Professional Documents
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Accident Reporting and Investigation
Accident Reporting and Investigation
Consultnet Ltd
Presentation Contents
Introduction
Incident Response Incident Investigation Incident Analysis Remedial Actions Incident Report Near Miss Reporting Cost of incidents Incident Statistics Summary of Responsibilities
Injured while handling, lifting or carrying Slips, trips or falls on same level Injured by hand tools
Fall from height Contact with moving machinery parts Injured by a person malicious Transport (excluding road traffic accidents)
Exposure/contact with harmful substance Road traffic accidents Injured by a person non-malicious Struck by something collapsing/overturning Contact with electricity Injured by an animal Fire or explosion Drowning or asphyxiation Miscellaneous or not otherwise classified
Introduction
Introduction
Incident Definitions
ACCIDENT - an undesired event that results in personal injury or property damage. INCIDENT - an unplanned, undesired event that adversely affects completion of a task. NEAR MISS - incidents where no property was damaged and no personal injury sustained, but where, given a slight shift in time or position, damage and/or injury easily could have occurred. Lost Time Accident an accident resulting in time off work Dangerous Occurrence - escape of flammable substance, explosion,
fire, collapse of load bearing apparatus, pipeline ruptures, pressure vessel ruptures, transport incidents, bursting of reveolving wheel, O/H electric line contact, building collapse(1993 Safety Health & Welfare at Work( General Application
)Regulations )
Reportable Incident
injured cannot return to work within 3 days of incident(1993 Safety Health & Welfare at Work( General Application )Regulations Form to be submitted to HSA( downloadable at www.hsa.ie )
Introduction
Level 2 Moderate
Medical Aid (1<days off<3)
Level 3 High
Fatality Lost Time Accident (>3 days) Serious Incident Reportable to HSA Disabling injury
Over E200,000
Injury Severity
Up to E30,000
Up to E100,000
1 day or more
* Front line Supervisor * Worker(s) /Witnesses involved * Area Safety Representative * Safety Manager
Supervisor - Immediately after personnel and area are safe Head of Department
* Front line supervisor * Worker(s)/Witnesses involved * Area Safety Representative * Head of Department * Safety Manager
Supervisor -Immediately after personnel and area are safe Head of Department
Head of Department
Initial response
Safety Manager
Contact insurance Contact hsa if required
Medical Aid(1<days off<3) E30,000<Damage<E200,000 1 day >Production Loss > 3 hours Product will not meet customer standards
Fatality Serious Injury - Lost Time(>3 days) Serious Incident Reportable to HSA Damage>E200,000 Production Loss < 1 day Loss of Customer or major customer dissatisfaction
Yes
Yes
Yes
Incident Report
Supervisor Responsible for completion and forward to Safety Manager within 24 Hours
Management Actions
Head of Department
track remedial actions
Managing Director
Management Actions
Interview witnesses Photographs Sketches, survey, site maps Relative positions Examine equipment & machinery Failed parts Examine Materials Examine records
Collect Evidence
Response and loss limiting actions Immediate causes (Substandard acts and conditions) Basic causes (personal & job factors) Program management (standards and compliance)
Analyse
Head of Department
track remedial actions
Does analyses show what happened, what should have happened and why? Yes Analyse causes
Safety Manager
Safety Manager
add to incident database Include in incident analysis
Issue incident information add to incident database Review at next safety committee meeting Include in incident analysis
Incident Response
Incident Investigation Incident Analysis Remedial Actions Incident Report Near Miss Reporting Cost of incidents Incident Statistics Summary of Responsibilities
Introduction
Reporting Incidents
Employee must report to Supervisor
Supervisor in conjunction with relevant Head of Department responsible for completion of Level 3 incident reports and also involves Safety Manager and Area Safety Representative
Initial Response
Typical Procedure
All incidents must be reported immediately by the employee concerned to their Supervisor:
If a Near Miss incident the Supervisor shall ensure a Near Miss Report is completed immediately. If a Level 1 incident the Supervisor in conjunction with the area Safety Representative completes the Incident Report Form and forwards to Safety Manager within 24 hours. If a Level 2 incident immediately after attending to any victim and minimisation of property damage the Supervisor ensures the accident scene is secured, prevents access by unauthorised persons and calls the Safety Manager and the area Safety Representative who will assist the Supervisor in completing the Incident Report Form, taking witness statements and completion of the investigation. If a Level 3 incident the Supervisor immediately after attending to any victim and minimisation of property damage ensures the accident scene is secured, prevents access by unauthorised persons and calls the Safety Manager, the area Safety Representative and the relevant Head of Department, who will assist the Supervisor in completing the Incident Report Form, taking witness statements and completion of the investigation.
