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Accident Investigation

presented March 2013

Lee Dykema

on 24 December 2013

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Transcript of Accident Investigation

Accident Investigation
Gather Information
Respond Immediately
Secure the Scene
Conduct the Investigation
Implement Corrective Actions
Follow up

employee incident report
Put the Employee at EASE
Describe in Detail
Root Cause Analysis
What is an Accident?
An accident is an unplanned, or unexpected event that interferes with or interrupts normal activity and potentially leads to personal injury and/or dollars loss
An accident is the end result of a failure in the management system
unsafe behaviors are caused by the perceived consequences and environment that an employee works within

common sense does not exist

management has the ultimate responsibility for ensuring the proper (safe) adjustments of the employees to the working environment
Leaders of Enviro-Clean have a responsibility to create, provide and maintain a safe work environment for our employees and our customers
Why do we Investigate Incidents?
We are looking to fix the systems or processes, not to find fault or place blame.
describe to me how it occurred
what is the normal way of completing task
let me know what you were doing before it happened
Items to Determine
goal is not to find blame but to prevent from happening again
talk to them individually
Have them Demonstrate
Practice Good Listening Skills
Ask Open Ended Questions
restate your understanding
ask them to clarify or repeat details
if they are physically able
do not put them at further risk
Tools to Accomplish
Encourage Further Contact
Managers Investigation Report
He was changing into his uniform and facing away from his locker. He removed shirt and pants from his locker and placed it on the bench. Changes shirt while standing. Starting with the right limb he put his pants on. He took out his shoes and put these on again starting with the right. He then stood up twisted to the right and reached for his safety glasses and hard hat. While twisting back he heard his left knee pop and pain began.
He was getting his stuff from the locker when felt a pain
Which one paints a better picture
If you only fix the symptoms – what you see on the surface – the problem will almost certainly happen again... which will lead you to fix it, again, and again, and again
Ask "why" and identify the causes associated with each step in the sequence towards the defined problem or event. "Why" is taken to mean "What were the factors that directly resulted in the effect?"
Unsafe Act or Unsafe Condition
98 % are a result of unsafe act or condition
Why employees take risks
did not know a risk existed
knew risk but felt nothing would happen to them
saw others do it with no consequences
trying to save time - felt rushed due to deadline
felt management encouraged risked taking to save time
under emotional stress or pressure
not convenient
Corrective Actions
Actions Completed
steps taken to and completed at time of the investigation
Actions Planned
Actions Recommended
steps yet to be completed
assigned to a person
assigned a completion date
may require further study and involvement of other people and /or resources
Employee reports that she was pulling a table out from the wall when wheels did not seem to move and the table fell forward landing on her foot.
Case Study
What is the cause?

What is the root cause?

What corrective actions would you suggest?
Case Study
What is the cause?

What is the root cause?

What corrective actions would you suggest?
Employee calls that she has fallen and has hurt knee and elbow.
employee reports while throwing trash into dumpster she slip and fell

she was wearing snow boots at the time

there was less snow than in picture but surface was icy
Employee calls that a table has fallen on her foot.
Other Reasons
Employee Incident Report
unsafe condition - some environment or hazardous situation - independent of employee action
unsafe act - an act by the person or another person (or both) which caused the accident and/or condition
If treatment is needed
first must receive approval
call Lee Dykema
Laurie Boreman
Steve Koster
Full transcript