Accident Investigation Training - UW Facilities
10/2/2017Accident Investigation TrainingHow to Conduct a Workplace Accident InvestigationEmma Corell, Accident Prevention ManagerEH&S, Research and Occupational SafetyGoals for this Training Learn simple tools that can be used toinvestigate simple and complex accidents. Learn the importance of root cause analysis. Walk away with resources that can helpminimize the occurrence of accidents in yourdepartment.10/2/201721
10/2/2017What is an Accident? Unplanned and unwanted event that disruptswork processes by causing injury or damage. Accidents are caused occurrences,rarely due to an a randomhappening or “Act of God.” Accidents are preventable and evenpredictable events.10/2/20173Why Investigate? Investigations can uncover deficiencies inprocedures and training or draw attention toneeded repairs/maintenance. Investigations lead to corrective actions thatprevent reoccurrence of accidents. Investigations are required by law for seriousaccidents (WAC 296-800-32020).10/2/201742
10/2/2017Leading Root Causes at UW Online Accident Reporting System (OARS)reports from 2013 (N 1,086), excludingMedical Centers, were categorized by thecauses identified by the supervisor.The leading root causes for accidentsreported at UW are people,policies/procedures/training, andenvironmental causes.“People” includes inattention, lack ofawareness, rushing, or failure to followestablished procedures.Only 9% of accidents have more than onecause identified.Two or MoreTwo9%or More 10/2/20175Supervisor Comments “When the determinations of the causal chain“Carelessness” arelimited to the technical flaw and individualfailure,the actions taken to prevent a“Human error” similar typicallyevent in the future are also limited: fixthe technical problem and replace or retrain“Inattention”the individual responsible. Putting thesecorrections in place leads to another mistake:“Rushing”The belief that the problem is solved. –Columbia Investigation Board, NASA 2003“N/A”“Accidental injury? I wasn't present.”10/2/201763
10/2/2017Accident Investigation Process1.2.3.4.5.6.7.Preserve and document the scene.Collect facts through interviews.Develop event sequence.Initiate online report.Determine causes.Recommend improvementsComplete report.10/2/201771. Preserve and Document the Scene Take immediate action to prevent injury ordamage. Secure and preserve the scene.until the investigation is complete.* Communicate with employees in the area. Take (many) photos from various view points.*For injuries that result in hospitalization or fatality, it is against the law tomove any equipment until L&I gives the okay unless you must move theequipment to remove victims or prevent further injury.10/2/201784
10/2/2017“Employee wasshocked by electricaloutlet whileunplugging cord.”10/2/201792. Collect Facts Through Interviews Interview affected employee(s) and witnessesas soon as possible. Interview at the accident scene, if possible. Keep the purpose of the investigation in mind.Make sure the interviewee understands aswell. Ask for the interviewee’s suggestions.10/2/2017105
10/2/20173. Develop the Sequence of Events Analyze the accident by breaking down– Events prior to accident– Events during– Events immediately after Identify gaps in your timeline and gatheradditional facts and information as needed.10/2/2017114. Initiate Report Accidents at the university are reported via theOnline Accident Reporting System (OARS). Report all accidents within 24 hours. OARS serves several purposes:– Meeting reporting requirements– Documenting your investigation– Requesting assistance from EH&S, if needed Accidents resulting in a fatality or hospitalizationmust be reported by calling EH&S at206.543.726210/2/2017126
10/2/20174. Determine the Causes Direct Cause – The immediate source of theaccident, often quickly identified Indirect Cause – An unsafe action or condition Root Cause – Policies, decisions,environmental or personal factors“Accidents usually result from multiple and interacting causal factors that may haveorganizational, cultural, technical or operational systems origins. If accident investigations donot relate to actual casual factors, corrective actions taken will be misdirected and ineffective.”(Manuele, 2011)Manuele, F. (2011). Reviewing Heinrich: Dislodging Two Myths From thePractice of Safety. Professional Safety, 51-61.10/2/201713The “Accident Missing guardCluttered work areaDefective toolsRushingIgnored safety rulesNot following proceduresEquipment failurePoor lightingProcedures not developedFailure to use safety equipmentInattentionNo funds to purchase equipmentPoor workspace designNo follow-up/feedbackRules not enforcedLack of TrainingLimited staffingNo safety leadership10/2/2017PPE not purchased/providedRoot Causes147
10/2/2017Accident ScenarioEllen tripped and fell on the stairs, spraining her ankle.10/2/20171510/2/2017168
