Accident Reporting, Investigation and Analysis

1. Accident Reporting, Investigation and Analysis ‘ Those who cannot remember the past are condemned to repeat it’ ©Consultnet Ltd

2. Accident Reporting, Investigation and AnalysisPresentation Contents Introduction Incident Response Incident Investigation Incident Analysis Remedial Actions Incident Report Near Miss Reporting Cost of incidents Incident Statistics Summary of Responsibilities

4. IntroductionWhy report and investigate accidents? ‘PREVENT A RECURRENCE OF THE SAME ACCIDENT’It is worth doing it well! • Learn from what went wrong • Determine the causes • Prevent recurrence • Improve the work environment • Meet regulatory requirements • Cost of incidents • Moral Obligation • Define trends • Provision of information in case of litigation • Reduction of operating costs by control of accidental losses • Expression of concern by management

5. IntroductionIncident Definitions • ACCIDENT - an undesired event that results in personal injury or property damage. • INCIDENT- an unplanned, undesired event that adversely affects completion of a task. • NEAR MISS - incidents where no property was damaged and no personal injury sustained, but where, given a slight shift in time or position, damage and/or injury easily could have occurred. • Lost Time Accident– an accident resulting in time off work • Dangerous Occurrence- escape of flammable substance, explosion, fire, collapse of load bearing apparatus, pipeline ruptures, pressure vessel ruptures, transport incidents, bursting of reveolving wheel, O/H electric line contact, building collapse(1993 Safety Health & Welfare at Work( General Application )Regulations ) • Reportable Incident– injured cannot return to work within 3 days of incident(1993 Safety Health & Welfare at Work( General Application )Regulations Form to be submitted to HSA( downloadable at www.hsa.ie )

6. IntroductionIncident Classification for Reporting • Near Miss Incident: a near miss incident where there is no loss be it injury or property damage however it could have resulted in personal harm/damage under slightly different circumstances, such incidents are reported to the Supervisor and formally logged on a Near Miss Report. • Level 1 - Minor Incident:a level one incident can typically be dealt with by the person identifying the problem. The supervisor should be informed and the incident formally logged on an Incident Report; this will permit assessment of the incident particularly with regard to the possibility of re-occurrence and the potential for a more serious event. Examples: minor localised fire, minor first aid injury(less than one day off work) • Level 2 - Serious Incident:immediate action should be taken where possible by the person identifying the incident. The supervisor should be immediately informed and should assess the situation. Thereafter, the supervisor will contact the necessary emergency services and officials as per the emergency plan. Examples: injury (person is likely to be out of work for more than one day but less than three days), containable fire, containable environmental damage. • Level 3 - Severe Incident:immediate action should be taken where possible by the person identifying the incident. The supervisor should be immediately informed and should assess the situation. The supervisor will contact the necessary emergency services and necessary personnel as per the site emergency plan. Examples:persons trapped, serious fire, threat to the safety of personnel, serious environmental damage, serious injury( person likely to be out of work > 3days), fatality.

7. Level of Incident and Investigation involved

8. Accident or Incident Occurs Initial response Supervisor actions as per emergency plan Medical Aid Prevent secondary accidents Notify emergency services Safety Manager Contact insurance Contact hsa if required • Is the Incident Level 2? • Medical Aid(1<days off<3) • E30,000<Damage<E200,000 • 1 day >Production Loss > 3 hours • Product will not meet customer standards • Is the Incident Level 1? • First Aid • Medical Aid (<1 day off work) • Damage < E30,000 • Production Loss < 3 hours • Product requires work to meet customer standards • Is the Incident Level 3? • Fatality • Serious Injury - Lost Time(>3 days) • Serious Incident Reportable to HSA • Damage>E200,000 • Production Loss < 1 day • Loss of Customer or major customer dissatisfaction No No Yes Yes Yes • Accident Team Investigates • Front line supervisor • Worker(s) /Witnesses involved • Area Safety Representative • Safety Manager • Accident Team Investigates • Front line supervisor • Worker(s) /Witnesses involved • Area Safety Representative • Safety Manager • Head of Department • Accident Team Investigates • Front line supervisor • Worker(s)/Witnesses involved • Area Safety Representative • Analyse • Response and loss limiting actions • Immediate causes (Substandard acts and conditions) • Basic causes (personal & job factors) • Program management (standards andcompliance) • Collect Evidence • Interview witnesses • Photographs • Sketches, survey, site maps • Relative positions • Examine equipment & machinery • Failed parts • Examine Materials • Examine records Incident Report Supervisor Responsible for completion and forward to Safety Manager within 24 Hours • Management Actions • Managing Director • review at next management meeting • Head of Department • track remedial actions • Safety Manager • Issue incident information • add to incident database • Review at next safety committee meeting • Include in incident analysis • Management Actions • Head of Department • track remedial actions • Safety Manager • add to incident database • Include in incident analysis No Does analyses show what happened, what should have happened and why? Collect more evidence and re-analyse Yes Analyse causes Report findings and actions Develop Remedial Actions inc. timescales and responsibilities Incident Investigation Flowchart

