Accident Investigation Most of the cost is hidden
Description: Accident Investigation Most of the cost is hidden Source: The cost of Incidents at work HSE The Incident Iceberg How By Fully Investigating Incidents Determining Root Causes Implementing Actions to Prevent Reoccurrence Why Investigate
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slide1. Accident Investigation<br>
slide3. Most of
the cost
is hidden Source: “The cost of Incidents at work” HSE The Incident Iceberg<br>
slide4. How By Fully Investigating Incidents
Determining Root Causes
Implementing Actions to Prevent Reoccurrence<br>
slide5. Why Investigate Incidents Opportunities:
Powerful tool to turn a negative situation into something positive
Opportunity to learn and prevent future incidents Done right, Incident investigation can be a motivator
and a team builder as it demonstrates concern,
commitment and a willingness to improve<br>
slide6. A piece of metal falls from a crane and hits the ground making a slight depression
A second piece of metal falls from a crane and hits a piece of equipment at ground level causing damage
A third piece of metal falls from a crane hitting a man below causing serious personal injury
The above 3 cases describe the results of an Incident, not the Incident itself Potential results from an Incident The difference between the above 3 events might only
be a matter of chance or good fortune<br>
slide7. So we need to consider not just actual consequences of an Incident but also potential consequences
The level of Incident Investigation should reflect the severity of the incident (actual and potential)<br>
slide8. Put the interviewee at ease
Explain the purpose of the interview
Be objective, open and fair
Establish the facts
Avoid interrogation and accusation
Treat the person considerately, avoid sarcasm, aggression, and unfriendliness
Do not interrupt, let them explain it as they remember things Conducting Interviews<br>
slide9. Avoid leading questions (do not put words into their mouth)
Be a good listener
At the end of the interview summarise and confirm what has been said
Conclude the interview and thank the interviewee
Conduct witness interviews individually, not as a group
Conduct interviews as soon as possible after the event – before people forget or have discussed the incident with others
Interview all those involved, including those involved in the lead up to the event Conducting Interviews<br>
slide10. Use the correct form
The witness should be asked whether they require the interviewer to write the statement for them or whether they would like to write it themselves
Make it legible
Make it accurate and to the point
No opinions – just the facts Taking Statements<br>
slide11. Logical order, from the beginning of the incident through to its conclusion
Summarise and confirm what has been said, record it and agree it
No alterations should be made and mistakes should be crossed through and initialled by the witness.
At the statement conclusion the witness should be allowed to read it through and be asked whether they want to add or alter anything therein. Taking Statements<br>
slide12. The interview is to gather evidence
Do not use it to
Blame somebody
Blame somebody else
Protect oneself / department
To enforce one’s own opinions or objectives Remember By conducting interviews in the correct manner
we are more likely to discover the facts<br>
slide13. Swiss Cheese Model<br>
slide14. Incident Components Pre Incident components can be grouped into 2 areas:
Immediate causes (the symptoms) and
Root causes (the underlying factors) It is vital that our Incident Investigation process
identifies both immediate and root causes<br>
slide15. Incident Components – Immediate Causes Unsafe acts
These are actions by people who wilfully or inadvertently disregard correct procedures or practices and thus in turn reduce the degree of safety:
Using equipment without authority
Using equipment incorrectly
Rendering safety devices inoperative by removing/disconnecting
Using unsafe / damaged faulty equipment<br>
slide16. Incident Components – Immediate Causes Failing to use P.P.E.
Horseplay
Unsafe loading or stacking
Taking an unsafe posture or position
Hazardous movements such as running, stepping or climbing over
Drinking alcohol or taking drugs<br>
slide17. Incident Components – Immediate Causes Unsafe conditions
These are environmental or physical conditions which, if left uncorrected may become the cause of an Incident:
Inadequate guarding of machinery
Faulty design, construction or maintenance, such as inadequate ventilation, lighting or poor means of access<br>
slide18. Incident Components – Immediate Causes Unsafe conditions
Defects in equipment tools or machinery such as frayed lifting ropes, chipped hammer head, incorrectly adjusted breaks
Lack of knowledge, skill or training
Poor housekeeping
Unsafe system of work
Excessive noise<br>
slide19. Incident Components – Root Causes Immediate causes are all deviations from required safe practice but they must be seen as the SYMPTOMS of more basic
underlying ROOT CAUSES.
