Accident Investigation Procedures for Supervisors

Transcription

1 Accident Investigation Procedures for Supervisors

2 ACCIDENT defined: An accident is "an undesired event that results in personal injury and/or property damage. Being "undesired" makes it something that must be "prevented whenever possible."

3 Why investigate accidents? Many individuals perceive accident investigation as cumbersome, non-productive, and serving no purpose or benefit. Actually, the more comprehensive the investigation, follow-up and corrective action(s), the less time you will spend dealing with accidents. Accident investigations must be viewed as a preventive technique aimed to prevent recurrence of the same or similar incident and accident types.

4 When shoud we investigate accidents? The less time between the accident and investigation, the better the information which can be obtained. Facts are clearer, more details remembered, and the conditions are nearest those at the time of the accident. Situations which should be permitted to delay the investigation are when medical treatment is needed or when the persons involved are emotionally upset. You should investigate an accident whenever: 1. Injury, illness, or property damage occurs (this includes employees, contractors, and the general public) 2. Near misses (these are cases when no injury, illness, or property damage occurred, but if conditions were slightly changed damage would be probable)

5 The 10 Step Process: 1. Understand the need for investigation 2. Prepare for the investigation 3. Gather the facts about the accident 4. Analyze the facts 5. Develop conclusions 6. Analyze conclusions 7. Make a report 8. Make appropriate recommendations 9. Follow through on recommendations 10. Follow-up on corrective actions

6 1. Understanding the Need To be successful we need to understand why we need to do it. In other words, what exactly is the need? Do we want to prevent future accidents? Are we merely interested in complying with internal or external (insurance) paperwork requirements? Will the investigation support us in case of litigation? Do we want to pinpoint managerial inefficiencies that may be causing similar accidents? The most important reason for conducting investigations is accidents indicate that something is wrong and should be corrected so that no person will injured again.

7 2. Prepare For The Investigation The best way to handle accidents, when they do occur, is to be prepared for them. After the unexpected happens, it is too late for preparation; we need to make sure two areas are addressed. 1. First you must have a plan or procedure 2. The second area is the training required for supervisors to conduct thorough accident investigations. We should be able to provide answers to questions such as these: Why is getting all the facts so important in accident investigation? In what way are reportable accidents only the "tip of the iceberg"? Why are accidents so much more visible than unsafe acts? What causes accidents? What are your responsibilities as a supervisor? Why is placing blame on people counterproductive? What can the supervisor do to help prevent these accidents from occurring?

8 3. Gather The Facts While the first two completed should be completed well in advance of any actual accidents, the "gathering of facts" begins only when an accident/incident has actually taken place. It marks the beginning of the investigation itself. First and foremost is the investigation, the facts about what happened and what allowed it to happen must be discovered. We start out knowing where we are going, what we are going to do and how we are going to do it, regardless of the specific situation to be found at the accident site.

9 4. Analyze The Facts This is an on-going process that begins when we gather the first facts and begin mentally weighing them. This weighing of facts includes statements of witnesses and their credibility. How much accuracy or inaccuracy can you expect from them? How do their stories compare with other evidence? What do the facts indicate about management and supervisory procedures, housekeeping, work environment, and so on? This analysis merges with the gathering of facts, and may suggest new questions and offer new direction for further fact gathering. Direction can be given to this step if everything is carefully documented and all actions are made a matter of record, supervisor's accident investigation reports should be used as a measurement tool.

10 5. Develop Conclusions As the facts are gathered and analyzed, conclusions can begin to be drawn about what happened and what caused it to happen. This should be formally presented, with statements of conclusions and the relevant facts on which they were based, so that this is a matter of verifiable record. This information allows us to see any gaps in our knowledge or reasoning, and may point to areas where more facts and analysis are needed. It will usually direct the investigator back to either the fact finding or analysis process, to repeat these steps until adequate and reasonable conclusions can be formed.

11 6. Analyze The Conclusions This is a continuous step that never really stops but may be repeated several times during the investigative process. As time was taken to formally develop tentative conclusions, time is now taken to examine and analyze those conclusions. This, too, may send us back to earlier steps to gather more facts or to review from a different standpoint. Eventually, our tentative conclusions can either be made firm or discarded all together.

12 7. Make A Report The accident report should bring all this material together; facts, analysis, and conclusions. Now all the information should be formalized into a report. Everything included in the report should be supported by facts and evidence; unsubstantiated statement or mere speculations do not belong in the final report. The report narrative should begin with a short synopsis, one or two lines, that tell what happened without details or causes. This should be followed by a detailed and more complete account of the accident. (In selecting detail, however, stick to essentials; leaving out anything that does not lead to an understanding of the incident or conclusions). A good report should be clear and concise, free of extraneous material. The reader may know nothing of the process or location involved, and yet must understand clearly what has happened and why.

13 8. Make Appropriate Recommendations The best report in the world has failed if it merely states facts and draws conclusions. Make specific recommendations indicating precisely what should be done to correct the situation. The accident report may present a list of several recommendations, each one separately stated, along with its specific corrective actions. The recommendations should clearly identify who is responsible for review and implementation.

14 9. Follow Through On Recommendations Just the recommendations in the report are not enough. The Supervisor should demand action to keep the same or similar event from happening again. Seeking County Administration to assist with enforcement of corrective actions is recommended. This is more easily done if single, specific, recommendations for corrective action have been identified, and have been individually assigned for implementation. Supervisor s can not rest after recommendations for corrective actions have been made, or even after responsibility for taking those actions has been assigned. Someone has to check on the corrective action to make sure it has been taken, and that it does, in fact, match the recommended or desired action.

15 10. Follow-Up On The Corrective Action Review the corrective actions made. Do these corrective actions address the need to prevent or reduce the same accident type from happening again? This step is essential at the end of the process, and should continue to be evaluated on a less formal basis.

16 SEVEN CONSIDERATIONS WHEN CONDUCTING INVESTIGATIONS 1. Reluctance to accept management responsibility It is human nature to have a supervisor review an accident as an indication of their ability or inability to supervise or manage their department. 2. Erroneous emphasis on single causes Our statement should be: The supervisor is analyzing all potential causes of the mishap and does not have a single cause to report at this time." 3. Failure to establish root causes Their investigation stopped with the direct cause of the accident and failed to get to the root issue. 4. Narrow interpretations of environment causes When a supervisor makes the error of thinking that unsafe conditions are the obvious defects in sidewalks, vehicles or other elements in the entity s environment, then they have committed the error of a narrow interpretation of unsafe conditions. 5. Allowing potential solutions to determine causes This occurs when the investigators set themselves up as sole judges of what is practical to correct when investigating an accident. 6. Treating minor injury accidents as minor events "The causes that produce today's minor accident, may, and often do produce tomorrow's serious accident." 7. Failure to understand the true nature of investigation Investigators must also be evaluators of statements, claims and opinions. They must exercise judgment and a questioning attitude. Some supervisors' may have trouble with this. Investigators must take a critical stance in the sense that they are willing to question anything, including information obtained from the employee involved and witnesses.

17 Interviewing Tips Put the person at ease Keep the interview private Get the person s own version Try not to interrupt Document critical data quickly Repeat their statements back to them End the interview on a positive note Ask the person for suggestions on corrective actions Leave the door open for future discussions on the accident

18 Dealing with an injured employee or citizen: DO!! Be Calm Be Courteous Be Compassionate Be Concerned DO NOT!! Admit Fault Promise to Pay Argue About Fault Argue About Liability

19 TEST Please go back to our main intranet site and log into the Accident Investigation TEST. Thank You for taking the time to help keep our employees safe!