9. Accident Reporting, Investigation and Analysis Introduction Incident Response Incident Investigation Incident Analysis Remedial Actions Incident Report Near Miss Reporting Cost of incidents Incident Statistics Summary of Responsibilities

10. IntroductionReporting Incidents • Employee must report to Supervisor • Supervisor responsible for initiating reporting procedure • Supervisor responsible for complete of incident report for near-miss, Level 1 and Level 2 incidents involves Safety Manager and Area Safety Representative • Supervisor in conjunction with relevant Head of Department responsible for completion of Level 3 incident reports and also involves Safety Manager and Area Safety Representative • Head of Department responsible for completion of corrective actions • Reports to Senior Manager and Safety Manager

11. Initial ResponseTypical Procedure All incidents must be reported immediately by the employee concerned to their Supervisor: • If aNear Missincident the Supervisor shall ensure a Near Miss Report is completed immediately. • If aLevel 1incident the Supervisor in conjunction with the area Safety Representative completes the Incident Report Form and forwards to Safety Manager within 24 hours. • If a Level 2 incident immediately after attending to any victim and minimisation of property damage the Supervisor ensures the accident scene is secured, prevents access by unauthorised persons and calls the Safety Manager and the area Safety Representative who will assist the Supervisor in completing the Incident Report Form, taking witness statements and completion of the investigation. • If aLevel 3incident the Supervisor immediately after attending to any victim and minimisation of property damage ensures the accident scene is secured, prevents access by unauthorised persons and calls the Safety Manager, the area Safety Representative and the relevant Head of Department, who will assist the Supervisor in completing the Incident Report Form, taking witness statements and completion of the investigation.

12. Initial Response The Supervisor • Takes control of the scene • Calls first aid and emergency services • Controls secondary incidents • Identifies sources of evidence • Preserves evidence from alteration or removal • Determines the loss potential • Notifies appropriate management Discuss you company’s emergency response procedures in the event of fire, injury, chemical spill

13. Accident Reporting, Investigation and Analysis Introduction Incident Response Incident Investigation Incident Analysis Remedial Actions Incident Report Near Miss Reporting Cost of incidents Incident Statistics Summary of Responsibilities

14. Incident Investigation and AnalysisTips for investigation and analysis • Encourage a no-blame reporting culture • Focus must be to improve working conditions and methods • Approach with an open and objective mind • All facts learnt corrective action taken • Fact finding not fault finding • An opportunity for employees and management to work together to correct an unacceptable situation • An incident will happen again if underlying causes are not corrected • Delve deep to establish underlying causes do not accept all answers given at face value • Be prepared to look beyong the injured person, his co-workers, supervisor, manager • Consider communication skills and language barriers • Get as much factual information as possible to get the complete picture

15. Incident InvestigationEffective Incident Investigation • Establish the facts: Who? What? When? Where? The size? • Analyse the facts isolating contributary factors: • Who or what was involved • What hazards were present? • What controls failed? • Identify actions to prevent a recurrence • Implement the corrective actions

