Accident Investigation You Did What…Again?

1. Accident InvestigationYou Did What…Again? Presented by: John Dietrich, Atkinson, Andelson, Loya, Rudd & Romo LaFaye Platter, Hemet USD Lucy Rebuck, Hemet USD Suzanne Trowbridge, Keenan & Associates

2. Why Investigate? • Prevent future incidents (leading to accidents). • Identify and eliminate hazards. • Expose deficiencies in process and/or equipment. • Reduce injury and worker compensation costs. • Maintain employee morale. • Meet DOSH rule requirement that you investigate serious accidents.

3. “You can’t manage risk and change culture from behind a desk”John Dietrich

4. “Common sense is not so common”Lucy Rebuck

5. Investigate All Incidents and Accidents Conduct and document an investigation that answers: • Who was present? • What activities were occurring? • What happened? • Where and what time? • Why did it happen?

6. How Do You Investigate??

7. How To Investigate – Main Steps • Develop a plan • Assemble an investigation kit • Investigate all incidents and accidents immediately • Collect facts • Interview witnesses • Write a report

8. Tips for Developing An Accident Investigation Plan • Develop your action plan ahead of time. • Your plan might include: • Who to notify in the workplace? • How to notify outside agencies? • Who will conduct the internal investigation?

9. Tips for Developing a Plan (continued) • What level of training is needed? • Who receives report? • Who decides what corrections will be taken and when? • Who writes report and performs follow up?

10. What Should Be in The “Investigation Kit” • Camera • Tape recorder • Gloves • Tape measure • Large envelopes • High visibility tape • Scissors • Personal protective equipment • First aid kit Report Forms

11. Root Cause Analysis • Direct Cause • Unplanned release of energy or hazardous materials • Indirect Cause • Unsafe acts and/or unsafe conditions • Root Cause • Policies and decisions, personal factors, environmental factors

12. The Five Whys Basic Question - Keeping asking “What caused or allowed this condition/practice to occur?” The “five whys” is one of the simplest of the root cause analysis methods.

13. 5 Whys In Action Suzy had an unwitnessed trip and fall accident: • Why? She wasn’t looking where she was going • Why? She was carrying a box 3) Why? She was wearing inappropriate shoes 4) Why? There was water on the ground 5) Why?

14. Begin Investigation Immediately • It’s crucial to collect evidence and interview witnesses as soon as possible because evidence will disappear and people will forget.

15. Fact Finding • Witnesses and physical evidence • Employees/other witnesses • Position of tools and equipment • Equipment operation logs, charts, records • Equipment identification numbers • Take notes on environmental conditions, air quality • Take samples • Note housekeeping and general working environment • Note floor or working surface condition • Take many pictures • Draw the scene

16. Interview Witnesses • Interview promptly after the incident • Choose a private place to talk • Keep conversations informal • Talk to witnesses as equals • Ask open ended questions • Listen. Don’t blame, just get facts • Ask some questions you know the answers to

17. Write The Report • Who • What • Where • When • Why – Root Cause • Prevention & Action Steps • Follow through

18. Case Study #1 • Handout to be provided

19. Case Study #1 - Findings • Morale a result of poor supervision & management

20. Case Study #2 • Eye Injury • Investigation results: wasn’t following safety protocol; training provided on correct chemical handling • Action steps: • Disciplined employee for failing to follow safety protocols

22. Case Study #3 • Bus Driver Crashes Bus While Texting • Investigation: • Employee trained not to text • Employee observed texting on run in the am • Letter of reprimand at end of am shift for texting • Accident in pm while texting

23. Conclusion • Root Cause Analysis • Close Loop On Accident Investigation Findings • Hold Everyone Accountable for Safety