OH NO! Now What Do I Do? Accident Investigations Pamela A. Boatright, CIH University of Oklahoma Health Sciences Center
What is an Accident? • An accident is any unplanned event that results in personal injury or in property damage.
Why Investigate? • Accident investigation concentrates on gathering all information about the factors leading to an accident. • The goal is preventing future accidents and injuries.
Why Investigate? • Determine direct causes • Uncover contributing causes • Prevent similar accidents • Document facts • Provide information on costs • Promote safety
Determine Direct Causes • Hazard control system failure? • Rules and regulations broken? • Defective machinery? • Poor layout of workspace?
Uncover Contributing Causes • Other factors may be: • Poor housekeeping • Failure to follow maintenance schedules • Inadequate supervision • Faulty equipment
Prevent Similar Accidents • Identification may help prevent similar accidents in the future by identifying needed actions and improvements.
Document Facts • Compensation and litigation issues • A permanent record of facts • Accident reconstruction may be needed • Facts must be recorded properly, accurately and thoroughly
Provide Information on Costs • Direct Costs • Indirect Costs
Promote Safety • Psychological and material benefits • Demonstrates the organization’s interest • Indicates management’s sense of accountability and commitment to safety • Fact-finding, not Fault-finding process
Be empathetic • Treat employees with respect • People do not like pain • Do not make assumptions • Be sensitive to the fact that the injured party may be embarrassed and defensive • Seek to fix the problem, not the blame
Cases to be Investigated • All on-the-job injuries, exposures or illnesses should be reported • Near-misses may hold important clues about potential accidents and should be reported also
Accident Causes and Their Control • Every accident can be attributed, directly or indirectly to: • Human factors (the worker or another person) • Situational factors (facilities, tools, equipment, or materials) • Environmental factors (noise, vibration, temperature extremes, illumination)
Human Factors • Any person who by action or failure to act causes an accident • deviation from standard operating procedures • deviation from safety rules and training WHY??
Why? • No safe job procedures exist • The employee did not know the standard job procedure • Employee knew, but did not follow the procedures • Employee followed procedures
Why? • Procedure encourages risk-taking • Employee changed the job procedure or by-passed safety procedures • Employee did not follow procedures because of the supervisor • Individual characteristics
Situational Factors • Hazardous Materials • Unsafe operations • Tools • Equipment • Facilities
Environmental Factors • Physical - noise, vibration, radiation, lighting, temperature • Chemical - toxic gas or vapors, fumes, mists, smoke • Biological - bacteria, fungi, parasites, insects, plants • Ergonomic - awkward or repetitive actions that place stress on the body
Sources of Situational or Environmental Hazards • Purchasing agents • Maintenance personnel • Employees
Examining Accident Causation • After-the-fact • Before-the-fact • Critical Incident Technique • Safety Sampling
After-the-fact • Crucial Questions: • Who? • How? • What? • Why? • When? (and following sequence) • Where?
Employer data Employee data Narrative Description Equipment Task description Time Factors Nature of Injury Preventive Measures Eight Data Elements
Fact-Finding • Interview witnesses as soon as possible, • Inspect the accident site before any changes occur. • Take photographs and make sketches. • Record pertinent data in maps. • Get copies of all reports. • Keep accurate notes in a bound notebook.
Fact-Finding • Documents containing normal operating procedures, flow diagrams, maintenance charts, or reports of difficulties or abnormalities may be useful. • Record pre-accident conditions, the accident sequence, and post-accident conditions.
Fact-Finding • Document the location of victims, witnesses, machineryk, energy sources, and hazardous materials. • Call in experts if needed.
Interviews • Get preliminary statements as soon as possible from witnesses. • Locate the position of witnesses on a map or chart. • Explain the purpose (prevention) and try to put the witness at ease. • Let the witness speak freely and take notes without distracting him/her.
Interviews • Use a tape recorder only with the permission of the witness. • Use sketches and diagrams to help the witness. • Make note of direct observations versus hearsay. • Try to use the exact words used by the witness.
Interviews • Word questions carefully and repeat or reword if the witness does not undestand the question. • Identify the qualifications of each witness (name, address, occupation, years of experience, etc.). • Supply each witness with a copy of their statements (signed statements desirable).
Before-the-fact • Systematic approach to identifying and evaluating an accident before it occurs • Critical Incident Technique • Safety Sampling
Critical Incident Technique • Ask a sampling of workers to describe job hazards • Management classifies “incidents” into hazard categories and identifies problem areas • A team can analyze the management systems in place that should have prevented the unsafe acts or conditions
Safety Sampling • Uses expertise within the organization • Make rounds to observe unsafe practices • Make observations during different times of the day and throughout the jobsite
Resources and References • http://www.osha.gov/ • http://www.cdc.gov/niosh/homepage.html • http://www.cdc.gov/ • http://atsdr1.atsdr.cdc.gov:8080/ • http://www.epa.gov/enviro/index_java.html • http://ace.ace.orst.edu/info/extoxnet/ • http://www.nsc.org/