Accident
Investigation and Reporting
An Accident: An unwanted, unforeseen, unplanned event which results in an injury or
loss of some kind
Near Miss (Incident): An unwanted/unplanned event that has the potential to result in a loss
Immediate/Direct Cause: The unsafe act or condition that results in an accident or incident
Root/Underlying Cause: The failure of procedures, management systems that have resulted in the
unsafe act or condition
Occupational Accident: An occurrence
arising out of or in the course of work that results in a fatal or non-fatal
occupational injury
Occupational injury: Death, any
personal injury or disease resulting from an occupational accident
Commuting (travel) Accident: An accident resulting in occupational injury involving loss of working
time occurring on the direct way between the place of work
Recent definitions for accident and near miss
Accident: An incident with a loss of some kind is
called accident.
Near miss: An incident without loss of any kind is
called incident.
Accidents causes
Causes of Accidents
Individual
and job factors
a)
Unclear lines of
responsibility
b)
Poor supervision
c)
Lack of
information, instruction and training
d)
Ineffective
communication
Unsafe Acts
a)
Misuse of
equipment
b)
Not following
safe procedures
c)
Showing off
d)
Many others
Unsafe
Conditions
a)
Poor
Housekeeping
b) Poor design and
construction
c)
Poor
illumination
d)
Hot weather
e)
Many others
Accident Prevention
Accident Prevention is the technique of anticipating
and controlling events so that accidents are eliminated and the subsequent
costs in time and money are avoided
The key to a successful prevention programme is
management committed to health and safety
Principles of Prevention
•
Avoid Risks
•
Evaluate risks
•
Combat risks at
source
•
Adapt to
Individual
•
Adapt to
technical progress
•
Coherent Policy
•
Priority to collective measures
•
Instruction to
employees
Preventative Strategy
Safe Place
Equipment/Access/Egress
Materials (Articles/Substances)/Environment:
Safe Person
Information, Instruction and Training
Safe Behaviour
Awareness, Knowledge, Competence
Supervision
Health Surveillance
Personal Protective Equipment
Safe Systems
Policies and Standards
Rules
Procedures
Safe systems of work
Permits to work
Clear lines of responsibility
Accident Investigation and analysis
Emergency preparedness
Purchasing controls
Aims of Accident Investigation
•
Determine cause
to prevent recurrence
•
Identify
weaknesses in management systems
•
Identify
weaknesses in risk assessment
•
Demonstrate
management commitment
•
Comply with
country’s legal requirements
•
Collect data to
establish losses
•
Provide
information for Civil/Criminal actions
•
Provide
information to insurance company
Immediate &
Longer Term Actions
•
First aid for
injured party
•
Calling medical
assistance if necessary
•
Make area safe
•
Isolation of the
accident scene
•
Implement
emergency plan
•
Report to
enforcing authority if necessary
•
Identification
of witnesses
•
Full
investigation to determine root cause
•
Making
recommendations
•
Implementing corrective
action
Overall Investigation process
Preparation Before Investigation
•
Who should be
involved and depth of investigation
•
Accident scene
untouched
•
Collate relevant
existing documents
•
Identifying who
are witnesses
•
Have legal
requirements been met?
•
Any equipment
needed?
•
Method to be
adopted
•
Style of report
and who should receive it
Investigation Team
Line Manager: Knowledge of the processes
Supervisor: Also has knowledge of the process
Safety Representative: Has legal right
Safety Practitioner: To advise on health & safety
Engineer: Advise on technical matters
Senior Manager from different department: Unbiased
Equipment required for investigation (Investigation
Kit):
a) Camera
b) Writing materials
c) Investigation forms
d) Measuring tape
e) Area plans
f) Protective equipment
g) A checklist
Four Steps to Investigation
1)
Gather the
information (the where, when and who of the adverse event)
2)
Analyse the
information (the ‘what happened and why’ stage)
3)
Identify the
risk control measures (possible solutions to be identified)
4)
The action plan
and its implementation (which should have SMART objectives)
1) Gather the Information
What activities were being carried out?
Was there anything unusual?
Were there adequate safe working procedures?
Were they being followed?
Was the risk known? If so why not controlled?
Did the organisation and arrangement of the work
influence the accident?
Was maintenance and cleaning sufficient?
Was the safety equipment sufficient?
Materials
-- Materials or substance
Equipment
--Tools, vehicles, machinery etc.
Environment
--Lighting, temperature etc
People
--Human error, inexperience, training
Other Factors
Nature of the work e.g. routine
Specialist examinations
Medical reports
Interviews/witness statements
Do not dismiss contradictory evidence
Documents
•
Risk assessments
•
Safe systems of
work
•
Incident/accident
history
•
Training records
•
Maintenance
records
•
Equipment
instructions
•
Monitoring, e.g.
dust, noise
•
Supervision
rotas
•
Inspection
reports
•
Pre–start
equipment checks
2) Analyse the information
Analysis should determine:
Cause of the injury
Immediate/direct causes
•
Unsafe acts e.g.
not wearing correct PPE
•
Unsafe condition
e.g. a cable trailing across a busy walkway
Root/underlying causes
“Root
Cause Analysis”
Entire
chain of events is evaluated to find "Root Causes" as well as the
immediate cause
"Root
causes” are safety system inadequacies
Personal
factors
Physical
or mental condition, skills, knowledge, etc.
