Accident Reporting and Investigation Training

Transcription

1 Accident Reporting and Investigation Training

2 Objectives What is an accident, what is a near miss? What should be reported? Why should you investigate? What are you looking for? How should you investigate? What should be the results of the investigation?

3 What is an Accident? Unplanned Unwanted Controllable event Disrupts the work process Causes injury to people or damage to property.

4 What is a Near Miss? Unplanned Unwanted Controllable event Disrupts the work process Does not cause injury to people or damage to property.

5 What is an Accident? Most are not an Act of God They are caused occurrences Predictable: the logical outcome of hazards Preventable and avoidable: hazards do not have to exist. They are caused by hazardous conditions or acts. Fatalities Accidents Minor incidents Near Miss Hazardous conditions/acts

6 Example Near Miss A 50 lb box falls off the top shelf of a 12 high rack and lands near a worker. Is this event unplanned, unwanted, and have the potential for injury? Should this be investigated?

7 Best Practice for Accident Prevention Employees should report all accidents and near misses regardless of the extent of injury or damage. Supervisors should investigate the near misses.

8 Why Investigate Near Misses? Two weeks later: Another 50 lb box falls off the top shelf of the 12 high rack but this time, hits a worker causing a serious head injury. Predictable? Yes. Preventable? Yes. Reporting the previous incident and taking corrective action may have prevented this from becoming an accident.

9 Won t reporting near misses make our insurance costs go up? Claims involving no costs are not used in the calculation of Workers Compensation cost. If near misses are reported and investigated, future accidents may be avoided, and may actually reduce WC costs.

10 Employee Accident Report Form

11 Accident Investigation Accidents should always be investigated and reviewed by the injured employee s immediate supervisor or designated safety coordinator. An Accident Investigation Form provides an outline for the supervisor to complete the investigation.

12 Accident Investigation Form

13 Goals of Accident Investigation The goals of accident investigation are to: Find the root causes Take the appropriate corrective action(s) Prevent a similar accident/incident from happening again No accident investigation has ever changed what has already happened and therefore should not assign blame, but instead should identify breakdowns in the safety process

14 Benefits of Accident Investigation Prevents future accidents by identifying and eliminating hazards Exposes deficiencies in processes and/or equipment Reduces injury frequency and workers compensation costs. Maintains worker morale Promotes greater safety awareness Facts are gathered in the event of litigation

15 Causes of Accidents Direct Cause Unplanned release of energy or hazardous materials Indirect Cause Unsafe acts and/or unsafe conditions Root Cause Policies and decisions, personal factors, environmental factors

16 Accident Weed Hazardous Conditions Indirect Causes Hazardous Practices Missing guard Poor housekeeping Horseplay Ignored safety rules Equipment failure Not using PPE Don t know how Root Causes No formal safety policies Rules not enforced Poor safety management Lack of maintenance, unsafe equipment Lack of supervision Lack of safety leadership

17 Does This Meet the Goal? What was the employee doing when injured? Where in the facility/job site did the accident happen? Employee was working in the maintenance shop. Employee was working alone. Describe what happened: Employee was moving welding gas bottles in the shop. While moving a bottle, felt a sharp pain in the lower back. What corrective steps will be taken (or could be taken) to prevent recurrence? Employee was not lifting correctly. Employee should be reprimanded and re-trained in proper lifting techniques.

18 Finding Root Causes The 5 Whys Basic Question - Keeping asking What caused or allowed this condition/practice to occur? or simply Why? until you find the root cause. The five whys is probably the simplest of the root cause analysis methods. It is a question-asking method used to explore the cause/effect relationships that led to the accident/incident.

19 5 Whys Real Life Example Injury - Employee lost four fingers on each hand during equipment repair. 1. Why did the employee lose his fingers? The ram on the press he was working on unexpectedly came down. Direct Cause 2. Why did the ram come down? Another employee, not seeing the worker, started up the machine. The machine was shut down, but not locked out. Indirect Cause

20 5 Whys Real Life Example 3. Why didn t the employee lock the press out? Employee had never been trained on hazardous energy control. Indirect Cause 4. Why hadn t the employee been trained on hazardous energy control? Company has no formal lockout/ tagout program. Root Cause 5. Why doesn t the Company have a lockout/ tagout program? Management does not see safety as a priority and the use of lockout procedures is not enforced. Root Cause

21 Benefits of the Five Whys Simplicity. It is easy to use and requires no advanced mathematics or tools. Effectiveness. It truly helps to quickly separate symptoms from causes and identify the root cause(s) of a problem. Comprehensiveness. It aids in determining the relationships between various problem causes. Flexibility. It works well alone and when combined with other quality improvement and trouble shooting techniques.

22 Benefits of the Five Whys Engaging. By its very nature, it fosters and produces teamwork. Inexpensive. It is a guided, team focused exercise. There are no additional costs. Note: You may not need all five whys in every situation. Sometimes you ll need more, often less.

23 Accident Investigation Process Being Prepared Timing Procedures Information Corrective Action Follow Up

24 Accident Investigation Kit Accident Investigation Forms Clipboard Diagram Paper Caution Tape Flashlight Tape Measure Camera Sample Containers/ Bags Protective Gloves

25 Begin Investigation Immediately It is crucial to collect evidence and interview witnesses as soon as possible because evidence will disappear and people will forget.

