Incident Investigation Training
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1 Incident Investigation Training Portage County Safety Council April 2016 August 12, 2016 Don Elswick Elswick August 12, 2016 Slide 1
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 August 12, 2016 Slide 2
3 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.. August 12, 2016 Slide 3
4 Occupational Hazards, October 1997 Fallacies in the Safety Fable 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 August 12, 2016 Slide 4
5 A Quiz! TO BE SURE YOU ARE COMFORTABLE WITH THESE FACT WRITING IDEAS.. LETS TAKE A QUIZ August 12, 2016 Slide 5
6 Timed Quiz Our work is comp. YOU WILL BE GIVEN A QUIZ LEAVE IT FACE DOWN UNTIL THE TIME STARTS YOU WILL HAVE 60 SECONDS TO ANSWER THE QUESTIONS August 12, 2016 Slide 6
7 Read the Following Story. Then Complete the Quiz. 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. August 12, 2016 Slide 7
8 60 Seconds 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? August 12, 2016 Slide 8
9 60 Seconds Our work is comp. 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? August 12, 2016 Slide 9
10 60 Seconds 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? August 12, 2016 Slide 10
11 Licensed Drivers and Numbers in Accidents by Age Our work is comp. a) ) What age group has the highest number of accidents? 2) What group has the highest number of drivers in fatal accidents? b) c) d) ) Based on 2009 National Safety Council statistics who would you want to be your driver? e) f) g) August 12, 2016 Slide 11
12 Driving Survey Our work is comp. 1) What age group has the highest number of accidents? a) , 326 b) , 465 c) , 694 d) , 424 e) , 921 f) , 271 g) , 135 2) What group above has the highest number of drivers in fatal accidents?. a) % b) % c) % 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% August 12, 2016 Slide 12
13 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 August 12, 2016 Slide 13
14 Why Do You Want To Know Why An Incident Occurs? Prevent further incidents Protect employees Save company money / protect jobs August 12, 2016 Slide 14
15 Basic Principles 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. August 12, 2016 Slide 15
16 Overview of the Method 1. ASSEMBLE A TEAM 2. DEVELOP A LIST OF FACTS 3. CONSTRUCT A FACT DIAGRAM 4. IDENTIFY TARGET FACTS AND SELECT CORRECTIVE ACTIONS August 12, 2016 Slide 16
17 Step #2 Develop a List of Facts Rules: ONE FACT AT A TIME DO NOT MAKE VALUE JUDGMENTS DO NOT INTERPRET JUDGE JUDGE JUDGE August 12, 2016 Slide 17
18 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.) August 12, 2016 Slide 18
19 Definitions / Discussion 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.) August 12, 2016 Slide 19
20 Communications Class is canceled today. We will meet again at 8:30 a.m. three days after two days before the day before tomorrow. August 12, 2016 Slide 20
21 Are We Close? He was not wearing a forearm guard He was using a utility knife He did not know about forearm guards Exposed blade Seven cm long cut to left forearm Cut towards himself RULES 1. ONE FACT AT A TIME 2. DO NOT MAKE VALUE JUDGMENTS 3. DO NOT INTERPRET August 12, 2016 Slide 21
22 What Are The Key Questions Again? What is the cause of this fact? Was it necessary? Was it sufficient? August 12, 2016 Slide 22
23 Find The End Result Our work is comp. He was not wearing a forearm guard Exposed blade He was using a utility knife He did not know about forearm guards Seven cm long long cut cut to to left left forearm Cut towards himself August 12, 2016 Slide 23
24 Select A New Result Identify The Fact(s) That Directly Caused It To Occur? He did not know about forearm guards He was not wearing a forearm guard Cut towards himself Seven cm long cut to left forearm? August 12, 2016 Slide 24 He was He was using using a a utility knife utility knife Exposed blade
25 Organizational Solutions Clarify Assignments Use a checklist Upgrade training Establish Operating Controls Revise Procedure Increase Audit Effort Improve Work Planning Improve Supervisory Example Improve Hazard Assessment Improve Training Assessment Resolve Conflict in Priorities August 12, 2016 Slide 25
26 Human Solutions Improve Hazard Recognition Address Physical Limitations Improve Procedure Use Increase Knowledge Re-Train on Procedure Improve Clarity of Directions Resolve Conflicting Demands Address Mental Limitations Address Fatigue Address Drug / Alcohol Issues Address Conduct or Behaviour Problem August 12, 2016 Slide 26
27 Material 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 August 12, 2016 Slide 27
28 Which Facts Would You Target? He did not know about forearm guards He was not wearing a forearm guard Cut towards himself Human Organizational Material Seven cm long cut to left forearm He was using a utility knife Exposed blade August 12, 2016 Slide 28
29 Step 4 Identify Target Facts and Selecting Corrective Actions TARGET CORRECTIVE ACTIONS BY DATE ORGANIZATION He did not know about forearm guards Add use of forearm guards to departmental rules and training. VLM x/x/xx HUMAN Cut towards himself Employee has committed to follow rule. PKL x/x/xx MATERIAL He was using utility knife Utility knifes will be replaced with box cutting knives that guard the blade. CKS x/x/xx August 12, 2016 Slide 29
30 Summing Up Glass Fell Near George George Called By Charlie Did Not See Oil Puddle Glass Panel Broken Ray On George Was Slipping Arm On Pipe Previous Scaffolding Passing By Day Replacing Glass Panel Glass Roofed Hall Obstructed Open Oil Can Foot In Oil Puddle Falling Down Burn On Arm Pallets Stocked In Alley Fork-Lift Passing By Oil Puddle On Floor No Insulation In Stock Safety Panel On Fork-Lift Damaged Overturned Oil Can Delay In Delivery Uninsulated Pipe Can In Alley Pipe Dismantled Previous Day Hot Pipe Causal Tree TM Diagram of the Accident Steam In Pipe August 12, 2016 Slide 30
31 Investigation Method 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 August 12, 2016 Slide 31
32 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 August 12, 2016 Slide 32
33 Thermometer or Thermostat August 12, 2016 Slide 33
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