[医学]AccidentInvestigation_Parks.ppt

Presented by: Donald L. Trussell DEP Safety Program Administrator 850-488-0878 or SC 278-0878,ACCIDENT INVESTIGATION,“The Basics”,Introduction,BABYLONIAN LAW WHY PRACTICE SAFETY? SAFETY EXCELLENCE,SAFETY CULTURE,CULTURE PARK SAFETY CULTURE WAY OF LIFE TEAMWORK/PARTNERSHIP,RISK,DEFINITION IDENTIFY POTENTIAL PROBLEMS,Responsibility/Accountability,BASIC CONCEPT MEASURE PERFORMANCE ACCOUNTABILITY: Put the “I” back in,ACCIDENTS,DONT JUST HAPPEN ARE THE LEADING CAUSE OF DEATH RESULT OF UNSAFE OR SUBSTANDARD ACTS AND CONDITIONS,ACCIDENTS/INCIDENTS,ACCIDENTS ARE INCIDENTS HAVE THE POTENTIAL TO HARM SHOULD ALWAYS BE INVESTIGATED,What is an accident?,An accident is?,An accident is:,Unwanted Unplanned Unforeseen Disruptive Can be major or minor,Is an accident and an injury the same thing?,NO!,Obvious Injury Costs,Insurance Premiums Medical Expenses Worker Compensation Rest of work crew “takes up the slack” Accident Cost Iceberg,Hidden Injury Costs,Lost time at work Reduced or lost income Pain and suffering Possibly having to learn a new job Training costs to the company Administrative costs (Investigation, ES&H, HR),Actions vs. Attitudes,Which is easier to see and report?,Actions vs. Attitudes,Which is easier to change?,What we would like to see.,That you understand why people do the things they do. That you know there are many factors that cause an accident. But mostlyThat you look deeply into why accidents happen!,Why do we investigate?,Prove the victim was at fault? no CYA .no Avoid law suits against the company.no Try to make the work place safer!,Accident Investigation = An opportunity to change the work climate by correcting unsafe conditions, procedures, or actions.,Elements of the Investigation,Describe who was involved Describe what happened Establish a time line Determine location of accident & all factors Establish a chain of events to understand how the accident occurred Determine the cause & root cause,First Goals of the Investigation,Establish the following: 1. Who 2. What 3. When 4. Where 5. How 6. Why,Who,Establish the person(s) who were involved in the accident, including witnesses. This includes all persons and not just an injured employee.,What,Describe in detail what happened.,When,Ensure times and dates are included in the statements.,Where,Get specific about the location, to include what Site, what facility, road name, etc.,How,Make sure your description of the incident is clear and describes the factors that caused the accident.,Why,Based on who/what/when/where/& how, you should be able to piece together why the accident happened. This involves piecing information together to form a conclusion of the cause & root cause of the accident.,Drawing Conclusions,From the who/what/when/where/how & why that you just gathered, you now need to determine both the cause and root cause of the accident.,“All things are hidden, obscure, and debatable if the cause of the phenomena be unknown, but everything is clear if this cause be known.” Louis Pasture,Cause of the Accident,The “cause” of the accident should describe what the immediate symptoms are of the accident. Example: An employee slipped on the floor because there was spilled coffee that made the floor slippery.,Root Cause,The “root cause” of the accident is the basic underlying reason, not always apparent, that caused the accident. Example: The root cause of the accident was that the person who spilled the coffee did not clean it up or establish a warning method to alert others of a hazard.,Casual Factors Incident,Loss Causation,Precedes The loss Slip, Trip, Fall,Causal Factors Basic Causes,THE DISEASE THIS IS THE “WHY” IT HAPPENED PEOPLE, EQUIPMENT, MATERIALS, ENVIRONMENT PERSONAL & JOB FACTORS,Causal Factors Lack of Control,STARTS THE SEQUENCE 3 WAYS TO GAIN CONTROL: PROGRAM STANDARDS COMPLIANCE,Multiple Source Causes-Controls,CHAIN 90/10 RULE 3 STAGES OF CONTROL: PRE-CONTACT CONTACT POST CONTACT,So how do I use this information when an accident occurs?,?,?,?,?,Begin Your Investigation,Get the affected persons statement. Get onlookers statements. Note the positions of people and things. Gather other information as needed, like manuals, records of training, safety, and maintenance. Get pictures when needed (picture worth 1000 words),Interview Tips,Need information - not placing blame. Try to form open ended, non-judgmental questions. Ask as many questions as it takes to clarify your understanding.,Begin Your Written Report,Gather all of your facts previously obtained, in particular who/what/when/where/how/why, and the cause/root cause of the accident. Additionally, gather written statements, information on similar incidents, and pictures to support your position when needed.,Example of Fact Gathering On July 29, 1999, on or about 10:45 am, Joe Employee was stacking concrete blocks and walked into a piece of steel re-enforcing bar that was protruding out of the end of the pipe storage shelving unit located inside the Project Materials compound, striking him in the face. A 1” cut was received across the middle of Mr. Employees forehead. He proceeded directly to the dispensary, where he received 4 sutures to close the laceration, then was released at 11:41am in a full duty status. He went to lunch, then informed his immediate supervisor of the incident upon returning to work at 12:30.,Your Conclusions: Cause: The accident was caused by Joe not paying attention to his surroundings and striking his head on the rebar. Root Cause #1: Somebody didnt properly store the rebar and left it in a haphazard state that was obviously unsafe. Root Cause #2: The supervisor has not been taking responsibility for his work area by monitoring for unsafe conditions.,So Now What?,At this point you have gathered facts, interviews, pictures, and all pertinent information. You have made conclusions and determined what the cause and root cause of the accident was. Question: What do you do with this information?,Corrective Action,You take corrective action that would prevent the reoccurrence of this type of injury in the future, such as: 1. You look around for similar things in your work center that would present the same type of hazard and implement corrective action. Examples: pipe storage, lumber storage, conduit storage, etc. 2. You should counsel the work center supervisor on proper storage methods and his responsibilities.,Finish Your Written Report,Now write your conclusions (cause & root cause) in your report, and finally wrap up your report by a “Corrective Actions Taken” paragraph. Attach all supporting documentation to the back of the report. You are now done with your written report.,To Recap Your Investigation,Who/what/when/where/how/why Conclusions (cause & root cause) Corrective Actions Taken,Uses of the Report,1. Toolbox Ta