26 Performing the Investigation First priority is care for the injured employee. Also, remove any danger that still exists, if it is safe to do so. Secure the scene, if necessary. Gather the facts. Complete accident investigation form Diagram the scene including location of injured worker, witnesses Take photos of the scene and related area

27 Performing the Investigation Record all observations made at the scene, such as: Environmental conditions temperature very high or very low, chemicals being used, inadequate lighting or ventilation, excessive noise, poor housekeeping practices, etc. Date and time of the accident near the beginning or end of the shift, overtime involvement, usual shift the employee works, etc. Condition of the worker fatigued, stressed, strained, experienced, supervised, any indication of drug or alcohol use, past medical conditions and prescription medications, etc., that may be relevant and may have played a role in or contributed to the accident. Machine, tool, or equipment involved was the worker wearing appropriate personal protective equipment, trained on how to use the equipment, any apparent malfunctions with the equipment, etc. Task employee was performing repetitive motions being used, materials being handled by the worker (number of pounds, ease of handling, etc.).

28 If You Need to Interview Witnesses Interview promptly after the incident Choose a private place to talk Keep conversations informal Talk to witnesses as equals Ask open ended questions Listen. Don t blame, just get facts Ask some questions you know the answers to

29 Corrective Actions When deficiencies are discovered, corrective actions should be taken. There is no better way to ruin moral than to investigate then do nothing.

30 Best Method For Hazard Control Hierarchy of hazard control (HHC) is used to recommend the most appropriate measure for controlling an observed hazard Always start from the top, and work your way towards the bottom Elimination Substitution Engineering Controls Administrative Controls Personal Protective Equipment

31 Elimination Where no hazard exists, no chance of injury or illness exists. The hazard is often eliminated through job, part, or workstation redesign. Example Employees are experiencing shoulder and back injuries due to repetitions tasks of manually stripping floor. Risk factors are eliminated by purchase and use of a riding floor scrubber.

32 Substitution If it s not feasible to eliminate a hazard, the next most effective approach is substitution by removing something that produces a hazard and replacing it with a lesser hazard. Examples Replace a larger parts container (70 lb capacity)\with a smaller part containers (20 lb capacity) to reduce lifting risk Substitute a natural pesticide for a pesticide that is a known carcinogen

33 Engineering Controls Use engineering controls when you cannot eliminate the hazard or provide a less hazardous substitute. Examples: Use mechanical aids (lift tables, hoists) to minimize bending, lifting, etc. Provide adjustable workstations to accommodate employees of different heights. Providing machine guarding.

34 Administrative Controls Administrative controls are the management procedures that do not actually eliminate or reduce the hazard, but try to reduce the employee s exposure to the hazard. Examples Training employees on safe lifting techniques. Job rotation for intense jobs. Requiring workers in hot environments to take breaks in cool rest areas and providing fluids for re-hydration. Posting Danger, Warning, Caution, signs.

35 Personal Protective Equipment Devices used by employees who must work in hazardous environments Does not eliminate the hazard and success relies on proper use of the equipment Common PPE includes protection for the: head, eyes and face, hands, feet, breathing zone

36 Personal Protective Equipment PPE should only be used after all other steps in the hierarchy have been investigated. Many organizations make the mistake of starting with PPE, allowing the hazard to exist and in many cases leaving it up to the employees to protect themselves from hazards.

37 Accident Investigation Example A food service worker for Yourtown School District was injured while cleaning filters in the exhaust hood system. The injury was serious and resulted in a torn rotator cuff, surgery, and extended time away from the job. The cost of the claim was $149,678. What was this employee doing to get so severely injured? If no investigation of this incident occurs, could a similar accident happen in the future? Let s investigate!

38 Accident Investigation Example Interview the injured worker Interview the supervisor Determine: Direct causes - Unplanned release of energy or hazardous materials Indirect causes - Unsafe acts and/or unsafe conditions Root causes - Policies and decisions, personal factors, environmental factors

39 Accident Investigation Example Direct Cause(s) Cart Moved resulting in loss of balance and fall Indirect Cause(s) Use of an inappropriate climbing device Why? Because that s the way we have always done this Root Cause(s) Appropriate climbing device not provided No procedure in place No training on proper procedure

40 Accident Investigation Example Root Causes: Inappropriate climbing device, No procedure, No training What corrective actions would you recommend? 1. Is there a way to eliminate the hazard? Task probably cant be eliminated, hood must be cleaned. 2. Are there engineering controls that could be applied? A proper climbing device should be provided. 3. Are there administrative controls needed? Training should be provided including use of proper device, the task should be supervised. 4. Would PPE help? PPE may reduce other exposures to injury while performing the task.

41 Follow-up Follow-up is crucial If changes are to be made, communicate the plans to employees (for example, in Toolbox meetings) A great way to reduce morale is for an accident to occur, but the hazard to remain

42 Check Effectiveness Make sure that the corrections are doing as they are designed to eliminate the hazards that caused the injury If similar injury occurs, review previous accident investigation report Were corrective actions implemented? Why did a similar accident still occur? What more can be done to prevent another similar accident?

43 Summary Goal of accident investigation is to determine the root cause(s) so you can take steps to prevent similar accidents in the future When investigating, consider direct, indirect, and basic causes of accidents Emphasize future prevention, not current blame Always follow through with corrective actions!

44 Questions?