Job
factors
Equipment,
workplace conditions
Recommendations
may include:
Policies
Equipment
Training
3) Identify the risk control measures
There may be:
•
No control
measures in place
•
Control measures
in place that were not used
•
Control measures
in place that failed
•
Combinations of
the above
Measures should be evaluated for:
•
Their ability to
prevent recurrences
•
Whether they are
practical
•
Whether they
will be used
•
Whether they
will remain effective
4) Take Action
•
Involve Senior
Management
•
Highest priority
risks control measures implemented first
•
Lower risks
control measure in order of priority
•
Specific Senior
Manager in charge of implementation
Report to Management
The
investigation is not complete until a report is prepared and submitted
Recommended
outline
Background
Information
Where
and when the accident occurred
Who
and what were involved
Operating
personnel and other witnesses
Account
of the Accident (What happened?)
Sequence
of events
Extent
of damage
Accident
type
Agency
or source (of energy or hazardous material)
Report shall
contain the following:
Who – The injured person
When – Date and time
Where – Location
What – Accident/injury
How – Detail of events
Why – Analysis of cause
Recommendations
Documentation
Possible breaches of law
Type of data collected
Incidents/Accidents
•
Incident
/accident or near miss reports
•
Reports to
enforcing authorities
•
Reports to
insurers
Work related ill health
•
Sickness absence
reports
•
Health
surveillance
•
Medical
diagnosis from outside organisation
Categorising Accident Data
•
Category of
person affected
•
Injury type
•
Part of body
injured
•
Severity of
injury
•
Age/sex of
person
•
Work activity
•
Shift/time of
day
•
Location of
accident
Accident Statistics
Accident Incident Rate:
Number of defined accidents / Average number
employed x 1000
Fatal Accident Incidence Rate:
Number of fatalities / Average number employed x
1000
Accident Frequency Rate
Number of defined accidents in period / Total
person hours worked in period x 100,000
Accident Severity (or Gravity) Rate
Total number of days lost in a period / Total
person hours worked in a period x 1000
Frequency & Incidence Rates
Communicating Data
Safety committees
Team briefings
Company magazines
Board meetings
Performance reviews for managers
Annual reports
Benefit of using accident data
a) Shows patterns and trends
Pattern -
Repeated events
Trend
- A line of general direction
b) Identify weaknesses in procedures
c) Prioritise safety measures
d) Identify areas for improvement
e) Set targets for reduction
Reporting of Accidents
Competent authority who should implement a policy for
- The recording, notification and investigation of occupational accidents and diseases.
- The recording, notification and investigation of commuting accidents, dangerous occurrences and incidents.
- Compilation, analysis and publication of statistics on such accidents, diseases and dangerous occurrences
- Establish procedures for employers to ensure information on accidents is maintained.
- Also many Countries require reporting of certain types of injury, diseases, dangerous occurrences and commuting accidents.
Examples of Reportable Events
Injuries: Death, fracture, amputations etc.
Diseases: Dermatitis, Asthma, lung diseases
Dangerous occurrences: Collapse of cranes, contact
with overhead power lines, etc
Commuting accidents
Examples of Non Reportable Events
Near
Misses, First Aid cases.
Reasons for Failure to Report Accidents
•
Ignorance of
procedures
•
Over complicated
procedures
•
Peer pressure
•
Management
retribution
•
Preserve
accident record
•
Lack of
management response
Benefits of Collecting Near Miss Data
1. To identify
underlying causes which may allow preventative action to be taken before
something more serious occurs
2. Gives message to
workforce that all failures are taken seriously not just those leading to
injury
3. Generally
accepted near misses greatly outnumber accidents and can therefore produce more
data from which a greater understanding of the deficiencies in management
systems can be identified and rectified
Accident Causation Models
Domino
Sequence
1)
Lack of
Management control
2)
Basic Causes –
Personal/Job factors
3)
Immediate Causes
( Unsafe Acts/conditions)
4)
Accident/Incident
5)
Loss/Injury
Domino
sequence states that the accident occurs only if there are series of failure.
Swiss
Cheese model
1.
Fallible Decisions
2.
Latent Failures
3.
Preconditions
4.
Unsafe acts
5.
System Defenses
Failure of the
above factors leads to accident.
Cost of an Accident:
There are two
types of costs
1.
Direct Costs
2.
Indirect Costs
1.
Direct Costs (Insured)
Accidents are more expensive than most people realize because
of the hidden costs. Some costs are obvious — for example, Workers'
Compensation claims which cover medical costs and indemnity payments for an
injured or ill worker. These are the direct
costs of accidents.
2.
Indirect Costs
But what about the costs to train and compensate a
replacement worker, repair damaged property, investigate the accident and
implement corrective action, and to maintain insurance coverage? Even less
apparent are the costs related to schedule delays, added administrative time,
lower morale, increased absenteeism, and poorer customer relations. These are
the indirect costs — costs that aren't so obvious until
we take a closer look.
Direct vs.
Indirect Costs
•
Indirect Costs are from 2 to 20
Times direct Costs
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