Accident/Incident Investigation Supervisor Training

N.C. Department of Labor Mine and Quarry Bureau

What is the root cause?

Responsibilities under the ACT

You are already aware of your responsibility as a supervisor You understand having reason to know You are familiar with the levels of negligence

Accident Prevention is paramount

Company safety culture - the atmosphere within the company that influences safe behavior Accomplished by shared beliefs, practices, and attitudes from management down to the newest hired worker A break-down of the culture leads to loss

How is the safety culture created?

Positive attitudes by management and employee Developing policy and procedures Supervisors taking responsibility and accountability Safety planning and goals Properly addressing unsafe behavior Motivate and train employees Employee involvement or buy-in

Accidents do occur
Any loss costs everybody Direct cost is only a small percentage of the actual cost of an accident medical expenses, workers compensation Indirect cost can be 4 to 7 times the direct cost wages of the injured, decreased productivity, emergency response cost, investigation cost, remediation cost to prevent recurrence, replacement cost of property and personnel, plus others

Leading Causes of Workplace Deaths

Miscellaneous 11% Caught Between Object/Equipment 5% Airplanes 5% Gunshot Wounds 8% Slips and Falls 8%

Motor Vehicles 32%

Heart Attacks/Strokes 13%

Struck by Moving, Falling or Stationary Objects 18%

The Three Basic Causes

Poor Management Safety Policy & Decisions Personal Factors Environmental Factors Basic Causes

Unsafe Act

Indirect Causes

Unsafe Condition

Unplanned release of energy and/or Hazardous material

ACCIDENT Personal Injury Property Damage

Minimize loss
Promote an active accident prevention program Perform task analysis Train employees in hazard recognition Front line supervisor must understand NEGLIGENCE

When loss occurs

Root causes of accidents are identified through recognition and investigation of unsafe behavior As supervisors you must recognize and investigate all unsafe acts, unsafe conditions, and correct root cause Example An accident involving a fall from a ladder; the broken rung on the ladder is easily recognized as a hazard and causation of the fall, however the root cause could be, improper maintenance, poor inspection technique, or inadequate training on recognizing the hazard Document the occurrence and train employees on recognizing and preventing future occurrence

What is The Aim of the Investigation?

EXONERATE INDIVIDUALS OR MANAGEMENT SATISFY INSURANCE REQUIREMENTS DEFEND A POSITION FOR LEGAL ARGUEMENT OR, TO ASSIGN BLAME

The aim of any accident/incident investigation

THE KEY RESULT SHOULD BE TO PREVENT A RECURRENCE OF THE SAME ACCIDENT

THE ACCIDENT

WHAT IS AN ACCIDENT?

THE ACCIDENT

AN UNPLANNED AND UNWELCOMED EVENT WHICH INTERRUPTS NORMAL ACTIVITY.

THE ACCIDENT

THREE BASIC TYPES OF ACCIDENTS

THE ACCIDENT
MINOR ACCIDENTS:

SUCH AS PAPER CUTS TO FINGERS OR DROPPING A BOX OF MATERIALS

THE ACCIDENT
MORE SERIOUS ACCIDENTS THAT CAUSE INJURY OR DAMAGE TO EQUIPMENT OR PROPERTY: SUCH AS A FORKLIFT DROPPING A LOAD OR SOMEONE FALLING OFF A LADDER

THE ACCIDENT
ACCIDENTS THAT OCCUR OVER AN EXTENDED TIME FRAME: SUCH AS HEARING LOSS OR AN ILLNESS RESULTING FROM EXPOSURE TO CHEMICALS

THE ACCIDENT

ACCIDENTS HAVE TWO THINGS IN COMMON

THE ACCIDENT
THEY ALL HAVE OUTCOMES FROM THE ACCIDENT

THE ACCIDENT

THEY ALL HAVE CONTRIBUTORY FACTORS THAT CAUSE THE ACCIDENT

OUTCOMES OF ACCIDENTS
NEGATIVE ASPECTS
DEATH & INJURY DISEASE DAMAGE TO EQUIPMENT & PROPERTY LITIGATION COSTS LOST PRODUCTIVITY

