excel worksheet and memo
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Chpt10PPT1.pptChapter 10
Incident Investigation, Analysis, and Cost
Chapter Objectives
- Basic types of incident investigation and analysis
- Methods of conducting an investigation and analysis
- Types of costs associated with incidents
- How to calculate incident-related costs
- The financial effects of off-the-job incidents
Incident Investigation and Analysis
- Ultimate purpose to prevent future incidents
- Must produce factual information leading to corrective actions
- Good record keeping systems are essential to incident investigation
- All incidents should be investigated regardless of severity of injury or amount of property damage
- Investigations must be fact-finding, not fault finding
- Investigating individual, board, or committee must not be involved with any disciplinary actions
Types of Investigations and Analysis
- Failure Mode and Effect approach
- Management Oversight and Risk Tree analysis (MORT)
- ANSI Z16.1 provides a Standard Information Management System for Occupational Safety and Health accidents
- The four M’s (Man, Machine, media and management)
- The three E’s (engineering, education, enforcement)
- The Five Why’s
- RCA
Cases to be Investigated
- Death or serious injury
- Near-miss incident
- Epidemic of minor injuries
Scope and Extend of Investigation will vary.
Persons Conducting the Investigation
- The safety and Health Professional
- Advisor and guide
- Special Investigative or Review committee
- Formed for serious events
- The Safety and Health committee
- Small or moderate sized companies
Choosing Team Members
- A trained facilitator.
- The employee(s) or contractor(s) involved in incident.
- The supervisor of people involved in incident.
- A design or process engineer, if the incident involves technical issues.
- Specialists or Subject Matter Experts if appropriate.
- Members of management may be tempted to take part in incident investigations because they have a real concern to get at root causes and improve operations.
- However, their presence can stifle the free flow of information or ideas, even though that isn’t their intent.
- Avoid having higher levels of management (above first line supervisor) on a team.
The 4 P’s of Data Gathering
- People, Position, Paper and Parts
- People - Interviews and written statements
- Position - what the status was before the incident occurred.
- Weather conditions
- Process & equipment status (i.e. normal operations, start-up, shutdown, maintenance, within operating limits / intended function)
- Job / work status (i.e. shift change, operating, maintaining)
- Human Factors issues (facility layout, design considerations, etc)
The 4 P’s of Data Gathering
- People, Position, Paper and Parts
- Paper - refers to the document trail both before and after the incident including:
- Logs, charts, notes, turnovers/handback logs, work orders, permits, JSA’s, tags, or printouts which indicate what was going on at the time or the state of equipment when the incident occurred.
- Electronic records and data in control systems, including trends or process variables and listings of alarms.
- Lab reports, metallurgical reports of broken parts.
- Copies of standing orders, procedures in use or applicable to the situation when the incident occurred.
- Training records
The 4 P’s of Data Gathering
- People, Position, Paper and Parts
- Parts refers to how the incident sight looks after the incident occurred and what the physical data is telling us.
- Parts, pieces and other things that you can pick up and carry away. Gather and save physical data like parts, pieces and other small objects, recording the location where they are found.
- Pictures, videos, sketches, or diagrams of the scene, equipment involved, or what was going on at the time. For pictures and videos, use the time/date logger on the camera to help understand when they were taken.
- Take necessary process and equipment samples. Document all samples with:
- Name of person collecting the sample
- Date and time sample taken
- Exact location/source of sample
- Record all samples taken on a sample log. If litigation is expected, chain of custody procedures may be necessary.
Developing the Sequence of Events
- A sequence of events is a compilation of the incident events arranged in a time sequence. The idea is that someone looking at the sequence can quickly grasp what events occurred and when. The sequence of events is an excellent way of organizing the data from an incident and preventing the team from jumping to conclusions
Using Why Trees
Root Causes
Various shapes
PROPER CONDITION
PROPER CONDITION
Incident
Five Why Method
Verify
Verify
Verify
Verify
Why 1 the incident
Why 2 - 1
Why 3 - 2
Why 4 - 3
Why 5 - 4
Root Cause
Accident Costs
- Direct
- Indirect
Accident Investigation
Michael Gautreaux, CSP
Session Objectives
- Examine accident investigation methodology
- Explore investigation techniques
- Participate in an accident investigation workshop
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What is an Accident?
- Any unexpected event which interrupts the smooth flow of profitable production or service
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What is an Accident Investigation?
- Analyzing
- Evaluating
- Reporting
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Why Investigate?
To Prevent Accidents
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Questions
- What Accidents Should be Investigated?
- When Should Accidents be Investigated?
- Who Investigates?
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Conducting an Accident Investigation
1. Respond immediately.
2. Investigate to find the facts.
3. Analyze the facts to determine the causes.
4. Develop specific corrective actions.
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Respond Immediately
- Ensure medical treatment
- Eliminate obvious hazards
- Secure the area and preserve evidence
- Try to get the big picture
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Investigate
- Conduct interviews
- Photograph/diagram scene
- Take samples
- Examine equipment
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Interviews
- ASAP
- Relaxed and private
- Look for facts
- Don’t lead
- Listen well and repeat the story
- Beware smoke screens
- Draw a diagram
- Consider tape-recording it
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Analyze Facts
- Concentrate on the underlying causes, not the symptoms
- Accidents rarely result from a single cause, but occur because of a network of multiple causes
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Contributing Causes
- Equipment
- Methods
- Personnel
- Environment
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Corrective Action
- Make your recommendations
- Follow through
- Mirror the results from your analysis
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Reporting the Investigation
- Provides information for group analysis
- Reports vary by size of operation and seriousness of accident
- Describes problem for further study
- Secures approval
- Documents measures
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Review Reports
- Take corrective action or explain why corrective action cannot be taken
- Refer the report to other supervisors or departments with similar problems
- Refer unsolved problems for further study
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Parts of a Program
- Notification
- Forms
- Training
- Communication
- Control plans
- Application to similar exposures
- Analysis and evaluation
- Monitor investigations
Policy
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Responsibilities
- Obtain management support
- Develop procedures
- Training
- Participate in some investigations
- Follow up on reports
- Analyze reports to identify patterns
- Audit program
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PROPER
CONDITION
PROPER
CONDITION
