Accident Reporting & Investigation Training: Mr. Yahya Abdi Hassan
Accident Reporting & Investigation Training: Mr. Yahya Abdi Hassan
Reporting
& Investigation
Training
outcome of hazards
Minor injuries
– Preventable and
avoidable - hazards do not Close calls
do -- or fail to do.
The Four Misconceptions About Safety
FUNDAMENTAL MISCONCEPTIONS
3. Safety is expensive.
Determine sequence of
events that led to
consequence
Offer corrective action
recommendations to
prevent recurrence of
the incident
Never to assign blame
or assess liability
What should be investigated?
All
incidents that
cause
Injury
Illness
Lost time
Property damage
Allnear-miss
incidents
Where should the
investigation be conducted?
The
investigation
must be
conducted at
the site of
the incident
Who should conduct the
investigation?
Team
Supervisor of the
affected employee
Safety committee
representative for
area
Safety officer
Affected
employee(s)
When should the
investigation be conducted?
Take photographs
INTERVIEW
The injured person and/or
be answered - CHECKLIST
Ask open-ended questions in a friendly manner
Collect Evidence
Photographs of equipment
Samples of chemicals
Broken parts or pieces
Investigate the Facts
Interview Witnesses
Individually
At the scene of the incident
Immediately after the
incident, if possible
With an open mind
Investigate the Facts
Review Records to Identify
Trends
Inspection records
Previous incident reports
Maintenance records
Workers’ compensation
insurance forms
Review the Facts to Find the
Cause
Review all information
Clarify the facts
Analyze information
Examine contributing
factors
List possible causes
Identify the cause
Examining Contributing Factors
Why?
Why? Why?
Why? Why?
Causes: Action:
Do you do it well?
Do you find the underlying causes?
Do you take corrective action?
Do you review your risk assessments as
a result?
Do you do it?
Most accidents are not
investigated
Ignoring or disregarding:
warning signs
statutory notices
Untidiness or carelessness
Horseplay
Safety in the workplace requires
Safesystems of work and good
organisation
Gooddefect reporting and maintenance
arrangements
Careful, safety-based work planning
The correct tools and equipment for
the job in hand
cont’d
Safety in the workplace requires
HUMAN INVOLVEMENT
Line management,
Fallible designers, planners etc.
decisions
CASUAL
SEQUENCE
Pre-conditions
Unsafe
acts
Systems
defenses
Local triggers
Technical faults
Atypical conditions
Environmental
Conditions, etc.
Limited windows of
Accident opportunity
ACCIDENT
Accident Reporting &
Investigation
Accident Causation
• causal factors
individual
• knowledge
• skills
• training
• experience
• personality
• attitude
• risk perception
Accident Reporting &
Investigation
Accident Causation
• causal factors
job
• task
• workload
• equipment
• controls
• procedures
• environment
Accident Reporting &
Investigation
Accident Causation
• causal factors
organisation
• culture
• leadership
• resources
• work patterns
• communications
ACCIDENT CAUSATION MODELS - 1
ACCIDENT
Accident investigation
Prevent recurrence
Change to safety programs
Change to procedures
Change to equipment design
Accident Reporting &
Investigation
Accident Prevention
• control measures
safety procedures/work instructions
adequate training
effective communications
good housekeeping
risk assessment
Acts and Conditions
UNSAFE ACT UNSAFE
CONDITIONS
Human errors No guarding
Failure to follow Trip hazards
procedures Poor maintenance
Violations Poor design
mistakes
Immediate causes (what) “4
Ps”
Premises
Plant/Substances
Procedures
People
Premises
Physical layout
Condition of building
Environment (weather)
Tripping & slipping hazards
PLANT/SUBSTANCES
Machinery guarding
Substance in use –toxic, harmful
Mobile plant
Item of work equipment – hand
tools, chairs
PROCEDURE
Written system of work/operating
procedure to be followed
Safety Policy
Work instruction
Quality standard
Custom and Practice – does not have to
be a document
People
Human factors
State of health (eye sight)
Abilities
Errors – skill based (slip or lapse), rule
based, knowledge based or violations
Behaviour – pressures, culture
Underlying causes
‘Root causes’ (Why)
Planning Communication
Risk Competence
Assessment Monitoring
Control Reviewing
(Supervision)
Co-operation