16. Incident InvestigationWho should lead investigation?The Supervisor(of those involved), why? • They have a personal interest • They know the people and conditions • They know how best and where to get the information needed • They will initiate or take any remedial action • They benefit from investigating Where there is major loss or loss potential or where multiple supervisors are involved it is beneficial that the investigation also involves the Head of Department for the area. In all cases it is recommended that the Supervisor involves the safety professional on his/her site to assist in the investigation

17. Incident InvestigationCollecting evidence and information Record: Pre-accident conditions, Accident sequence,Post-accident conditions • Position evidence – people(witnesses), equipment, materials & environment, use sketches maps, photos, video (Consider plant line up, valve alignment, tools labels, signs) • People evidence– statements from all involved and witnesses, interview separately • Parts evidence – machinery, tools and other equipment that could have contributed to the incident • Paper evidence– all relevant records such as training records, equipment records( maintenance, servicing), MSDS, procedures, codes of practice, pre-start checklists, permits, area rules, standards Consider reconstructing incident from above information

18. Initial ResponseTypical Procedure In the event of a Level 2 or Level 3 incident, immediately following the incident the Supervisor shall ensure the following: • Photographs of the scene are taken • If there is a possibility that the accident could become a fatality the scene must remain undisturbed until viewed by HSA Inspector and Gardai where required. • Arrange for survey plans of the site to be prepared. These are to include the following : • Locality Plan & details of accident site; • Detailed plan of view showing details after the accident and include such things as: Equipment used in rescue operations; Position of materials, ladders, equipment, etc. involved in the accident; Position from where photographs were taken; Position of persons involved in the accident; and other relevant information. • A sectional view (if necessary). Any sections made are to be marked on the detailed plan. • Take evidence from witnesses at the scene and make note of any piece of evidence. • Check relevant equipment, maintenance and training records • Analyse condition of equipment materials with specalist input where necessary • Prepare a report detailing the circumstances of the accident within 24 hours and submit to the Safety Manager. The report will include the Incident Report Form and witness incident analysis forms which provides for systematically identifying immediate causes, basic causes and lack of control.

19. Incident InvestigationAccident Photography • Photograph the scene from all sides • Use long, medium, close-up sequence • Accompany with good notes and sketches • Identify by number, time, date & name of photographer

20. Incident InvestigationInterviewing Witnesses • Calm, objective, impartial, open mind, search for facts not opinions • Do not interrogate/cross examine • As soon as possible( theorising increases as memory decreases) • Interview separately and privately, use a tape recorder only with witness permission • If significant conflict follow up interviews may be necessary • Assure them the information is being used for accident prevention not to apportion blame • Get the individuals version • Use open questions (cannot be answered with a simple yes or no) • Do not express an opinion or argue • Record critical information quickly • If not at the site of the accident use visual aids, sketches etc. • End on a positive note and keep the line open • Review completed statement with witness and have it signed Helpful Interview Questions What were you doing? Where were you working?How were you injured?How do you think the accident occurred?What is the safety procedure for the job?How were you trained for the job?Have you fully described the circumstances of the accident as you know them? Take a look at the Witness Incident Analysis form recommended for Level 2/3 incidents

21. Incident InvestigationParts ExaminationParts – machinery, tools and other equipment that could have contributed to the incident • Proper item for task • Damage - type, extent, pattern • Previous damage – defects, misuse • Wear • Safeguards – machine guards, emergency cut-offs • Labels, signs, markings

22. Accident Reporting, Investigation and Analysis Introduction Incident Response Incident Investigation Incident Analysis Remedial Actions Incident Report Near Miss Reporting Cost of incidents Incident Statistics Summary of Responsibilities

23. Incident analysisWhat’s involved? • Determine what happened –immediate cause –unsafe practices/conditions ( ask the question would the accidnet have happened if this particular factor was not present?) • Determine why it happened basic causes –personal/job factors • Cover deficiencies in the management system WOULD THE ACCIDENT HAVE HAPPENED IF THIS PARTICULAR FACTOR WAS NOT PRESENT? • Determine appropriate remedial action based on the immediate and basic causes • Apportion responsibility to implement corrective actions • Report findings to senior management • Follow-up and monitor corrective actions

