ACCIDENT INVESTIGATION TRAINING

1. Contents

2. About The Course

A. Who Should Attend?
B. Course Objectives

3. Introduction

A. What Is An Accident?
        B. The Cost Of Accidents
C. Why Investigate Accidents?
D. Definition
E. Test Your Knowledge

4. Causes

  A. Causes
B. Cause Of Most Accidents
C. Test Your Knowledge

5. Who, When, And What?

        A. Accidents To Be Investigated
B. Who Can Investigate?
C. When To Investigate?
D. Test Your Knowledge

5. Investigation Process

A. One - Secure The Scene
B. Two - Collection Of Facts
C. Tools For Investigation
D. Three - Sequence Of Events
E. Interviewing Witnesses
F. Sample Questions
G. Four - Determine The Cause
H. Primary Cause
I. 5 Whys!
J. Benefits Of Using 5 Whys!
K. 5 Whys Example
L. Casual Factors
M. Five - Recommendations
N. Corrective Actions
O. Six - Write The Report
P. Test Your Knowledge

6. Investigating Exercise

A. Case Study
B. Collect The facts!
C. Interview The Witnesses
D. Sequence Of Events
E. Casual Factors
F. 5 Whys!
G. Primary Cause
H. Recommendations

7. Conclusion

A. Resources
B. Thank You!This training course is designed for anyone who may be called upon to investigate an accident, incident or a near miss situation. The list includes:

Health and safety committee members
Safety Officer/ EHS staff
Human Resources
Supervisior
To understand the need to investigate accidents.
To learn the steps to conduct a thorough accident investigation.
To comprehend all the necessary tools that can be used during an investigation.
To learn how to identify the possible causes of accidents and how to distinguish contributing causes from the primary cause of accidents.
To develop recommendations and solutions to minimize the recurrence of workplace accidents.

Throughout this course, we will use the terms like: Accident, Incident, and Near Miss. These terms are defined as:

Accident: An unplanned event that interrupts the completion of an activity, and that may (or may not) include injury or property damage.
Incident: An unexpected event that did not cause injury or damage, but had the potential to do so.
Near Miss: Near misses are those incidents in which no property is damaged and no personal injury is sustained, but where, given a slight shift in time or position, damage and/or injury may easily occur.

To prevent or decrease the likelihood of future injury or illness.
To determine the cause of the accident.
To identify and correct unsafe behaviors and conditions.
To identify training needs for employees.
To document the events.
To complete OSHA-required reporting.

Minor Accident:

Supervisor
Trained Safety Committee Member
Human Resources/EHS employee

Major Accident:

Supervisor
EHS employee/HR/Safety Committee Member
OSHA (if hospitalization of 3 or more employees or a fatality occurs)

Accident investigations should be conducted as soon as possible after the accident occurs because:

Witnesses memories fade with time.
Equipment and clues may be moved

Investigation Process

Steps to follow:

Secure the accident scene.
Collect the facts about what happened.
Develop the sequence of events.
Determine the causes of the accident.
Recommend corrective action.
Write the report.

Actions:

Check for danger.

Help injured employees.

Secure the scene to prevent injuries to others due to unsafe conditions.

Identify and separate witnesses.

Maintain items as they were during the accident.

Gather an investigation team.
Report to the scene.
Record initial observations - Take pictures or draw sketches.
Interview witnesses.

Things that may be needed for an investigation:

Digital Camera
Accident analysis form, clipboard, and pens.
Barricade tape
Flashlight
Tape measure
Voice recorder
Personal Protective Equipment (as appropriate)

Developing the sequence of events should answer these questions:
Who, What, When, Where, and Why?

Discuss what happened leading up to and after the accident.
Interview witnesses separately.
Encourage witnesses to describe the accident in their own words.
Don’t be defensive or judgmental.
Use open-ended questions.
Don’t interrupt.

The following questions can help the investigator develop the sequence of events:

What was the employee doing at the time of the accident?
Was the employee qualified to perform this operation?
Were company procedures being followed?
Is the job or process new? Had the employee received training on this operation prior to the incident?
Were the proper tools or equipment being used?
Was the proper supervision being provided?
Where did the accident occur?
What was the physical condition of the area when the accident occurred?
What were the witnesses doing at the time of the incident?
What did the witnesses see, hear, or smell?
What immediate or temporary actions could have prevented the accident or minimized its effect?

The cause of an accident may be easily determined. However, it is important to delve deeper into the circumstances surrounding the accident and try to determine all the causes of an accident. This is important to distinguish between the primary cause and secondary cause(s) of an accident.

Primary cause: The cause that contributed the most to the accident. This is the cause that, if removed, the accident probably would have been prevented.

It is important to identify all causes to an accident, but the primary cause of the accident should be the focus of the remedial action.

The 5 whys is an investigative technique used to determine the primary cause of an accident or incident. 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 the primary cause of a problem.

It is easy to use, and it requires no advanced mathematics or tools.
It quickly separates symptoms from causes and identifies the primary cause of a problem.
It helps in determining the relationships between various causes of the problem.
It can be combined with other quality improvement and troubleshooting techniques.
It encourages teamwork.
It is inexpensive.

