Accident Investigation Tabletop Exercise. MEMIC 2014 Slide 1

Transcription

1 Accident Investigation Tabletop Exercise MEMIC 2014 Slide 1

2 Agenda Accident Investigation Tabletop Exercise for Supervisors AGENDA Time Activity 9:00 9:10 AM Introduction / Objectives / Assumptions / Ground Rules 9:10 9:25 AM Tabletop Exercise Move 1 9:25 9:40 AM Tabletop Exercise Move 2 9:40 9:55 AM Tabletop Exercise Move 3 9:55 10:10 AM Hotwash (Q&A / Conclusions / Opportunities) 10:10 10:15 AM Closing Comments /Adjourn MEMIC 2014 Slide 2

3 Introduction You will be participating in Accident Investigation Training presented in a tabletop exercise format. This tabletop exercise will consist of a hypothetical scenario told in a narrative, presented through three moves, or snapshots, representing specific points in time. The narrative depicts a hypothetical scenario at our facility. Following group examination of the scenario, there will be facilitated discussion periods, which will foster interaction and understanding among the participants. MEMIC 2014 Slide 3

4 Goal & Objectives GOAL Improve supervisor accident investigation techniques Complete our company s written accident investigation report Perform root cause analysis Determine multiple causes of the accident scenario and develop corresponding corrective actions or solutions MEMIC 2014 Slide 4

5 Tabletop Exercise Simulates a situation / incident in an informal, stressfree environment Is designed to elicit discussion as participants examine and resolve problems based on existing programs / procedures Is scenario driven (the narrative) Focuses on roles and responsibilities Builds management skills MEMIC 2014 Slide 5

6 Exercise Roles & Responsibilities Participants i Respond to the situation presented based on: Facilitator Your knowledge of accident investigation and reporting procedures Your companies current policies and procedures Your insights derived from prior training and experience Provides scenario / situation updates Moderates discussion Provides additional information or resolves questions as needed MEMIC 2014 Slide 6

7 Assumptions In any exercise, some assumptions and make believe are necessary to complete the exercise in the allotted time. During this exercise, assume: The scenario could actually occur Events occur as they are presented There are no hidden agendas or trick questions All participants receive information at the same time MEMIC 2014 Slide 7

8 Exercise Rules Everyone will contribute Varying view points and disagreements are expected There often is no one solution Respond based on your knowledge of company plans and capabilities (you may only use existing assets) The situation narratives serve as the basis for discussion MEMIC 2014 Slide 8

9 Exercise Rules (Con t t.) Silence indicates agreement Decisions are not precedent setting and may not reflect the company s final position on a given issue. This is an opportunity to discuss and present multiple options and potential solutions Facilitator has the right to table any issue for later resolution MEMIC 2014 Slide 9

10 Tips for Participants Treat the situations as real events. Participate openly. Asking questions and sharing thoughts is strongly encouraged and will enhance the exercise experience. Issues arising i from the exercise will be thoroughly discussed. Keep the objectives in mind throughout the exercise. As you review the scenarios, you should consider what actions are appropriate based on your company s accident investigation policy and procedures, the information provided, applicable regulations and applicable policies. i MEMIC 2014 Slide 10

11 Move 1 Narrative Tuesday April 22, 2014, 2:00 PM At 11:00 AM you receive a call that t someone has been seriously injured while operating the large abrasive grinder. Upon arriving at the scene, you find that Joe Smith was seriously injured. Paramedics, who already arrived at the scene shortly before you, indicate that Joe is unconscious and has very serious injuries to the face, chest and hands. The paramedics carry Joe to the ambulance and rush him to the hospital. Injects As a new supervisor, you were just assigned to this area within the past two weeks. You are not familiar with this particular grinder, including it s maintenance. A copy of your company s accident investigation report form is provided and should be used in this exercise. The ambulance just left the site. MEMIC 2014 Slide 11

12 Company s Accident Investigation Reportt MEMIC 2014 Slide 12

13 Move 1 Questions 1. What are your next steps? 2. What should you do at the scene? 3. Who do you have to report this accident to? 4. What kind of time frame do you have for reporting and investigating the accident? MEMIC 2014 Slide 13

14 Move 2 Narrative Wednesday April 23, 2014, 10:00 AM It is morning the day after the accident and the update on Joe Smith is that he suffered the following injuries: Severe fractures of the chin and lower jaw (medical treatment will involve reconstructive bone and plastic surgery). Three fingers were severed from the fragments of the abrasive stone traveling at high speed when it broke (the doctors were able to reattach the fingers). Severe e e contusions uso s to the chest that should oud heal with just rest treatment. MEMIC 2014 Slide 14

15 Move 2 Narrative Wednesday April 23, 2014, 10:00 AM You also found that one of Joe s co-workers was working within 30 ft. of Joe on another piece of machinery when the accident occurred. You also find out that the stone was replaced approximately a month ago and Joe was grinding a piece of 8 gauge hardened ed pate plate steel, 4 inches wide x 10 inches long. Injects Upper management is asking that a thorough accident investigation be completed. An extra replacement stone is in the supply warehouse. Two other workers use the grinder on almost a daily basis. The local news media wants to interview you about the incident. MEMIC 2014 Slide 15

16 Move 2 Questions 1. What are your next steps? 2. What information do you need to complete the Accident Investigation Report? 3. Are there any particular people you should be trying to confer with? 4. What communication do you provide to the workforce? 5. What other precautions / response are required at this time? MEMIC 2014 Slide 16

17 Move 3 Narrative Friday April 25, 2014, 8:30 AM Joe s medical update is that he came through h the facial surgery pretty well, however, he will have to go through a number of plastic surgery operations to reconstruct his lower jaw. Doctors did not provide any update on the use of his injured fingers. You found that the tool rest was adjusted within 1/8 of the grinding stone surface. MEMIC 2014 Slide 17

18 Move 3 Narrative (con t.) Friday April 25, 2014, 8:30 AM You also learned that Joe may have been grinding on the side of the stone instead of the face of the stone. The stone was not designed for side grinding. Your last major find is that the plant s abrasive grinding stones are stored in an area where they are out in the open and not very well protected. Injects Joe s family is asking questions. The insurance carrier wants more information. MEMIC 2014 Slide 18

19 Move 3 Questions 1. What are your next steps? 2. Who should be communicating with Joe s family? MEMIC 2014 Slide 19

20 Action Items MEMIC 2014 Slide 20

21 This concludes the exercise. MEMIC 2014 Slide 21