24. Incident Analysis THE DOMINO SEQUENCEHow Accidents Happen The domino described below is a model that will help you see how accidents happen. Lack of Control Immediate Cause Basic Cause Accident Loss • Lack Of: • Training • Resources • Belief Undesired, Unplanned Event Which Disrupts Work Activity • Organizational • Failure to: • - Plan • Direct • Organize • Control • Unsafe Act • Unsafe Condition • Death • Injury • Property damage • Lost Time • Lost Productivity

25. Incident Analysis Lack of Control Organisational failure means that the organisation, at one or more levels, did not effectively/properly plan, direct, organize, control or combination thereof, its resources Resources are: Time, Tools, Equipment, Materials, Manpower • Failure to PLAN means: All aspects of the job, task or operation were not planned effectively so that an unexpected accident was not eliminated. • Failure to DIRECT means: Personnel involved in the job, task or operation were not instructed and trained as to the potential hazards involved and means to eliminate or control those hazards. • Failure to ORGANIZE means: All resources that were needed to do the job safely were not present, proper, and/or in safe operating condition. • Failure to CONTROL means: Failure to ensure that the job or task was actually conducted as planned, organized and directed.

26. Incident Analysis Basic Cause • Personal and job factors - lead a person to commit an unsafe condition or act • Job factor - Lack of Training/ Lack of Resources • No training at all • Training that was incomplete or inadequate or not understood • Training that was not repeated frequently enough • Resources (time, tools, equipment, materials, manpower) necessary • to do the job safely are not provided • Resources not proper (skills, size, abilities, type) • Resources not in safe operating condition • Inadequate supervision • Inadequate work standards, procedures, work practices, maintenance • Personal factor - Lack of Belief • There is a belief that a negative consequence will not result because of their • action. Lack of belief is almost always caused by past experience. Factors that • can contribute to it are: • Poor morale/low motivation/stress • Peer pressure • Productivity pressures • Inadequate resources • Inadequate capability

27. Incident Analysis Immediate Cause • Immediate causes are the unsafe acts and/or conditions that lead directly to the accident. • Unsafe acts account for 85% of accidents; unsafe conditions account for 14% of accidents. • However, 85% of the unsafe conditions were caused by an unsafe act. • Therefore, we can say that 97% of all accidents are caused directly or indirectly by an unsafe act.

28. Incident Analysis Accident • An accident is: “An unplanned, undesirable event which disrupts work activity” • An accident always results in a loss.

29. Incident Analysis Loss • The loss is the result of an accident. (Disruption of work activity). • Approximately 30 different losses have been identified as potential results of accidents, for example: Death Lost Productivity • Injury Civil Penalties • Lost Time Replacement Costs • Damaged Morale Economic Loss • Damaged Tools Loss of Client Goodwill • Damaged Equipment Lost Competitiveness • Lost Materials

30. Human Element of Accident Causation Organisational Process Local Working Conditions Active Failures Defences Latent Failures Latent Failures Latent Failures Active Failures Active & Latent Fallible Decisions Training & Skills Work Atmosphere Line Management Deficiencies Planning Supervision Psychological Precursors of Unsafe Acts Communication Job Factor Team Work Unsafe Acts Communication Person Factor Inadequate Defences Tools & Equipment Accident Senior Management Line Management Frontline Supervisor Operators Maintenance Crews Safety Equipment Casual Sequence Human Elements of Accident Causation (Reason 1990)

31. Incident analysisLoss Causation Model • Lack of Control • Inadequate • Systems • Standards • Compliance Basic Causes Personal Factors Job/system factors Immediate Causes Substandard Acts/practices Substandard Conditions Incident Event Contact with energy or surface • Loss • Unintended harm or damage • People • Property • Processes Problem Solving Model • In an incident analysis situation use this model and write down the loss, incident event, immediate, basic causes and relevant lack of controls under each heading in list form as per the Incident Report Form • This makes it possible to identify the causes and relevant corrective actions to prevent a reoccurrence.

