Accident in Ves
Accident in Ves
Most workplace injuries and illness are not due to “accidents”. More often than not it
is a predictable or foreseeable eventuality.
By “accidents” we mean events where employees are killed, maimed, injured, or
become ill from exposure to toxic chemicals or microorganisms (TB, hepatitis, HIV)
A systematic plan and follow through of investigating incidents or mishaps and
altering behaviors can help stop a future accident.
Let’s take the 50 lb carton falling 12 feet for the second time, only this time it hits a
worker, causing injury. Predictable? Yes. Preventable? Yes. Investigating why the
carton fell will usually lead to solution to prevent it from falling in the future.
“The Tip of the Iceberg”
Accidents
Accidents or injuries are the tip of
the iceberg of hazards.
Investigate incidents since they are
potential “accidents in progress”.
Incidents
Don’t investigate only accidents. Incidents should also be reported and investigated.
They were in a sense, “aborted accidents”.
Criteria for investigating an incident: What is reasonably the worst outcome,
equipment damage, or injury to the worker? What might the severity of the worst
outcome have been? If it would have resulted in significant property loss or a
serious injury, then the incident should be investigated with the same thoroughness
as an accident investigation.
The “Accident Weed”
Hazardous Hazardous
Conditions Practices
Missing guard Horseplay
Root Causes
Root Cause Analysis
Direct Cause – Unplanned release of energy or
hazardous materials
Root cause analysis is a systematic technique that focuses on finding the real cause of a
problem and dealing with that, rather than just dealing with its symptoms.
A root cause is the cause that, if corrected, would prevent recurrence of this and similar
occurrences.
A root cause of a consequence is any basic underlying cause that was not in turn caused
by more important underlying causes.
The Five Whys
Basic Question - Keeping asking “What caused or
allowed this condition/practice to occur?” until you get to
root causes.
The “five whys” is one of the simplest of the root cause
analysis methods. It is a question-asking method used to
explore the cause/effect relationships underlying a
particular problem. Ultimately, the goal of applying the 5
Whys method is to determine a root cause of a defect or
problem.
The following example demonstrates the basic process:
My car will not start. (the problem)
Flexibility. It works well alone and when combined with other quality
improvement and trouble shooting techniques.
Engaging. By its very nature, it fosters and produces teamwork and teaming
within and without the organization.
Often the answer to the one “why” uncovers another reason and generates
another “why.” It often takes “five whys” to arrive at the root-cause of the
problem. You will probably find that you ask more or less than “five whys” in
practice.
Why Investigate?
Root causes should be determined. Example: An employee gets cut. What is the cause?
It is not just the saw or knife or the sharp nail. Was it a broken tool and no one reported?
Did someone ignore a hazard because of lack of training, or a policy that discourages
reporting? What are other examples of root causes? Enforcement failure, defective PPE,
horseplay, no recognition plan, inadequate labeling.
Investigate All Incidents and Accidents
Also answer:
– Is this a company or industry-recognized hazard?
– Has the company taken previous action to control this
hazard?
– What are those actions?
– Is this a training issue?
Develop a plan
Collect facts
Interview witnesses
Write a report
How To Investigate
Develop a plan
The next several slides will outline each component you need for effective accident
investigation. Then we will look into each component in more detail.
The time to develop your company’s accident investigation plan is before you have an
incident or an accident.
The who, when, where, what and how should be developed before the incident.
accident investigation training, investigation tools and your policies and procedures should
be developed before the incident or accident.
One size will not fit all. Your company’s motor vehicle investigation reports will differ from
your warehouse investigations, as will your off-site investigations.
Tips for Developing An Accident Investigation Plan
Preplanning will help you address situations timely, reducing the chance for
evidence to be lost and witnesses to forget. All procedures, forms, notifications,
etc. need to be listed out as step-by-step procedures. You might wish to develop
a flow chart to quickly show the major components of your program.
Tips for Developing a Plan (continued)
– What level of training is needed?
First, make sure you and others don’t become victims! Always check for still-
present dangerous situations. Then, help the injured as necessary. Secure the
scene and initiate chains of custody for physical evidence. Identify witnesses and
physical evidence. Separate witnesses from one another If physical evidence is
stabilized, then begin as quickly as possible with interviews.
Fact Finding
Witnesses and physical
evidence
Employees/other witnesses
The outcome of an investigation of the 50 lb. carton falling off the top shelf of the 12
ft. high rack might include correction of sloppy storage at several locations in the
warehouse, moving unstable/heavy items to floor level, conducting refresher training
for stockers on proper storage methods, and supervisors doing daily checks.
When Accidents Occur, What Is Required By L & I?
WAC 296-800-32005
Report the death, probable death, or the in-
patient hospitalization of 1 or more employees
within 8 hours to Labor and Industries at
1-800-4BE-SAFE
WAC 296-800-32010
WAC 296-800-32015
WAC 296-800-32020
Evaluate facts relating to cause of accident by
involving the following people:
– Person assigned by employer
– Immediate supervisor of injured employee
– Witnesses
– Employee representative
– Any other person who has the experience and skills
WAC 296-800-32025
– Document your findings
Link to Sample Accident Investigation form
Need further help?