Accident InvestigationAccident InvestigationWorkshopWorkshop

Why investigate accidents?Why investigate accidents? Investigation ProcessInvestigation Process Root Cause & Contributing CausesRoot Cause & Contributing Causes

MethodsMethods Supervision, Policies, Procedures, RulesSupervision, Policies, Procedures, Rules

EquipmentEquipment Materials, Safeguards, Product, MachineryMaterials, Safeguards, Product, Machinery

EnvironmentEnvironment Facilities, Heat/Cold, Agents, AtmosphereFacilities, Heat/Cold, Agents, Atmosphere

PersonnelPersonnel Training, Fatigue, Protection, FitnessTraining, Fatigue, Protection, Fitness

Corrective Action

Response

Fact-Finding

Analysis

Follow-Up

WHY DO ACCIDENTS OCCUR?WHY DO ACCIDENTS OCCUR? SUPERVISION POLICES

METHODS PROCEDURES RULES

FACILITIES HEAT/COLD

ENVIRONMENT AGENTS ATMOSPHERE

MATERIAL SAFEGUARDS

EQUIPMENT PRODUCT MACHINERY

TRAINING FATIGUE

PERSONNEL PROTECTION FITNESS

ACCIDENT

SYSTEM FAULTS

SYSTEM FAULTS

SYSTEM FAULTS

SYSTEM FAULTS

Round Robin Round Robin Accident Investigation Accident Investigation

Accident InvestigationAccident InvestigationCase StudyCase Study

Describe in detail, how the incident occurred Describe in detail, how the incident occurred and what part of the body it affected:and what part of the body it affected: Employee fractured left foot. Employee slipped while Employee fractured left foot. Employee slipped while

climbing up ladder.climbing up ladder. Describe the root causes and how they Describe the root causes and how they

contributed to this accident:contributed to this accident: Employee failed to maintain three points of contactEmployee failed to maintain three points of contact..

What should be done, and by whom to prevent What should be done, and by whom to prevent recurrence of this type of incident in the future:recurrence of this type of incident in the future: Employee should be more careful while on laddersEmployee should be more careful while on ladders..

Accident InvestigationAccident InvestigationCase StudyCase Study

Describe in detail, how the incident occurred Describe in detail, how the incident occurred and what part of the body it affected:and what part of the body it affected: Employee sustained burns to hands and face while Employee sustained burns to hands and face while

filling the hot lugger for the fill pipe.filling the hot lugger for the fill pipe. Describe the root causes and how they Describe the root causes and how they

contributed to this accident:contributed to this accident: Employee failed to wear proper clothing and PPE while Employee failed to wear proper clothing and PPE while

working with hot materials.working with hot materials. What should be done, and by whom to prevent What should be done, and by whom to prevent

recurrence of this type of incident in the future:recurrence of this type of incident in the future: Face shields should be placed near fill-pipe.Face shields should be placed near fill-pipe.

Accident InvestigationAccident InvestigationCase StudyCase Study

Describe in detail, how the incident occurred and Describe in detail, how the incident occurred and what part of the body it affected:what part of the body it affected: 65 year-old male struck in the head and neck from debris 65 year-old male struck in the head and neck from debris

that blew off the scaffold system. Claimant was walking that blew off the scaffold system. Claimant was walking across the parking area at time of accident.across the parking area at time of accident.

Describe the root causes and how they contributed Describe the root causes and how they contributed to this accident:to this accident: Foreman did not secure debris against high winds.Foreman did not secure debris against high winds.

What should be done, and by whom to prevent What should be done, and by whom to prevent recurrence of this type of incident in the future:recurrence of this type of incident in the future: Crew should review housekeeping practices and weather Crew should review housekeeping practices and weather

forecasts.forecasts.

Accident InvestigationAccident InvestigationCase StudyCase Study

Describe in detail, how the incident occurred Describe in detail, how the incident occurred and what part of the body it affected:and what part of the body it affected: While traveling back from the jobsite, the foreman was While traveling back from the jobsite, the foreman was

involved in a three vehicle accident. Pete, who was involved in a three vehicle accident. Pete, who was sitting in the passenger seat sustained a neck strain.sitting in the passenger seat sustained a neck strain.

Describe the root causes and how they Describe the root causes and how they contributed to this accident:contributed to this accident: Driver was not at fault – no further actions required.Driver was not at fault – no further actions required.

What should be done, and by whom to prevent What should be done, and by whom to prevent recurrence of this type of incident in the future: recurrence of this type of incident in the future: NoneNone

Accident InvestigationAccident InvestigationCase StudyCase Study

Describe in detail, how the incident occurred and Describe in detail, how the incident occurred and what part of the body it affected:what part of the body it affected: Employee was carrying 5-gallon buckets of bonding adhesive Employee was carrying 5-gallon buckets of bonding adhesive

from the loading area to the work area. Employee claims he from the loading area to the work area. Employee claims he felt soreness in his back two days later.felt soreness in his back two days later.

Describe the root causes and how they contributed to Describe the root causes and how they contributed to this accident:this accident: No specific incident event identified. Employee may have tried to No specific incident event identified. Employee may have tried to

hurry to move buckets without using proper body mechanics.hurry to move buckets without using proper body mechanics. What should be done, and by whom to prevent What should be done, and by whom to prevent

recurrence of this type of incident in the future:recurrence of this type of incident in the future: Employees should be reminded to lift with their legs, keep stomach Employees should be reminded to lift with their legs, keep stomach

tight, and inspect their path of travel.tight, and inspect their path of travel.