Initial Response
The Supervisor
Takes control of the scene Calls first aid and emergency services Controls secondary incidents Identifies sources of evidence Preserves evidence from alteration or removal Determines the loss potential Notifies appropriate management
Discuss you companys emergency response procedures in the event of fire, injury, chemical spill
Incident Investigation
Incident Analysis Remedial Actions Incident Report Near Miss Reporting Cost of incidents Incident Statistics Summary of Responsibilities
Incident Investigation
Incident Investigation
They have a personal interest They know the people and conditions They know how best and where to get the information needed They will initiate or take any remedial action They benefit from investigating
Where there is major loss or loss potential or where multiple supervisors are involved it is beneficial that the investigation also involves the Head of Department for the area. In all cases it is recommended that the Supervisor involves the safety professional on his/her site to assist in the investigation
Incident Investigation
Initial Response
Typical Procedure
In the event of a Level 2 or Level 3 incident, immediately following the incident the Supervisor shall ensure the following:
Photographs of the scene are taken If there is a possibility that the accident could become a fatality the scene must remain undisturbed until viewed by HSA Inspector and Gardai where required. Arrange for survey plans of the site to be prepared. These are to include the following :
Locality Plan & details of accident site; Detailed plan of view showing details after the accident and include such things as: Equipment used in rescue operations; Position of materials, ladders, equipment, etc. involved in the accident; Position from where photographs were taken; Position of persons involved in the accident; and other relevant information. A sectional view (if necessary). Any sections made are to be marked on the detailed plan.
Take evidence from witnesses at the scene and make note of any piece of evidence. Check relevant equipment, maintenance and training records Analyse condition of equipment materials with specalist input where necessary Prepare a report detailing the circumstances of the accident within 24 hours and submit to the Safety Manager. The report will include the Incident Report Form and witness incident analysis forms which provides for systematically identifying immediate causes, basic causes and lack of control.
Incident Investigation
Accident Photography
Photograph the scene from all sides
Use long, medium, close-up sequence Accompany with good notes and sketches
Incident Investigation
Interviewing Witnesses
Calm, objective, impartial, open mind, search for facts not opinions Do not interrogate/cross examine As soon as possible( theorising increases as memory decreases) Interview separately and privately, use a tape recorder only with witness permission If significant conflict follow up interviews may be necessary Assure them the information is being used for accident prevention not to apportion blame Get the individuals version Use open questions (cannot be answered with a simple yes or no) Do not express an opinion or argue Record critical information quickly If not at the site of the accident use visual aids, sketches etc. End on a positive note and keep the line open Review completed statement with witness and have it signed
Helpful Interview Questions
What were you doing? Where were you working? How were you injured? How do you think the accident occurred? What is the safety procedure for the job? How were you trained for the job? Have you fully described the circumstances of the accident as you know them?
Take a look at the Witness Incident Analysis form recommended for Level 2/3 incidents
Incident Investigation
Parts Examination
Parts machinery, tools and other equipment that could have contributed to the incident
Proper item for task Damage - type, extent, pattern Previous damage defects, misuse Wear Safeguards machine guards, emergency cut-offs Labels, signs, markings
Incident Analysis
Remedial Actions Incident Report Near Miss Reporting Cost of incidents Incident Statistics Summary of Responsibilities
Determine why it happened basic causes personal/job factors Cover deficiencies in the management system
WOULD THE ACCIDENT HAVE HAPPENED IF THIS PARTICULAR FACTOR WAS NOT PRESENT?