A root cause is one which gives rise to an unsafe act or unsafe condition which could trigger off a chain reaction (domino effect) in turn giving rise to other unsafe acts or conditions.<br>
slide20. Incident Components – Root Causes Lack of policies, Lack of standards, procedures or risk assessments
Lack of knowledge, information and training
Lack of commitment, Attitudes , Tradition
Behaviour in the workplace
Financial restrictions
Suitability
Supervision<br>
slide21. HSE identify 4 steps
Information gathering
Analysis
Risk control measures
Action plan and implementation HSG245: Investigating Accidents and Incidents<br>
slide22. HSE also refer to
Immediate causes – the agent of injury, e.g the blade
Underlying causes – the unsafe acts and conditions, e.g. the guard removed
Root causes – the initiating event or failings from which all other causes or failings spring, e.g. the lack of supervision HSG245: Investigating Accidents and Incidents<br>
slide23. Investigation Strategy Take control
Ensure your own safety and that of others
Make the area safe
Attend to the injured
“Freeze” the scene<br>
slide24. Investigation Aims Obtain information about injured parties
Find out what task was being done
Find out what happened
Identify people involved and witnesses
Gather physical evidence<br>
slide25. What was the Identified Loss, e.g. Injury to Person and details
What Event caused the loss, e.g. struck by and details
What were the Substandard Conditions, e.g. Inadequate Guards or Barriers and details
What were the Substandard Acts, e.g. Operating Equipment without Authority and details
Identify Immediate (Corrective) Actions to prevent reoccurrence – there should be a corrective action for each identified substandard condition and substandard act
Where Substandard Acts are one of the immediate causes, immediate action may need to be taken against the individuals involved Immediate Causes Immediate Causes need Immediate Action<br>
slide26. Immediate Causes Event
Fall on Same Level
Substandard Conditions
Poor Housekeeping or Disorderly Workplace
Substandard Acts
Failure to Create or Secure a Safe Environment
Immediate Actions
Clear up the water<br>
slide3. Most of
the cost
is hidden Source: “The cost of Incidents at work” HSE The Incident Iceberg<br>
slide4. How By Fully Investigating Incidents
Determining Root Causes
Implementing Actions to Prevent Reoccurrence<br>
slide5. Why Investigate Incidents Opportunities:
Powerful tool to turn a negative situation into something positive
Opportunity to learn and prevent future incidents Done right, Incident investigation can be a motivator
and a team builder as it demonstrates concern,
commitment and a willingness to improve<br>
slide6. A piece of metal falls from a crane and hits the ground making a slight depression
A second piece of metal falls from a crane and hits a piece of equipment at ground level causing damage
A third piece of metal falls from a crane hitting a man below causing serious personal injury
The above 3 cases describe the results of an Incident, not the Incident itself Potential results from an Incident The difference between the above 3 events might only
be a matter of chance or good fortune<br>
slide7. So we need to consider not just actual consequences of an Incident but also potential consequences
The level of Incident Investigation should reflect the severity of the incident (actual and potential)<br>
slide8. Put the interviewee at ease
Explain the purpose of the interview
Be objective, open and fair
Establish the facts
Avoid interrogation and accusation
Treat the person considerately, avoid sarcasm, aggression, and unfriendliness
Do not interrupt, let them explain it as they remember things Conducting Interviews<br>
slide9. Avoid leading questions (do not put words into their mouth)
Be a good listener
At the end of the interview summarise and confirm what has been said
Conclude the interview and thank the interviewee
Conduct witness interviews individually, not as a group
Conduct interviews as soon as possible after the event – before people forget or have discussed the incident with others
Interview all those involved, including those involved in the lead up to the event Conducting Interviews<br>
slide10. Use the correct form
The witness should be asked whether they require the interviewer to write the statement for them or whether they would like to write it themselves
Make it legible
Make it accurate and to the point
No opinions – just the facts Taking Statements<br>
slide11. Logical order, from the beginning of the incident through to its conclusion
Summarise and confirm what has been said, record it and agree it
No alterations should be made and mistakes should be crossed through and initialled by the witness.