Here is an example of the 5 whys technique:

An employee was injured. - Why?
He slipped on the wet floor. - Why?
He didn’t know the floor was wet. - Why?
The employee mopping the floor did not put out a caution wet floor sign. - Why?
The employee mopping was in a hurry. - Why?

He wanted to get home for his son’s birthday party.

Causes of an accident may include one or more of the following areas:

Environment: Poor housekeeping, poor visibility, or noise.
Equipment/Facilities: Unguarded equipment, lack of preventive maintenance, equipment failure, and poorly designed facilities.
Policies/Procedures: Lack of disciplinary policy or policy not enforced, and policy not communicated or not understood.
Training: Deficient orientation or job specific training, lack of supervisor training, and hazards overlooked in training.
Communication: Lack of worker communication, lack of supervisor instruction, lack of understanding of the task.
Productivity: Heavy workload, tight schedule, long hours, inadequate staffing, changes in process, ill employees.
Hazards: Unidentified or not labeled, known but not reported, PPE not adequate or defective.
Work Behaviors: Shortcuts taken, tools/equipments used improperly, refusal to follow procedures, horseplay.
Personal Protective Equipment: Availability, required but not used, trained how to use, adequate fit, lack of enforcement on use.

Once you have determined the primary cause of the accident, use that information to develop corrective action recommendations.

Recommended preventive actions should make it very difficult, if not impossible, for the incident to recur. The investigative report should list all the ways to "foolproof" the condition or activity.

Recommended corrective actions could include:

Employee training
Preventive maintenance activities
Better operating procedures
Hazard recognition training
Increased management awareness of risks involved in processes.
Enforcing disciplinary policies
Changes to environment or equipment

The last step in the accident investigation process is to write the report. The investigator should prepare a report for management, the safety committee, and/or the workers compensation insurance provider. The report should be complete and should contain all of the facts, analysis, and recommendations from the investigation.

What is next?

Correct, interview the witnesses!

You speak to the employee who was nearly hit by the box and learn that he saw an employee using a forklift to place a box on the other side of the aisle from where the employee was standing.

You ask what the employee was doing, and he states he was looking to see if a product was in stock yet because he had a customer waiting.

You ask the employee to explain his actions from the time he entered the warehouse until after the box fell.

Next, you interview the employee who knocked the box off of the top shelf. You ask her to tell you what happened.

This is what she tells you:

“I was moving the box to the top shelf and I guess I pushed it too far because the box on the other side of the aisle fell. There’s nothing to stop it, there should be a bar there or something, but we just have to use our best judgment about how far to move it and it’s hard to see up that high. I didn’t see anyone in the aisle, and I blocked the aisle on the other side, as is the procedure in case a box falls. My spotter was sick, so I had to work without one.”

You speak to the warehouse supervisor and find out that the employee using the forklift has been on the job for 6 months and is certified to operate the forklift. The supervisor also tells you that they are frequently understaffed due to absent employees and high turnover. Now that we have gathered the facts, we can develop the sequence of events. You do so as follows:

The employee from the sales floor went into the warehouse, bypassed the barricade and found the product he was looking for on the shelf. The employee noticed the forklift on the other side of the aisle that was lifting a large box to place on the top shelf. When the box from the top shelf was pushed from the other side, it fell into the aisle where the employee was standing almost hitting him. There were no other employees in the area at the time.

Possible causal factors:

Sales employee violated safety rules by bypassing barricade.
Warehouse employee violated safety protocols by failing to have a spotter.
The shelf does not have a bar or other device to keep the box on one side from pushing the box on the other side off.
The warehouse is frequently understaffed.

Let’s use the 5 whys to determine the primary cause of the accident:

An employee was almost hit by a box falling from a shelf. - Why?
Another employee was placing a box on the top shelf and pushed the box into the aisle where the employee was standing. - Why?
The employee could not see that the box was too far over. - Why?
The employee did not have a spotter. - Why?
No spotter was available. - Why?
The warehouse was understaffed. - Why?

Employee absences and high turnover in warehouse staff.

We can see from our analysis, that the primary cause of the incident is understaffing in the warehouse. It would be tempting to stop the analysis with the cause of the sales employee being in the aisle where he should not have been, but the primary goal of investigating an incident is to make sure the conditions creating the dangerous situation do not reoccur. Telling employees to stay out of the aisle does not address the primary cause of the incident.

What recommendations would you suggest to prevent an accident from happening in the future?

In this example, we could recommend several remedial measures:

A plan to provide adequate staffing for the warehouse.
Supervisor and employee re-training on safety procedures.
Safety training for sales staff or other employees who are allowed access to the warehouse.
Changing the design of the shelving to prevent boxes from being able to move too far on the shelf.

This completes the Accident Investigation Training Course.

Thank you for attending! FOR ONLINE PLEASE VISIT-https://www.proprofs.com/training/course/?title=MjIyMjk3D&c=8&p=2

Skill India by Shubhrant Mishra

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