Determine appropriate remedial action based on the immediate and basic causes Apportion responsibility to implement corrective actions Report findings to senior management Follow-up and monitor corrective actions
Incident Analysis
Undesired, Unsafe Act Unsafe Condition Unplanned Event Which Disrupts Work Activity
Incident Analysis
Lack of Control
Organisational failure means that the organisation, at one or more levels, did not effectively/properly plan, direct, organize, control or combination thereof, its resources
Resources are: Time, Tools, Equipment, Materials, Manpower
Failure to PLAN means: All aspects of the job, task or operation were not planned effectively so that an unexpected accident was not eliminated. Failure to DIRECT means: Personnel involved in the job, task or operation were not instructed and trained as to the potential hazards involved and means to eliminate or control those hazards. Failure to ORGANIZE means: All resources that were needed to do the job safely were not present, proper, and/or in safe operating condition.
Failure to CONTROL means: Failure to ensure that the job or task was actually conducted as planned, organized and directed.
Incident Analysis
Personal and job factors - lead a person to commit an unsafe condition or act
No training at all Training that was incomplete or inadequate or not understood Training that was not repeated frequently enough Resources (time, tools, equipment, materials, manpower) necessary to do the job safely are not provided Resources not proper (skills, size, abilities, type) Resources not in safe operating condition Inadequate supervision Inadequate work standards, procedures, work practices, maintenance
Incident Analysis
Immediate Cause
Immediate causes are the unsafe acts and/or conditions that lead directly to the accident. Unsafe acts account for 85% of accidents; unsafe conditions account for 14% of accidents. However, 85% of the unsafe conditions were caused by an unsafe act. Therefore, we can say that 97% of all accidents are caused directly or indirectly by an unsafe act.
Incident Analysis
Accident
An accident is: An unplanned, undesirable event which disrupts work activity An accident always results in a loss.
Incident Analysis
Loss
The loss is the result of an accident. (Disruption of work activity). Approximately 30 different losses have been identified as potential results of accidents, for example: Death Injury Lost Time Damaged Morale Damaged Tools Damaged Equipment Lost Materials Lost Productivity Civil Penalties Replacement Costs Economic Loss Loss of Client Goodwill Lost Competitiveness
Latent Failures
Latent Failures
Latent Failures
Active Failures
Fallible Decisions
Training & Skills Work Atmosphere
Unsafe Acts
Communication Person Factor
Inadequate Defences
Tools & Equipment
Senior Management
Line Management
Frontline Supervisor
Safety Equipment
Casual Sequence
Basic Causes
Immediate Causes
Substandard Acts/practices Substandard Conditions
Incident
Loss
Unintended
Compliance
In an incident analysis situation use this model and write down the loss, incident event, immediate, basic causes and relevant lack of controls under each heading in list form as per the Incident Report Form This makes it possible to identify the causes and relevant corrective actions to prevent a reoccurrence.
SUBSTANDARD ACTIONS Operating equipment without authority Failure to warn Failure to secure Operating at improper speed Making safety devices inoperable Removing safety devices Using defective equipment Using equipment improperly Failure to use PPE properly Improper loading Improper placement Improper lifting Improper position for task Servicing equipment in operation Horseplay Under influence of alcohol or drugs Working in dangerous situation Non-adherence to rules/standards
SUBSTANDARD CONDITIONS Inadequate guards or barriers Inadequate or improper protective equipment Defective tools equipment or materials Congested or restricted action Inadequate warning system Fire and explosion hazard Poor housekeeping disorder Hazardous environmental conditions(gas, dust etc.) Noise exposures Radiation exposure High or low temperature exposures Inadequate or excess illumination Inadequate ventilation Defective PPE
Personal factors
Job Factors
Inadequate Leadership Inadequate engineering Inadequate purchasing Inadequate maintenance Inadequate tools & equipment Inadequate work standards Wear & Tear Abuse or misuse
Introduction Incident Response Incident Investigation Incident Analysis Incident Report Near Miss Reporting Cost of incidents Incident Statistics Summary of Responsibilities
Remedial Actions
Introduction Incident Response Incident Investigation Incident Analysis Remedial Actions Near Miss Reporting Cost of incidents Incident Statistics Summary of Responsibilities
Incident Report
Note: Timeliness of report is critical, best reports are written promptly Accident reports are usually discoverable this means they can be used by parties to an action for damages or criminal charges
Incident Report
Where to?
