1 Accident Investigatin APPLICABLE STANDARD: EMPLOYEES AFFECTED: All emplyees WHAT IS IT? Accident investigatin is the prcess f determining the rt causes f accidents, n-the-jb injuries, prperty damage, and clse calls in rder t prevent them frm ccurring again. WHY IS IT IMPORTANT? Accident investigatin will lead yu t the real cause f why smething happened, and armed with that knwledge, yu can take affirmative steps t prevent future accidents frm ccurring. WHAT IS REQUIRED? Develp an accident investigatin prcess that fcuses n: fact finding, nt fault finding determining the rt causes f why the event ccurred making changes s the event des nt happen again. Set a plicy that accidents and clse calls (large and small) will be investigated with equal vigr. Prvide training and tls t staff cnducting accident investigatins. Audit cmpleted investigatins t ensure they are being cmpleted n a timely basis with an adequate level f detail. HOW DO YOU DO IT? Wrkplace accidents shuld be investigated as sn as pssible after they ccur. The gals f a timely and thrugh accident investigatin shuld be t: determine the cause f the accident prevent the accident frm happening again imprve health and safety cnditins in the wrkplace determine whether a vilatin f federal r state safety and health standards cntributed t the accident determine cmpany r individual liability in case f future legal actin determine the need fr repairs r replacement f damaged items
2 determine the need fr additinal educatin and training fr emplyees. A thrugh and cmplete accident investigatin invlves several steps, specifically: backgrund investigatin site investigatin interviews analysis and reprting. The fllwing utline discusses these steps in mre detail. Backgrund investigatin Review the emplyment and injury recrds f any injured emplyee(s) and/r thers whse actins cntributed t the accident. Review reprts f any injuries and/r damage t equipment, machines, building, r prperty. Cmpile a list f witnesses t the accident. Gather infrmatin abut nrmal cnditins and/r peratins f the area. Infrmatin wuld include maps, flr plans, wiring diagrams, and any ther piping r architectural drawings r peratinal guidelines. Meet with supervisrs and ther emplyees respnsible fr the affected area and emplyees f the affected area t utline the purpse and gals f the investigatin. Ensure that there is a basic understanding f the materials, equipment, peratin, r prcess invlved. Site investigatin Arrive at the scene f the accident as sn as pssible after the incident has ccurred. Restrict the accident scene t authrized persns during the site investigatin. Ensure that mvable evidence is secured t prevent tampering r ther changes. Determine what physical changes may have ccurred fllwing the accident. Changes culd be attributed t clean-up, weather, maintenance, and nrmal usage. Tur the entire area and recrd pertinent initial perceptins f the status and cnditin f building, grunds, equipment, lighting, and ventilatin. Sketch r draw parts f the accident scene where equipment r machinery invlved in the accident is lcated r where actins that cntributed t the accident ccurred. Use the fllwing guidelines when sketching r drawing an accident scene: Use squared (graph) paper. If distance r size is imprtant determine the
3 value fr each square and nte this at the bttm f each sketch. Orient each sketch with an arrw pinting nrth. Label all bjects. Use arrws t indicate paths f travel f individuals and/r vehicles. Indicate the distance f mvable bjects frm tw fixed lcatins. Nte the lcatin f witnesses present at the time f the accident. Take phtgraphs f the verall scene, damaged areas, and pertinent machinery and/r equipment. Phtgraphs shuld be made befre any adjustments ccur t the scene f the accident. Prir t taking phtgraphs, determine if the area has been altered. If items have been mved r changed, d nt mve them back fr phtgraphs. Phtgraph items as fund, yet dcument the change and the individual respnsible r knwledgeable f the change. Fr clse-ups, use reference items such as a ruler r level measurer t indicate size r slpe f the items phtgraphed. Fr each clse-up, phtgraph the same item frm a distance t prvide a reference. Phtgraph the area where the injured wrker(s) were fund, using reference marks t indicate individuals placement. Interviews Prepare a list f witnesses and ther individuals t be interviewed. When pssible, d nt allw mre than 24 hurs t elapse befre cnducting interviews. Cnduct interviews in a private setting t avid interruptins and distractins. Prepare a list f questins in advance f any interview. Use questins that require narrative answers. Avid questins that suggest an expected answer (Example: Isn t it true that the injured emplyee was running? ) r that can be answered with either yes r n. Questins shuld be structured frm the fllwing six key elements: Wh? What? Where? When? Hw? Why? Wh questins identify all parties invlved. What questins identify pertinent actins, events, and physical bjects. Where questins lcate participants, witnesses, and key bjects invlved in the accident. When questins determine the time f the accident and establish relatinships between pairs f activities r events. Hw questins prvide infrmatin n the interactin and relatinships amng participants, equipment, and the events leading up t, during, and after the accident. Why questins determine unsafe acts r hazardus cnditins.
