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Incident Investigation Training

Portage County Safety Council – April 2016

August 12, 2016

Don Elswick

[email protected]

https://youtu.be/CCbWyYr82BM

Elswick August 12, 2016 • Slide 1

mailto:[email protected]





August 12, 2016 • Slide 2

Pessimism –vs- Optimism

The pessimist sees difficulty in every opportunity. The optimist sees opportunity in every difficulty. Winston Churchill

The pessimist sees failure in every accident. The optimist sees opportunity to analyze, learn and prevent recurrence in every accident. The only time an accident is totally negative is when we do not learn from it. Dale Janes


A Quiz!

Find a learning partner…..

Find out the first job (taxes paid) and discuss two (2)

safety and health myths

Example: Training should be required on all incident

investigations with attorneys involved…..


Fallacies in the Safety Fable

Occupational H

azard

s,

Octo

ber

1997

Low recordable rates indicate safety programs that are working well

Safety professionals and attorneys can keep workers safe

Conditions cause Accidents

Enforcing rules improve safety

Rewards improve safety

Investigating to find the root cause of accidents will improve safety

Awareness Training improves safety


A Quiz!

TO BE SURE YOU ARE COMFORTABLE

WITH THESE FACT WRITING IDEAS …..

LETS TAKE A QUIZ


Timed Quiz

YOU WILL BE GIVEN A QUIZ

LEAVE IT FACE DOWN UNTIL THE TIME

STARTS

YOU WILL HAVE 60 SECONDS TO

ANSWER THE QUESTIONS

Our work is comp.


On a bright sunny day, a contractor arrived at a construction

site. An accident had occurred.

A worker, wearing safety glasses, hard hat and safety

harness, was shouting, in Italian, at a co-worker standing

nearby. The other worker was wearing no safety

equipment.

It seems a beam had fallen and ruined a day’s work.

Watching the discussion were two other workers. One, a

young bearded worker, was chatting with another worker

who had long hair and wore jeans.

Read the Following Story.

Then Complete the Quiz.


60 Seconds -----

1. There are 5 people at the site. T F ?

2. It is spring or summer. T F ?

3. A steel beam has fallen. T F ?

4. The contractor saw a worker shouting. T F ?

5. The worker was shouting to tell his friend the boss was coming. T F ?

6. One worker is Italian. T F ?

7. The worker wearing the safety equipment did not cause the accident. T F ?

8. The worker not wearing safety equipment caused the accident. T F ?


60 Seconds -----

9. The worker not wearing safety equipment is not safety conscious. T F ?

10. Management is only concerned about meeting the work schedule. T F ?

11. The two workers chatting are wasting time. T F ?

12. The bearded worker is chatting with a woman. T F ?

13. If the long haired person in jeans is a man, is it possible that the

bearded man loves him? T F ?

Our work is comp.


60 Seconds -----

14. This is a good time to have a safety meeting. T F ?

15. Did you identify any mental models that might allow you to jump to

unfounded conclusions? T F ?

16.Did answering these questions change your first impression

of the scene? T F ?

17. No one was injured so the accident is no big deal. T F ?


Licensed Drivers and Numbers in Accidents by Age

Our work is comp.

1) What age group has the highest number of

accidents?

2) What group has the highest number of drivers in

fatal accidents?

3) Based on 2009 National Safety Council statistics

who would you want to be your driver?

a) 16-19

b) 20-24

c) 25-34

d) 35-44

e) 45-54

f) 55-64

g) 65-74


Driving Survey

1) What age group has the

highest number of

accidents?

a) 16-19 | 10, 326

b) 20-24 | 17, 465

c) 25-34 | 36, 694

d) 35-44 | 38, 424

e) 45-54 | 41, 921

f) 55-64 | 33, 271

g) 65-74 | 19, 135

2) What group above has

the highest number of

drivers in fatal

accidents?.

a) 25-34 | 18.3%

b) 45-54 | 17.3%

c) 35-44 | 15.6%

3) Based on 2009 National

Safety Council statistics

who would you want to be

your driver?

16 year old

number of accidents: 1,311

fatality: 1.5%

Our work is comp.


Session Objectives

Define when to investigate and how to collect information for and use

information from the investigation

Describe how to complete the four steps of an investigation including:

– How to list facts and conduct interviews

– Proper documentation for investigation

– How to decide upon appropriate actions to prevent recurrences

Practice completing investigation from example scenarios


Why Do You Want To Know Why An Incident Occurs?

Prevent further incidents

Protect employees

Save company money / protect jobs


An accident results from a combination of several causes.

The solution to each accident can be found in a detailed

analysis of the accident itself.

Basic Principles


1. ASSEMBLE A TEAM

2. DEVELOP A LIST OF FACTS

3. CONSTRUCT A FACT DIAGRAM

4. IDENTIFY TARGET FACTS AND SELECT CORRECTIVE ACTIONS

Overview of the Method


Step #2 – Develop a List of Facts

Rules:

– ONE FACT AT A TIME

– DO NOT MAKE VALUE JUDGMENTS

– DO NOT INTERPRET JUDGE

JUDGE

JUDGE


Definitions / Discussion

ONE FACT AT A TIME

– Work through each fact on its own before moving on to

the next

– Order is not important at this point

NO INTERPRETATION

– Avoid to interpret facts in a particular way (i.e., Aisle too

narrow, etc.)