OUTCOMES OF ACCIDENTS
POSITIVE ASPECTS
ACCIDENT INVESTIGATION CHANGE TO SAFETY PROGRAMS

CONTRIBUTING FACTORS
ENVIRONMENTAL

DESIGN
SYSTEMS & PROCEDURES HUMAN BEHAVIOR

CONTRIBUTING FACTORS
ENVIRONMENTAL
NOISE VAPORS, FUMES, DUST LIGHT HEAT CRITTERS

CONTRIBUTING FACTORS
DESIGN
WORKPLACE LAYOUT DESIGN OF TOOLS & EQUIPMENT

CONTRIBUTING FACTORS
SYSTEMS & PROCEDURES
LACK OF SYSTEMS & PROCEDURES INAPPROPRIATE SYSTEMS & PROCEDURES

CONTRIBUTING FACTORS
HUMAN BEHAVIOR
COMMON TO ALL ACCIDENTS NOT LIMITED TO THE PERSON INVOLVED IN THE ACCIDENT

WHO SHOULD INVESTIGATE

DEPENDENT ON SEVERITY OF THE ACCIDENT
INVESTIGATION TEAM
INDIVIDUALS INVOLVED SUPERVISOR SAFETY SUPERVISOR UPPER MANAGEMENT OUTSIDE CONSULTANTS

INVESTIGATION STRATEGY
GATHER INFORMATION & ESTABLISH FACTS ISOLATE ESSENTIAL CONTRIBUTORY FACTORS DETERMINE CORRECTIVE ACTIONS

IMPLEMENT CORRECTIVE ACTIONS

INVESTIGATION STRATEGY
FACT GATHERING
BE IMPARTIAL & OBJECTIVE COMPILE PROCEDURES & RULES FOR THE AREA GATHER MAINTENANCE RECORDS ON EQUIPMENT INVOLVED

INVESTIGATION STRATEGY
FACT GATHERING (CONTINUED)
ISOLATE ACCIDENT SCENE PHOTOS & DIAGRAMS DO NOT DISCARD OR DESTROY ANYTHING

INVESTIGATION STRATEGY
FACT GATHERING (CONTINUED)
TIME IS OF THE ESSENCE OBTAIN INFORMATION
INJURED WITNESSES SUPERVISORS OTHER PERSONNEL

INVESTIGATION STRATEGY
FACT GATHERING (CONTINUED)
INTERVIEWS (SEPARATELY)
WHAT WERE YOU DOING? HOW DO YOU THINK THE ACCIDENT OCCURRED? HOW WERE YOU TRAINED FOR THE JOB? WHAT IS THE SAFETY PROCEDURE FOR THIS JOB?

INVESTIGATION STRATEGY
FACT GATHERING (CONTINUED)
OBTAIN FACTS NOT OPINIONS
MAKE IT CLEAR THE OBJECT OF THE INVESTIGATION IS TO AVOID RECURRENCE, NOT TO APPORTION BLAME

INVESTIGATION STRATEGY
ISOLATE ESSENTIAL CONTRIBUTORY FACTORS
INVESTIGATION TEAM
EVALUATES ALL FACTORS CONCERNED

INVESTIGATION STRATEGY
ISOLATE ESSENTIAL CONTRIBUTORY FACTORS
INVESTIGATION TEAM
ISOLATES THE KEY FACTOR(S) BY ASKING THE FOLLOWING QUESTION....

INVESTIGATION STRATEGY
WOULD THE ACCIDENT HAVE HAPPENED IF THIS PARTICULAR FACTOR WAS NOT PRESENT?

INVESTIGATION STRATEGY
DETERMINE CORRECTIVE ACTIONS
INVESTIGATION TEAM
INTERPRETS & DRAWS CONCLUSION DISTINCTION BETWEEN INTERMEDIATE & UNDERLYING CAUSES

INVESTIGATION STRATEGY
DETERMINE CORRECTIVE ACTIONS
INVESTIGATION TEAM
RECOMMENDATIONS BASED ON KEY CONTRIBUTORY FACTORS AND UNDERLYING CAUSES

INVESTIGATION STRATEGY
IMPLEMENT CORRECTIVE ACTIONS
INVESTIGATION TEAM
RECOMMENDATION(S) MUST BE COMMUNICATED CLEARLY STRICT TIME TABLE ESTABLISHED FOLLOW UP CONDUCTED

BENEFITS OF ACCIDENT INVESTIGATION

PREVENTING RECURRENCE IDENTIFYING OUT-MODED PROCEDURES

IMPROVEMENTS TO WORK ENVIRONMENT

BENEFITS OF ACCIDENT INVESTIGATION

INCREASED PRODUCTIVITY IMPROVEMENT OF OPERATIONAL & SAFETY PROCEDURES RAISES SAFETY AWARENESS LEVEL

BENEFITS OF ACCIDENT INVESTIGATION

WHEN AN ORGANIZATION REACTS SWIFTLY AND POSTIVELY TO ACCIDENTS AND INJURIES, ITS ACTIONS REAFFIRM ITS COMMITMENT TO THE SAFETY AND WELL-BEING OF ITS EMPLOYEES