Easy Incident & Accident Investigations Presented by Joe Angyus, CSP October 7, 2009
Three Common Myths 1. Accidents, by definition, “just happen” 2. Many accidents are caused by “stupidity” 3. No accidents = safe workplace
Establish an investigation process n Determine n Who n Write what to investigate; will investigate; and policy on investigation procedure “Those designated simply have to take the time, understanding that, in the long run, inadequate investigations will cost them even more time” – Frank Bird, Jr. , Practical Loss Control Leadership
Reporting incidents Employees who: But when employees: n Fear n Buy in n Have concern n Perceive n Want to avoid n See importance the value n Misunderstand n Believe in end goal n Won’t n They’re more likely to report!
Phases of Investigation 1. Initial actions at the scene 2. Gather information (Four P’s) 3. Analyze all significant causes 4. Develop and take corrective actions 5. Write the report 6. Review the findings and recommendations 7. Follow up to verify effectiveness of the actions
Initial actions at the scene n Take control n Ensure first aid, call emergency services n Control secondary incidents n Identify sources of evidence n Preserve evidence n Determine n Notify loss potential personnel
Gathering Information n Interviewing n Photos, witnesses (people) sketches, or maps (positions) n Equipment exam (parts) – Material failure analysis n Records check (paper)
Write a good description n Description should contain: 1. What was the injured attempting to do? 2. What went wrong? 3. What was the outcome (loss)? n Be thorough, but keep it simple!
Writing a good description 1. What was the injured attempting to do? The injured was attempting to replace a defective air valve by using a 12 ft. step ladder.
Writing a good description 2. What went wrong? Since it was leaning unsecured against the air receiver tank, the ladder slipped outward as the injured climbed to access the valve.
Writing a good description 3. What was the outcome (loss)? The injured fell 7 ft. to the floor beneath the tank, striking against hydraulic lines causing a fractured left collarbone and significant bruising to his right arm and shoulder.
Analyze significant causes n Start n Work with the event (loss) backwards by asking “why” n Identify n Don’t the unsafe acts/conditions stop at “symptoms” n Determine system failures
Take immediate corrective actions n At the scene n With n By the people involved the frontline leader n Examples: – Re-instruct the injured – Replace the tool
Take long-term corrective actions n Identify and correct system deficiencies n Types of system deficiencies could include: – Standards for tools and equipment selection, use and inspection – Training program – Employee observation – Management controls
Review the findings and recommendations n Management’s role in investigation process: – Demonstrates importance – Verify problems solved – Determine who else needs to know – Identify why the safety program didn’t adequately control the hazard
Follow up to verify action effectiveness n Evaluate how systems are working after actions taken n Circle back with injured employee
Questions? ? ? ? If you have further questions, please contact: –Joe Angyus ~ joe_angyus@toc. org – 800 -733 -8621
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