DON’T MAKE VALUE JUDGMENTS

– Above all do not be negative.

– Facts are facts, not good or bad, they just are what they

are. (i.e., Unsafe, careless, bad design, poor judgement,

etc.)

Definitions / Discussion

Communications

Class is canceled today.

We will meet again at 8:30 a.m.

three days

after two days before the day

before tomorrow.



Are We Close?

RULES

1. ONE FACT AT A

TIME

2. DO NOT MAKE

VALUE

JUDGMENTS

3. DO NOT

INTERPRET

Seven cm

long cut to left

forearm

He was using

a utility knife

Cut towards

himself

He was not

wearing a

forearm guard

He did not

know about

forearm

guards

Exposed

blade


What Are The Key Questions Again?

What is the cause of this fact?

Was it necessary?

Was it sufficient?


He was using

a utility knife

Cut towards

himself

He was not

wearing a

forearm guard

He did not

know about

forearm

guards

Exposed

blade

Find The End Result

Seven cm

long cut to left

forearm

Seven cm

long cut to

left forearm

Our work is comp.


Cut towards

himself

He was not

wearing a

forearm guard

Exposed

blade

He did not

know about

forearm

guards

He was using

a utility knife

Select A New Result

Identify The Fact(s) That Directly Caused It To Occur

He did not

know about

forearm

guards

?

He was

using a

utility knife ?

Seven cm

long cut to

left forearm


Organizational Solutions

Clarify Assignments

Upgrade training

Establish Operating Controls

Revise Procedure

Increase Audit Effort

Improve Work Planning

Use a checklist

Improve Supervisory

Example

Improve Hazard Assessment

Improve Training

Assessment

Resolve Conflict in Priorities


Improve Hazard Recognition

Improve Procedure Use

Increase Knowledge

Re-Train on Procedure

Improve Clarity of Directions

Resolve Conflicting Demands

Address Physical Limitations

Address Mental Limitations

Address Fatigue

Address Drug / Alcohol Issues

Address Conduct or Behaviour

Problem

Human Solutions


Modify Equipment Design

(Materials of Construction, Size,

Pressure and Temperature

Constraints, etc.)

Add Guarding

Instrumentation and Controls

Management of Change

Modify Preventative

Maintenance

Reduce Noise

Increase Lighting

Change Specifications

Communicate Limitations

Material Solutions


Which Facts Would You Target?

Seven cm

long cut to left

forearm

Cut towards

himself

He was not

wearing a

forearm guard

Exposed

blade

He did not

know about

forearm

guards

He was using

a utility knife

•Human

•Organizational

•Material


TARGET CORRECTIVE ACTIONS BY DATE

ORGANIZATION

HUMAN

MATERIAL

He did not

know about

forearm guards

Cut towards

himself

He was using

utility knife

Add use of forearm guards to

departmental rules and training. VLM x/x/xx

Employee has committed to

follow rule. PKL x/x/xx

Utility knifes will be replaced

with box cutting knives that

guard the blade. CKS x/x/xx

Step 4 – Identify Target Facts and Selecting

Corrective Actions


Summing Up

Burn

On Arm

Steam In Pipe

Hot

Pipe

Uninsulated

Pipe

Pipe Dismantled

Previous

Day

No Insulation

In Stock

Delay

In Delivery

Arm On Pipe

Falling

Down

Slipping

Foot In

Oil

Puddle

Oil Puddle

On Floor

Overturned

Oil Can

Open Oil

Can

George Was

Passing By

Did Not See Oil

Puddle

George Called

By Charlie

Glass Fell Near

George

Fork-Lift

Passing By

Glass

Roofed Hall

Obstructed

Safety Panel On

Fork-Lift Damaged

Can In Alley

Pallets Stocked

In Alley

Ray On

Scaffolding

Replacing

Glass Panel

Glass

Panel

Broken

Previous

Day

Causal TreeTM

Diagram of the Accident


1. ASSEMBLE A TEAM

(Consider: Injured, observers, safety professional, person experienced

in the method, safety committee member, decision maker, supervisor.)

2. DEVELOP A LIST OF FACTS

Rules:

a. One fact at a time.

b. No value judgments

c. No interpretations

3. CONSTRUCT A DIAGRAM

a. Find the end result

b. Identify the fact(s) that directly caused it to occur

c. Check your logic

i. Was it necessary?

ii. Is/are the fact(s) sufficient?

a. If not, what else directly caused it?

b. If the fact(s) are both necessary and sufficient, start again with a new result.

4. IDENTIFY TARGET FACTS AND SELECT CORRECTIVE ACTIONS

Investigation Method


On Difficult Solutions

The things you refuse to meet

today always come back at

you later on, usually under

circumstances which make

the decision twice as difficult

as it originally was.

--- Eleanor Roosevelt

http://www.houseofquotes.com/authors/Eleanor_Roosevelt.htm

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