10/2/2017Ishikawa (Fishbone) MeasurementsMother NatureManpower10/2/201717Ishikawa (Fishbone) DiagramCauseEffectEquipment/MaterialsPeopleBroken lightsRushingMissing banisterInattentionWearing high heelsChip in the floorEarly morningMust arrive at 8:00 sharpStrict dress codePolicies/Procedures10/2/2017Stairs encouragedSlipped and fellwhilewalking upAccidentstairs, sprainingankleSlick flooringRainingEnvironment189
10/2/2017The Five WhysRepeatedly asking the question “Why” may lead you to the root cause of an accident.You will find that the most obvious cause will only lead to more questions.Example: You are on your way to work and you car stops in the middle of the road.Why did your car stop?Because it ran out of gas.Why did it run out of gas?Because I didn’t buy gas on my way to work.Why didn’t you buy gas on your way to work?Because I didn’t have any money.Why didn’t you have any money?Because I lost it all during a poker game last night.Why did you lose at poker?Because I’m terrible at bluffing.10/2/201719Accident ScenarioEmployee was lifting equipment into truck andinjured back.10/2/20172010
10/2/20175. Recommend Improvements Using your root cause analysis, look ahead tosee how the risk of similar incidents can bereduced. Identify solutions that are practical, specific,effective, and based on consultation. Rank your solutions in order of priority. Make a plan and take the first step. Follow-up.10/2/2017216. Complete the Report Document your findings in the OARS report. Set a target date to complete your suggestedcorrective actions. Once you complete the corrective actions ortake the first step to completing thecorrections, the report can be closed. Continue to follow-up and make steps towardsimprovement.10/2/20172211
10/2/2017EH&S and Investigations EH&S may assist with the investigation when anaccident involves a:––––––Hospitalization or fatalityChemical spill and/or exposureBloodborne pathogen exposureRecombinant/synthetic DNA exposure or spill.FiresPhysical hazard such as a damaged sidewalkEH&S is available to assist with an investigation uponrequest.10/2/201723Room to ImproveNone9%Two or More e32%10/2/2017Policies/Procedures/Training19%2412
10/2/2017Resources EH&S website: http://ehs.washington.edu/– Online Accident Reporting System 10/2/20172513
Ishikawa (Fishbone) Diagram 10/2/2017 17 Cause Effect Accident Machines Methods Measurements Mother Nature Materials Manpower Slipped and fell while walking up stairs, spraining ankle Accident Ishikawa (Fishbone) Diagram 10/2/2017 18 Cause Effect People Policies/ Procedures Equipment /Materials Environment Rushing Inattention Wearing high heels .
accident reporting and investigation of each accident and incident (near-miss); and periodic review of the program to keep it up to date. The direct cause of an accident usually results from one or more previous unsafe actions or conditions. A good accident investigation program discovers the events leading up to an incident or accident.
This report is an independent product of the Paducah Gaseous Diffusion Plant Accident Investigation Board appointed by William E. Murphie. The Board was appointed to perform a U.S. Department of Energy Type B Accident Investigation of this accident and to prepare an investigation report in accordance with DOE O 225.1A, Accident Investigations.
National Training Center appointed a Type B Accident Investigation Board (the Board) to investigate the accident in accordance with DOE Order 225.1A, Accident Investigations. Although the accident investigation encompassed the cases of all three competitors who became ill, the Board focused primarily on the illness suffered by
RBC Insurance Accident Claim351.17 RBC Insurance Accident Claim188.37 Pilot Insurance Accident Claim259.95 State Farm Accident Claim182.16 State Farm Insurance Accident Claim178.70 Pafco Accident Claim115.46 Royal & Sunnaliance Accident Claim98.19
traffic accident data. The training of basic-level accident investigation technicians to identify, collect, record, and report the cause of accidents is an,essential phase of the overall highway safety program. The new Standard No. 18 made it necessary to locate substantive resource materials on accident investigation and reporting at the basic .
Lack of employee or supervisor training 2. Improper or outdated methods . Accident Reporting & Investigation Sample Program 12/2022 Page 5 . 3. Lack of enforcement of safety regulations . The accident investigation must be completed promptly to ensure that the physical conditions remain unchanged. C. In addition, the accident investigations .
ACCIDENT INVESTIGATION AND ACCIDENT STATISTICS . 9.1 REPORTING OF ACCIDENTS/INCIDENTS . 9.1.1 Contractor's Responsibility (a) Accidents involving death or serious injury . 24 hours of an accident/incident listed below occurring in Hong Kong waters: -a vessel is involved in a collision with another vessel, a port . 3.
are taken following an accident, an investigation of the accident will be conducted by the immediate supervisor, in conjunction with any witnesses to the accident to determine the cause. The findings of the investigation shall be documented on the Supervisor's Report of Investigation form. Distribution of the completed form will be as follows: a.