32. Incident Form: Immediate Causes

33. Incident Form: Basic Causes

34. Accident Reporting, Investigation and Analysis Introduction Incident Response Incident Investigation Incident Analysis Remedial Actions Incident Report Near Miss Reporting Cost of incidents Incident Statistics Summary of Responsibilities

35. Incident analysisRemedial Actions • Temporary Actions – correct substandard actions and conditions • Permanent Actions – remedy personal factors and job factors Remedial Actions must be: • Communicated clearly • Responsible person identified and timescale established for their completion • Follow-up conducted by Investigation Team • Department Manager responsible to ensure completion

36. Accident Reporting, Investigation and Analysis Introduction Incident Response Incident Investigation Incident Analysis Remedial Actions Incident Report Near Miss Reporting Cost of incidents Incident Statistics Summary of Responsibilities

37. Incident ReportTypical Contents • Title, date and time • Location of the accident • Type of injury or damage/who and what was involved • Cost of losses • Description of what happened including emergency response sequence • How the accident occurred/extent of damage • Immediate(direct(energy sources, haz. materials etc.) & indirect causes(unsafe acts and conditions) & basic causes (personal/environmental factors) • Lack of control(management policies) • Remedial actions temporary & permanent • Management review • Other Note: • Timeliness of report is critical, best reports are written promptly • Accident reports are usually ‘discoverable’ this means they can be used by parties to an action for damages or criminal charges

38. Incident ReportWhere to? Incident reports forwarded to the Safety Manager are processed as follows : • All incident reports are analysed and the summary information is presented at the next monthly management meeting and safety committee meeting • All Level 2 and Level 3 incidents are reviewed at the next weekly management meeting. Any lessons learned are communicated to management and employees from information distributed to all Supervisors(for inclusion in tool box talk ) and on Company Notice Boards • Incident reports are copied to the relevant Head of Department and General Manager in the case of Level 2 and Level 3 incidents

39. Accident Reporting, Investigation and Analysis Introduction Incident Response Incident Investigation Incident Analysis Remedial Actions Incident Report Near Miss Reporting Cost of incidents Incident Statistics Summary of Responsibilities

40. Near Miss ReportingReporting of Near Miss Incidents is critical 1 Serious or Major Injury • Near misses provide a much larger base for more effective control of accidental loss • Eliminate the causes of near misses, reduce the potential for more serious accidents, this is the basis of any proactive safety management system • High potential incidents should be analysed thoroughly Accident Ratio Study 10 Minor Injuries 30 Property Damage 600 Incidents with no visible injury or damage Near miss

41. Accident Reporting, Investigation and Analysis Introduction Incident Response Incident Investigation Incident Analysis Remedial Actions Incident Report Near Miss Reporting Cost of incidents Incident Statistics Summary of Responsibilities

42. Analysis of costsConsider the following: • Cost of dealing with incident( such as first aid, emergency supplies, staff downtime) • Costs of incident investigation( such as staff time, consultants time) • Cost of getting back to business( such as re-scheduling, clean-up, hire of equipment) • Business Costs( such as cost of injured persons salary, replacement salary, lost orders) • UK HSE useful incident cost calculator template – next slide

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44. Accident Reporting, Investigation and Analysis Introduction Incident Response Incident Investigation Incident Analysis Remedial Actions Incident Report Near Miss Reporting Cost of incidents Incident Statistics Summary of Responsibilities

45. Accident Statistics Analysis • Accident data base should be established • Identify trends and focus systems where they can produce the greatest return on invested time and energy • Accident analysis statistics should be: • produced regularly by the Safety Department • reviewed at regular management and safety committee meetings • summary available to all employees • Identify repetitive or signifcant items

46. Accident Statistics Analysis • Statistics may include: • Number of near-miss, property damage, first aid, medical aid, lost time incidents, fire, environmental events • Lost time injury frequency rates and severity rates Lost Time Incident Frequency Rate(LTIFR)=(Total Lost Time Incidents/Total Hours Worked) x 100,000 Lost Time Incident Severity Rate(LTIFR)=(Total hours lost/Total Hours Worked) x 100,000 • Costs • Cause and control analysis Type of accidents by department, work section, occupation Equipment/substances involved Activity at time of injury Age of person/length of service Time of day Immediate causes(substandard acts and conditions) Basic causes( Personal and job factors) Lack of control(inadequate programme standards or compliance with standards) Remedial action completion by department Problem solving project teams to address critical problems identified