Incident reports forwarded to the Safety Manager are processed as follows : All incident reports are analysed and the summary information is presented at the next monthly management meeting and safety committee meeting All Level 2 and Level 3 incidents are reviewed at the next weekly management meeting. Any lessons learned are communicated to management and employees from information distributed to all Supervisors(for inclusion in tool box talk ) and on Company Notice Boards Incident reports are copied to the relevant Head of Department and General Manager in the case of Level 2 and Level 3 incidents
Introduction Incident Response Incident Investigation Incident Analysis Remedial Actions Incident Report
10
Minor Injuries
30
Property Damage
600
Incidents with no visible injury or damage
Near miss
Near misses provide a much larger base for more effective control of accidental loss Eliminate the causes of near misses, reduce the potential for more serious accidents, this is the basis of any proactive safety management system High potential incidents should be analysed thoroughly
Introduction Incident Response Incident Investigation Incident Analysis Remedial Actions Incident Report Near Miss Reporting
Cost of incidents
Incident Statistics Summary of Responsibilities
Consultnet Ltd
Introduction Incident Response Incident Investigation Incident Analysis Remedial Actions Incident Report Near Miss Reporting Cost of incidents
Incident Statistics
Summary of Responsibilities
Introduction Incident Response Incident Investigation Incident Analysis Remedial Actions Incident Report Near Miss Reporting Cost of incidents Incident Statistics
Summary of Responsibilities
Incidents
Summary of Responsibilities
All Employees must report all incidents to their Supervisor All Supervisors responsible for initiaiting accident investigations All Heads of Department are responsible for taking appropriate action on the conclusions and results of any incident investigation within their Department. All Heads of Departments are responsible to ensure that the supervisors in their department are fully aware of, understand and initiate the Incident Reporting and Investigation Policy and attend relevant training. The Safety Manager will be responsible for providing technical support to the Supervisor in the course of the incident investigation, issuing incident information for communication to all employees, producing the incident statistics and presentation to monthly management and safety committee meeting The Safety Manager will ensure that management, employees and their representatives are adequately consulted and informed on the incident investigation policy and provision of training as regards implementation of the policy In the event that a Level 2 or Level 3 incident meets the requirement of reporting to the Health & Safety Authority, the Safety Manager contacts the relevant Inspector, submits the completed statutory report form and coordinates any subsequent investigation with the Inspector. The Safety Manager is responsible for reporting Level 2 & 3 incidents to the Company Loss Adjuster and Company Insurance Co-ordinator and coordinating any subsequent follow-up investigation.
Initial response
Safety Manager
Contact insurance Contact hsa if required
Medical Aid(1<days off<3) E30,000<Damage<E200,000 1 day >Production Loss > 3 hours Product will not meet customer standards
Fatality Serious Injury - Lost Time(>3 days) Serious Incident Reportable to HSA Damage>E200,000 Production Loss < 1 day Loss of Customer or major customer dissatisfaction
Yes
Yes
Yes
Incident Report
Supervisor Responsible for completion and forward to Safety Manager within 24 Hours
Management Actions
Head of Department
track remedial actions
Managing Director
Management Actions
Interview witnesses Photographs Sketches, survey, site maps Relative positions Examine equipment & machinery Failed parts Examine Materials Examine records
Collect Evidence
Response and loss limiting actions Immediate causes (Substandard acts and conditions) Basic causes (personal & job factors) Program management (standards and compliance)
Analyse
Head of Department
track remedial actions
Does analyses show what happened, what should have happened and why? Yes Analyse causes
Safety Manager
Safety Manager
add to incident database Include in incident analysis
Issue incident information add to incident database Review at next safety committee meeting Include in incident analysis
Irish HSA Accident Notification information and accident statistics UK IChemE comprehensive information source on major incidents UK HSE Report on Accident Investigation UK guidance on use of digital images as evidence EU research on work related accidents US site on injury research and control The Investigation Process Research Library US based OSHA accident investigation information, safety pays software and fatal facts information CHEMSAFETY.gov is the US Chemical Safety and Hazard Investigation Board's site, it investigates major chemical accidents US based OSHA Studies of Occupational Fatalities. Links to OSHA reports of fatality/catastrophe investigations United States Chemical Safety & Hazard Investigation Board Australian guidance on learning from accidents Canadian based information on reporting and investigating accidents New Zealand information on Aftermath - The Social and Economic Consequences of Workplace Injury and Illness
Investigation Process Research Library