and diagrams to help the
    witness.
   Emphasize areas of direct observation and
    label hearsay accordingly.
   Record the exact words used by the witness
    to describe each observation.

                  HU 151, Lecture 7, Accident Investigation   19
Interviewing

   Word each question carefully and be sure the
    witness understands.
   Identify the qualifications of each witness
    (name, address, occupation, years of
    experience, etc.).
   Supply each witness with a copy of their
    statements (signed statements are
    desirable).


                 HU 151, Lecture 7, Accident Investigation   20
Problem Solving Techniques
Change Analysis


   This technique emphasizes change to correct
    the problem.
   Examination of deviations from the norm are
    scrutinized.
   Consider all problems to result from some
    unanticipated change.
   Analyze the changes to determine its cause.



                  HU 151, Lecture 7, Accident Investigation   21
Problem Solving Techniques
Change Analysis

   Use the following steps in this method:
       Define the problem (What happened?).
       Establish the norm (What should have happened?).
       Identify, locate, and describe the change (What, where, when, to
        what extent).
       Specify what was and what was not affected.
       Identify the distinctive features of the change.
       List the possible causes.
       Select the most likely causes.


                           HU 151, Lecture 7, Accident Investigation       22
Problem Solving Techniques
Job Safety Analysis

   Job safety analysis (JSA) is part of many existing accident
    prevention programs.
   In general, JSA breaks a job into basic steps, and identifies
    the hazards associated with each step as well as
    prescribing controls for each hazard.
   A JSA is a chart listing these steps, hazards, and controls.
   Review the JSA during the investigation if a JSA has been
    conducted for the job involved in an accident.
   Perform a JSA if one is not available to determine the
    events and conditions that led to the accident.



                       HU 151, Lecture 7, Accident Investigation   23
Problem Solving Techniques
Job Safety Analysis




                      HU 151, Lecture 7, Accident Investigation   24
Investigation Report

   An accident investigation is not complete until
    a report is prepared and submitted to the
    proper authorities.
   Suggestion of items to include in your report.




                  HU 151, Lecture 7, Accident Investigation   25
Investigation Report
    Background Information
        Where and when the accident occurred
        Who and what were involved
        Operating personnel and other witnesses
    Account of the Accident (What
     happened?)
        Sequence of events
        Extent of damage
        Accident type
        Agency or source (of energy or hazardous
         material)   HU 151, Lecture 7, Accident Investigation   26
Investigation Report
    Discussion (Analysis of the Accident - HOW;
     WHY)
        Direct causes (energy sources;
         hazardous materials)
        Indirect causes (unsafe acts and
         conditions)
        Basic causes (management policies;
         personal or environmental factors)


                   HU 151, Lecture 7, Accident Investigation   27
Investigation Report

   Recommendations (to prevent a recurrence)
    for immediate and long-range action to
    remedy:
       Basic causes
       Indirect causes
       Direct causes (such as reduced quantities or
        protective equipment or structures)




                      HU 151, Lecture 7, Accident Investigation   28
           CASE STUDY - Bus

Accident Description:

“I was checking the steering fluid in bus engine.
   I had to climb up on the front tire and when I
   was getting down, I felt my left knee pop.”




                HU 151, Lecture 7, Accident Investigation   29
      QUESTIONS TO UNCOVER CAUSES
    Why did employee have to stand on the tire?
    Are there other ways of checking fluids?
    What is the process for getting down?
    What type of training did you receive for checking
    fluids? By who?
    What is the distance between tire and first step to get
    down?
     Each additional step?
    Tell me what you did from the time you arrived at work?
    What was going on/happening around you at the time
    you were getting down?
    What type of shoes were you wearing?
    Have there been similar incidents? Explain.
    What was the weather?

                     HU 151, Lecture 7, Accident Investigation   30
         Investigation Findings – Bus
    Driver was not trained how to check fluids on this type of
    bus.
    There are two step ladders available, but none close by.
    No process or procedures in place for checking fluids.
   Ladder use is covered in Accident Prevention Program
    but there was no training specific to ladder use provided
    to drivers.
    Distance from tire to the peg step is 90 cm, step to
    ground is 50 cm.
    Driver had washed bus prior to checking fluids and area
    around the bus was still wet.
    Shoes being worn did not have good tread on soles to
    prevent slipping.
    Another driver came up and started talking as driver
    was getting down.

                     HU 151, Lecture 7, Accident Investigation   31
          Accident Causes – Bus
Direct causes
 Improper body movement


Indirect causes
 Failure to use proper equipment - step ladder
 Wearing inappropriate footwear
 Lack of step ladders available and not close by
 Employee was distracted


Basic causes
 Inadequate training in pre-trip procedures for all
  types of buses
 No designated bus wash area



                HU 151, Lecture 7, Accident Investigation   32
      CORRECTIVE ACTION PLAN
          CAUSES                        CORRECTIVE ACTIONS                  TIME SCALE
  Improper body movement              Develop procedures and train       Immediately
                                         drivers on procedures           Mr. Y.
   Failure to use proper             Enforce safety rules/discipline     Immediately
  equipment – step ladder                        policy                  Mr. X
   Wearing inappropriate            Develop, implement and enforce       6 Months
         footwear                         safety procedures              Ms R
Lack of step ladders available     Ensure adequate number of step        6 Months
      and not close by               ladders and ensure they are         Mr. F
                                           readily available
  Employee was distracted               Safety awareness training        Immediate,
                                                                         Ongoing
                                                                         Mr. T
Inadequate training in pre-trip    Train staff on use of all equipment   1 Year
  inspections for all types of               and procedures              Mr. J
            buses

No designated bus wash area             Designate bus wash area          2 Years
                                                                         Mr. V
                            HU 151, Lecture 7, Accident Investigation                    33
HU 151, Lecture 7, Accident Investigation   34

				
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