4 Befre starting the interview, advise the persn t be interviewed that the purpse f the sessin is t determine the cause f the accident and t prevent any future ccurrence. Start the interview by asking the individual t describe what happened. D nt interrupt with questins. After the individual has given his r her initial statement, ask the prepared questins and any additinal questins prmpted by the individual s statement. Recrd the individual s statement, the questins asked, and the answers received in the rder that they ccur. Let the individual talk, but nt ramble. Interrupt when necessary t turn the cnversatin back t the subject at hand. Clse the interview when all questins have been answered and when the individual indicates n additinal infrmatin can be prvided. Encurage the individual t cntact yu if ther pertinent infrmatin cmes t mind. Immediately after the interview, review the individual s statement and answers and recrd yur impressins and judgments. Analysis and reprting After all fact-finding effrts are cmplete, analyze the data t determine all causes f the accident. Then prepare a cmprehensive reprt utlining the identified causes and describing crrective measures t prevent similar future accidents. T best understand why an accident ccurred and t plan fr preventive actins, it is imprtant t realize that mst accidents have mre than ne cause. It is imprtant t realize that an accident may be the result f the interactin f seemingly unrelated events. Causes The cause f an accident is any behavir, cnditin, act, r missin withut which the accident may nt have happened, r the severity f the injuries wuld have been less. Causes can be characterized as direct, indirect, r cntributing. Direct causes are acts r missins that directly relate t the accident. These culd include wrkers r ther individuals wh: perate equipment in an unsafe manner r perate equipment knwn t have safety defects r deficiencies d nt fllw required r necessary safety precautins r prcedures fail t crrect knwn damage t r faulty peratins f equipment, machinery, r vehicles. Indirect causes are cnditins that directly cntribute t the ccurrence f a direct cause. These causes culd include: defective r unusual cnditins f equipment, machinery, vehicles, buildings, r grunds defective r unusual cnditins f wrkers r ther individuals, such as intxicatin, physical defects r limitatins, r psychlgical defects r
5 limitatins hazardus r unusual cnditins f weather. Cntributing causes are cnditins, prgrams, acts, r missins that are nt directly related t the accident but did cntribute t the ccurrence r existence f a direct r indirect cause. These causes culd include lack f r inadequate: Analysis safety prgram training prgrams preventive maintenance prgrams crrective maintenance prgrams supervisin enfrcement design f equipment, machinery, vehicles, r facilities advisry r warning cmmunicatin, labels, r signs. Cllect and crrelate data. The fllwing are examples f materials that can be used t ascertain all causes related t the accident. These materials shuld be cllected and rganized t allw investigatrs t review all infrmatin at ne time: summary f emplyment and injury recrds f pertinent emplyees summary f rientatin and training recrds fr pertinent emplyees summary f nrmal cnditins and/r peratin f the pertinent area descriptin f usual and safe peratins r use f materials, equipment, facilities, peratins, r prcesses invlved summary f inspectins f materials, equipment, and facilities invlved summary f witness statements that includes an utline f areas f agreement and disagreement between statements summary f pertinent recrds f preventive maintenance r repair written cmpany plicies r directives that pertain t the materials, equipment, facilities, peratins, r prcesses invlved. Review data and pse hypthetical causes. The investigatr shuld review all pertinent data. After the initial review, the investigatr shuld utline ptential direct, indirect, and cntributing causes. It is imprtant that all ptential causes be listed and that the investigatr nt draw preliminary cnclusins as t the prbability that a ptential cause was r was nt related t the incident. It may be helpful t have a secnd individual cnduct an independent review f the pertinent data t list all f the ptential causes. Test ptential causes. Review again the pertinent data lking fr specific data that affirm r reject each ptential cause. Cnnect related direct, indirect, and
6 cntributing causes. Reprting A written reprt shuld be generated that cntains the fllwing sectins: Statement f the prblem. This sectin shuld include: a review f the incident a summary f injuries, lst time, and equipment and/r prperty damage. Review f the data. This sectin shuld include: a summary f witness statements a summary f relevant findings cncerning the accident and wrk histry f affected emplyees and the peratin f machinery r equipment a strybard with phtgraphs r sketches an verview f existing, written cmpany plicies r directives. Causes. This sectin shuld list the direct, indirect, and cntributing causes that have been affirmed by the data. A reference shuld be made t the data that supprt each cause. Recmmendatins. These shuld be based directly n each f the nted causes. These recmmendatins culd include the fllwing: mre r imprved training fr emplyees new cmpany plicies r directives, r better clarificatin r disseminatin f existing nes imprved cmmunicatin between emplyees, supervisrs, and management design r peratin changes r imprvements t machines, equipment, r prcesses different r imprved safety equipment different r imprved prtectin frm natural phenmena r disasters different r imprved systems t accunt fr pssible physical, physilgical, r psychlgical limitatins f emplyees, custmers, r thers.
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