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Accident Investigation (Accident Theory History (Accident Ratio Study…
Accident Investigation
What/How Long?
Investigation goals
Determine Sequence
Don't blame
Fair/Consistent
Find out why...
Individual violated?
Supervisor didn't enforce?
Corrective actions
Update Overall program
Worker thru Mgmnt
Find/fix problems
Reporting
Thorough
Do
Formal policy
Emp Training
Necessary
Don't
Punishment
Fault/blame
Incentives
Reward safety
Inhibits reporting
Fear incentive loss
Reward reporting
Accidents
Near misses
Causal factors
Corrective actions
Documentation
Forms/Tools
Used to investigate
Determine Causal Factors
Why?
Avoid future $$$
Iceberg costs
Near misses - key
Prevent Accidents
Performed retroactively
Proactive improvements
Legal compliance
Det. total $$
Pre-investigation decisions
Levels
Near Miss
Potentially minor
Potentially catastrophic
Document
Determine causes
Recommend correctives
First aid
Investigate
Interview
Determine causes
Recommend correctives
Document all
Recordable injury
Investigate
Interview
Injured
Witnesses
Use analytics
Determine causes
Recommend correctives
Short report
Catastrophic
Examples
Fatality
Many injured
Major property damage
Team investigation
Interview
Injured
Witnesses
Others
Use analytical techs
Determine causes
Recommend correctives
Full report w/ techs listed
Who?
Accident Theory History
Accident Ratio Study
Not Causation Theory
Near miss/Property damage
Usually precursor to
Major injury accident
Full investigation may prevent
Major injury accident
Levels
Near miss/close call (600)
Property Damage (30)
Minor injury (10)
Serious/major injury (1)
Domino Theories
G. W. Heinrich
1931
5 action types lead to accident
Ancestry/Social
Fault/Person
Unsafe Act
By person
Unsafe Condition
Equipment
Environment
Injury
Bird & Germain
Loss Causation Model
Widely used
5 Dominos
Lack of control
Basic causes
Personal
Job
Immediate causes
Substandard practices
Conditions
Exist @ time of accident
Incident
Loss
Injury
Property damage
Multiple Causation Theory
Expansion of Dominos
Many acts, conditions, causes
Complex/Simple
Obvious/Obscure
Systemic
Discover all factors
Ask questions
To fix problem
Cause & Effect Concept
Determine causal factors
Causation v. correlation
Epidemiological Model
Based on disease model
Epidemiological Triangle
Host/Injured person
Agent/Energy
Mechanical
Thermal
Chemical
Electrical
Ionizing
Vehicle
Equipment
Weapon
Environment
Narrow scope
Haddon Matrix Theory
1972
3 phases
Pre-injury
Injury
Post-injury
3 Factors
Human
Equipment
Environment
Other Theories
Technical/Engineering
For low level causes
Narrow scope
Human error
Can blame
Can be useful
MORT
Management Oversight & Risk Tree
Links all level causes
Widely used
Sequence of Events Theory
Investigation theory
Document all events in sequence
Validate or discover causes
Using Analytics
Phases
Investigative
Discover facts
Interview witnesses
Obtain documentation
Analytical
Recommendation
Develop corrective actions
Prevent similar accidents
Equal in value
Thinking analytically
Structured process
Systematic & exhaustive
Root Causes
Levels
Direct cause
Root cause
Meanings
1st cause
Last cause
Preventable cause
Management
Layered Investigations
ID all causal factors
Layers of recommendations
Complexity
Det time of investigation
Involves potential incidents
Recommendations
Main focus of investigation
Link
Facts
Analysis
Causal factors
Corrective actions
Objectives
Sequence of Events
Accidents have
Able to determine
Know accident causation theories
Usually multiple causes
Use break down/analytical
Definitions
Accident
Occurrence
In sequence of events
Produces unintended... [or]
Injury
Death
Property damage
Incident
Unintentional event
May cause harm/damage
Near miss
Occurrence
In sequence of events
Potential but doesn't produce/
Injury
Death
Property damage
"You were lucky!"
Accident Investigation
Structured process
Sequence of events
Did/could produce
Injury
Death
Property damage
Uncover
Determine [&]
Causal factors
Produced Accident
Events
Circumstances
Incorporate & Analyze
Root Causes
Basic Causes
Immediate Causes
Lower level Causes
Upper level Causes
Management Causes
Corrective actions
Prevent recurrence
Fixes
@ appropriate level
Risk
In everything
Occurrence
Probability
Severity
Property Damage Accident
Often unreported
$$ Cost a factor