Accident Reporting & Investigation

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    Accident Reporting &

    Investigation

    Paul CraythorneHealth, Safety & Environmental Advisor

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    Accident Reporting &

    Investigation Course Objectives

    to understand:

    accident definition

    accident causation

    accident costs

    accident prevention

    accident reporting/notification

    accident investigation

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    Accident Reporting &

    Investigation Common Uninformed Comments

    accidents just happen

    we dont have many accidents

    safety is expensive

    the insurance will paysafety is just common sense

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    Accident Reporting &

    Investigation Accident Definition

    what is an accident?

    unplanned & uncontrolled event

    that led to, or could have led to:

    injury to persons, damage to

    property/plant/equipment, impairmentto the environment or some other loss

    to the company

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    Accident Reporting &

    Investigation Accident Definition

    accident types minor dangerous occurrence

    near miss

    plant/equipment damage

    minor injury lost time injury

    disablement/fatality

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    Accident Reporting &

    InvestigationAccident Definition

    Frank Bird (Accident Triangle) 600 near misses

    30 property damage

    10 minor injuries

    1 serious injury (lost time or fatal)

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    Accident Reporting &

    InvestigationAccident Causation

    environment

    personal fault

    unsafe act

    unsafe condition

    accident

    injury/damage

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    Accident Reporting &

    InvestigationAccident Causation

    causal factors individual

    job

    organisation

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    Accident Reporting &

    InvestigationAccident Causation

    causal factors individual

    knowledge

    skills

    training experience

    personality

    attitude

    risk perception

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    Accident Reporting &

    InvestigationAccident Causation

    causal factors job

    task

    workload

    equipment controls

    procedures

    environment

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    Accident Reporting &

    InvestigationAccident Causation

    causal factors organisation

    culture

    leadership

    resources work patterns

    communications

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    Accident Reporting &

    InvestigationAccident Causation

    Kings Cross Fire (1987) - 31died discarded cigarette

    accumulation of rubbish

    poor cleaning regime

    wooden escalator failure of fire fighting equipment

    lack of emergency training

    poor safety culture

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    Accident Reporting &

    InvestigationAccident Causation

    Herald of Free Enterprise (1987) -189 died

    failure to close bow doors

    no checking/reporting system

    commercial pressures

    internal friction

    disease of sloppiness

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    Accident Reporting &

    InvestigationAccident Causation

    Clapham Junction (1988) - 35 died& 500 injured

    signal failure

    incorrect maintenance

    degradation of working practices

    training problems

    communication problems

    poor supervision

    excessive working hours

    failure to learn lessons

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    Accident Reporting &

    InvestigationAccident Causation

    Piper Alpha (1988) - 167 died maintenance error

    inexperience

    poor maintenance procedures

    communications breakdown

    permit to work system fault

    safety procedures not practised

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    Accident Reporting &

    InvestigationAccident Causation

    Automotive Supplier (1999) - 1died

    poor safety culture

    lack of guarding

    lack of training

    poor perception of risk

    no safe systems of work

    no risk assessment programme

    no effective accident system

    no communication

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    Accident Reporting &

    InvestigationAccident Costs

    insured costs

    uninsured costs

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    Accident Reporting &

    InvestigationAccident Prevention

    reasons humane

    economic

    legal

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    Accident Reporting &

    InvestigationAccident Prevention

    control measures safety procedures/work instructions

    adequate training

    effective communications

    good housekeeping

    guards/safety devices/warning signs

    adequate working environment

    regular safety inspections

    risk assessment

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    Accident Reporting &

    InvestigationAccident Reporting/Notification

    internal report form HSE RIDDOR report

    injury claim requirement

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    Accident Reporting &

    InvestigationAccident Investigation

    reasons identify root causes

    identify faults

    identify corrective/preventative action

    prevent recurrence

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    Accident Reporting &

    InvestigationAccident Investigation

    investigation team supervisor

    safety rep

    engineer

    manager

    safety officer

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    Accident Reporting &

    InvestigationAccident Investigation

    investigation objectives establish chain of events

    identify root causes

    identify faults

    identify corrective/preventative action

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    Accident Reporting &

    InvestigationAccident Investigation

    investigation techniques attend promptly

    ensure medical attention

    leave scene undisturbed

    take photographs/sketches

    take measurements

    take samples

    gather documentation

    interview witnesses

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    Accident Reporting &

    InvestigationAccident Investigation

    investigation techniques interviewing witnesses

    explain purpose

    their version of events

    do not listen to hear say

    ask open questions

    avoiding leading or implying

    do not apportion blame

    express appreciation

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    Accident Reporting &

    InvestigationAccident Investigation

    investigation report identify team

    summarise consequential events

    identify root causes

    describe other weaknesses

    identify corrective/preventative action

    allocate responsibility & timescale