At the statement conclusion the witness should be allowed to read it through and be asked whether they want to add or alter anything therein. Taking Statements<br>
slide12. The interview is to gather evidence
Do not use it to
Blame somebody
Blame somebody else
Protect oneself / department
To enforce one’s own opinions or objectives Remember By conducting interviews in the correct manner
we are more likely to discover the facts<br>
slide13. Swiss Cheese Model<br>
slide14. Incident Components Pre Incident components can be grouped into 2 areas:
Immediate causes (the symptoms) and
Root causes (the underlying factors) It is vital that our Incident Investigation process
identifies both immediate and root causes<br>
slide15. Incident Components – Immediate Causes Unsafe acts
These are actions by people who wilfully or inadvertently disregard correct procedures or practices and thus in turn reduce the degree of safety:
Using equipment without authority
Using equipment incorrectly
Rendering safety devices inoperative by removing/disconnecting
Using unsafe / damaged faulty equipment<br>
slide16. Incident Components – Immediate Causes Failing to use P.P.E.
Horseplay
Unsafe loading or stacking
Taking an unsafe posture or position
Hazardous movements such as running, stepping or climbing over
Drinking alcohol or taking drugs<br>
slide17. Incident Components – Immediate Causes Unsafe conditions
These are environmental or physical conditions which, if left uncorrected may become the cause of an Incident:
Inadequate guarding of machinery
Faulty design, construction or maintenance, such as inadequate ventilation, lighting or poor means of access<br>
slide18. Incident Components – Immediate Causes Unsafe conditions
Defects in equipment tools or machinery such as frayed lifting ropes, chipped hammer head, incorrectly adjusted breaks
Lack of knowledge, skill or training
Poor housekeeping
Unsafe system of work
Excessive noise<br>
slide19. Incident Components – Root Causes Immediate causes are all deviations from required safe practice but they must be seen as the SYMPTOMS of more basic
underlying ROOT CAUSES.
A root cause is one which gives rise to an unsafe act or unsafe condition which could trigger off a chain reaction (domino effect) in turn giving rise to other unsafe acts or conditions.<br>
slide20. Incident Components – Root Causes Lack of policies, Lack of standards, procedures or risk assessments
Lack of knowledge, information and training
Lack of commitment, Attitudes , Tradition
Behaviour in the workplace
Financial restrictions
Suitability
Supervision<br>
slide21. HSE identify 4 steps
Information gathering
Analysis
Risk control measures
Action plan and implementation HSG245: Investigating Accidents and Incidents<br>
slide22. HSE also refer to
Immediate causes – the agent of injury, e.g the blade
Underlying causes – the unsafe acts and conditions, e.g. the guard removed
Root causes – the initiating event or failings from which all other causes or failings spring, e.g. the lack of supervision HSG245: Investigating Accidents and Incidents<br>
slide23. Investigation Strategy Take control
Ensure your own safety and that of others
Make the area safe
Attend to the injured
“Freeze” the scene<br>
slide24. Investigation Aims Obtain information about injured parties
Find out what task was being done
Find out what happened
Identify people involved and witnesses
Gather physical evidence<br>
slide25. What was the Identified Loss, e.g. Injury to Person and details
What Event caused the loss, e.g. struck by and details
What were the Substandard Conditions, e.g. Inadequate Guards or Barriers and details
What were the Substandard Acts, e.g. Operating Equipment without Authority and details
Identify Immediate (Corrective) Actions to prevent reoccurrence – there should be a corrective action for each identified substandard condition and substandard act
Where Substandard Acts are one of the immediate causes, immediate action may need to be taken against the individuals involved Immediate Causes Immediate Causes need Immediate Action<br>
slide26. Immediate Causes Event
Fall on Same Level
Substandard Conditions
Poor Housekeeping or Disorderly Workplace
Substandard Acts
Failure to Create or Secure a Safe Environment
Immediate Actions
Clear up the water<br>