47. Accident Reporting, Investigation and Analysis Introduction Incident Response Incident Investigation Incident Analysis Remedial Actions Incident Report Near Miss Reporting Cost of incidents Incident Statistics Summary of Responsibilities

48. IncidentsSummary of Responsibilities • All Employees must report all incidents to their Supervisor • All Supervisors responsible for initiaiting accident investigations • All Heads of Department are responsible for taking appropriate action on the conclusions and results of any incident investigation within their Department. • All Heads of Departments are responsible to ensure that the supervisors in their department are fully aware of, understand and initiate the Incident Reporting and Investigation Policy and attend relevant training. • The Safety Manager will be responsible for providing technical support to the Supervisor in the course of the incident investigation, issuing incident information for communication to all employees, producing the incident statistics and presentation to monthly management and safety committee meeting • The Safety Manager will ensure that management, employees and their representatives are adequately consulted and informed on the incident investigation policy and provision of training as regards implementation of the policy • In the event that a Level 2 or Level 3 incident meets the requirement of reporting to the Health & Safety Authority, the Safety Manager contacts the relevant Inspector, submits the completed statutory report form and co-ordinates any subsequent investigation with the Inspector. • The Safety Manager is responsible for reporting Level 2 & 3 incidents to the Company Loss Adjuster and Company Insurance Co-ordinator and co-ordinating any subsequent follow-up investigation.

49. Accident or Incident Occurs Initial response Supervisor actions as per emergency plan Medical Aid Prevent secondary accidents Notify emergency services Safety Manager Contact insurance Contact hsa if required • Is the Incident Level 2? • Medical Aid(1<days off<3) • E30,000<Damage<E200,000 • 1 day >Production Loss > 3 hours • Product will not meet customer standards • Is the Incident Level 1? • First Aid • Medical Aid (<1 day off work) • Damage < E30,000 • Production Loss < 3 hours • Product requires work to meet customer standards • Is the Incident Level 3? • Fatality • Serious Injury - Lost Time(>3 days) • Serious Incident Reportable to HSA • Damage>E200,000 • Production Loss < 1 day • Loss of Customer or major customer dissatisfaction No No Yes Yes Yes • Accident Team Investigates • Front line supervisor • Worker(s) /Witnesses involved • Area Safety Representative • Safety Manager • Accident Team Investigates • Front line supervisor • Worker(s) /Witnesses involved • Area Safety Representative • Safety Manager • Head of Department • Accident Team Investigates • Front line supervisor • Worker(s)/Witnesses involved • Area Safety Representative • Analyse • Response and loss limiting actions • Immediate causes (Substandard acts and conditions) • Basic causes (personal & job factors) • Program management (standards andcompliance) • Collect Evidence • Interview witnesses • Photographs • Sketches, survey, site maps • Relative positions • Examine equipment & machinery • Failed parts • Examine Materials • Examine records Incident Report Supervisor Responsible for completion and forward to Safety Manager within 24 Hours • Management Actions • Managing Director • review at next management meeting • Head of Department • track remedial actions • Safety Manager • Issue incident information • add to incident database • Review at next safety committee meeting • Include in incident analysis • Management Actions • Head of Department • track remedial actions • Safety Manager • add to incident database • Include in incident analysis No Does analyses show what happened, what should have happened and why? Collect more evidence and re-analyse Yes Analyse causes Report findings and actions Develop Remedial Actions inc. timescales and responsibilities Incident Investigation Flowchart

50. Accident InvestigationCase Study • Form teams for the investigating and reporting • Analyse the facts • Identify the immediate and basic causes • Recommend remedial actions • Complete Incident Report • Present findings Remember Rudyard Kipling's I keep six honest serving men,They taught me all I knew,Their names are What and Why and How and Where and When and Who