Accident Investigation

Transcription

1 Accident Investigation Why? When? What, Root Cause? Corrective Actions? January 2018

2 Opportunities? The State of Georgia has had over 4,500 chances to use Accident Investigation techniques in FY2018. Unfortunately, we are having more opportunities with nearly every line of coverage. Have you completed investigations on your claims? Corrective Actions taken? FY2017 Automobile Liability, 424 General Liability, 349 Indemnification, 3 Property, 149 FY2018 Automobile Liability, 379 General Liability, 375 Property, 172 Workers Compensation, 2450 Auto Physical Damage, 1053 Workers Compensation, 2591 Claim count from July 1 to December 21, 2016 vs Auto Physical Damage, 1024

3 Why Investigate? Prevention of future incidents, injuries, accidents, etc. Identify and eliminate hazards. Expose deficiencies in process and/or equipment. Reduce injury and workers compensation costs. Maintain worker morale. Incident Investigation Prevention

4 What Is An Accident? An unplanned, unwanted, but controllable event which disrupts the work process and causes injury to people. Most everyone would agree that an accident is unplanned and unwanted. The idea that most accidents/incidents are preventable might be a new concept.

5 What Is An Incident? An incident may disrupt the work process, but does not result in injury or damage. It should be looked at as a wake up call. It can be thought of as the first of a series of events which could lead to a situation in which harm or damage does occur. Example of an incident: A 50 lb carton falls off the top shelf of a 12 high rack and lands near a worker. This event is unplanned, unwanted, and has the potential for injury.

6 The Tip of the Iceberg Accidents or injuries are the tip of the iceberg of hazards. Investigate incidents since they are potential accidents in progress. Incidents, Near Miss Accidents Investigate them ALL! Criteria for investigating an incident: What is reasonably the worst outcome, equipment damage, or injury to the worker? What might the severity of the worst outcome have been? If it would have resulted in significant property loss or a serious injury, then the incident should be investigated with the same thoroughness as an accident investigation.

7 Investigate All Incidents and Accidents Conduct and document an investigation that answers: Who was present? What activities were occurring? What happened? Where and what time? Why did it happen?

8 Actions At The Accident Scene Check for danger Help the injured Secure the scene Identify and separate witnesses Gather the facts First, make sure you and others don t become victims! Always check for stillpresent dangerous situations. Then, help the injured as necessary. Secure the scene and initiate chains of custody for physical evidence. Identify witnesses and physical evidence. Separate witnesses from one another If physical evidence is stabilized, then begin as quickly as possible with interviews.

9 When to Investigate? Immediately after incident Interview witnesses before memories fade Assess the scene before clues are moved Finish investigation promptly. In some cases you may have to wait for trauma to subside. Usually in incidents where the witness and injured were close.

10 Fact Finding Take notes on environmental conditions, air quality, witnesses and physical evidence Employees/other witnesses Position of tools and equipment Equipment operation logs, charts, records Equipment identification numbers Take samples Note housekeeping and general working environment Note floor or working surface condition Take lots of pictures. Draw the scene if applicable. Some scenes are more delicate then others. If items of physical evidence are time sensitive address those first. If items of evidence are numerous then you may need additional assistance. Some scenes will return to normal very quickly. Are you prepared to be able to recreate the scene from your documentation? Consider creating a photo log. The log should describe the date, time, give a description of what is captured in the photo and directionality. Link to sketch of accident scene.

11 Interview Witnesses Interview promptly after the incident Choose a private place to talk, Individually! Keep conversations informal Talk to witnesses as equals Ask open ended questions Listen. Don t blame, just get facts. Ask some questions you know the answers to Your method and outcome of interview should include: who is to be interviewed first, who is credible, who can corroborate information you know is accurate, how to ascertain the truth based on a limitation of the number of witnesses. Be respectful. Are you the best person to conduct the interview? If the issue is highly technical, consider an internal or external specialist for assistance.

12 The Five Whys Basic Question Keep asking, What caused or allowed this condition/practice to occur? until you get to the root causes. The five whys is one of the simplest of the root cause analysis methods. It is a question-asking method used to explore the cause/effect relationships underlying a particular problem. Ultimately, the goal of applying the 5 Whys method is to determine a root cause of a defect or problem. The following example demonstrates the basic process: My car will not start. (the problem) 1) Why? - The battery is dead. (First why) 2) Why? - The alternator is not functioning. (Second why) 3) Why? - The alternator belt has broken. (Third why) 4) Why? - The alternator belt was well beyond its useful service life and has never been replaced. (Fourth why) 5) Why? - I have not been maintaining my car according to the recommended service schedule. (Fifth why and the Root Cause)

13 Benefit of Asking the Five Whys Simplicity. It is easy to use and requires no advanced mathematics or tools. Effectiveness. It truly helps to quickly separate symptoms from causes and identify the root case of a problem. Comprehensiveness. It aids in determining the relationships between various problem causes. Flexibility. It works well alone and when combined with other quality improvement and trouble shooting techniques. Engaging. By its very nature, it fosters and produces teamwork and teaming within and without the organization. Inexpensive. It is a guided, team focused exercise. There are no additional costs. Often the answer to the one why uncovers another reason and generates another why. It often takes five whys to arrive at the root-cause of the problem. You will probably find that you ask more or less than five whys in practice.

14 Sequence of Events Events leading up to the incident Describe events of the incident Events that happened immediately after the incident Draw a chart of the events

15 Recommend Corrective Actions

16 Write a Report The report should include: An accurate narrative of what happened? How and Why the Accident Happened? Who was involved? What injuries occurred or what equipment was damaged? How were the employees injured? Clear description of unsafe act or condition. Sequence of events. Recommended immediate corrective action. Recommended long-term corrective action. Recommended follow up to assure fix is in place. Recommended review to assure correction is effective.

17 Planning to be SAFE! Corrective Actions: The main reason for Incident Investigations Here s the key. Do you give (0) Advice: Stay out of trouble when you are out tonight. (1) Action: Come home by 11:00. (2) Plan: I ll be staying up. See you at home by 11:00. Decide which of these 4 root causes applies Decide who didn t: 1. Know 2. Understand 3. Believe 4. Observe Start with these clues to find a corrective action Devise a Plan to: 1. Teach 2. Educate 3. Persuade 4. Assign

18 Questions? Contact Information C. G. Lawrence, III, MS, CSP, REM, ARM-P Chief Loss Control & Safety Officer (404) Hiram Lagroon, BS Chief Loss Control & Safety Officer (404)