test 1 chapt 1 to 6 Flashcards
first thee priorities of a company when an accident occurs
Provide emergency response
protect the employees involved from further harm
determine what happened to prevent from happening again
The length of time needed to investigate an accident depends on what?
The complexity of the accident,
not the severity of the accident is what determines the length of the investigation.
definition of
Accident
the occurrence in a sequence of events that produces unintended injury, death, or property damage
incident - definition
An unintentional event that may cause personal harm or other damage
definition of
near miss -
near miss - An occurrence in a sequence of events that had the potential to produce injury, death, or property damage but did not.
accident investigation -
A structured process of uncovering the sequence of events that produced or had the potential to produce injury, death, or property damage to determine the causal factors and corrective actions.
causal factors -
Events and circumstances that produced the accident.
Causal factors incorporate “root causes,” “basic causes,” “immediate causes,” lower level causes, upper level causes, and management causes. When discovering causal factors, it is important to analyze all causes at all levels.
corrective actions -
The actions taken to prevent recurrence of the accident.
Corrective actions are the “fixes” to prevent future accidents. These fixes should be performed at the appropriate level.
Three goals of an accident investigation
*
- Determine the accident sequence without placing blame
- Recommend Corrective Actions
- Update the overall safety Program
Know and label the accident ratio diagram per Bird and Germain
serious or major injury 1 minor injury 10 property damage accidents 30 Incidents 600 (no visible injury or damage) (near miss/close call)
Know and label the accident ratio diagram per Bird and Germain
serious or major injury 1 minor injury 10 property damage accidents 30 incidents with no visible injury or damage 600 (near miss & close calls)
How Heinrich’s Domino theory works
The first domino starts the accident sequence.
An accident occurs by comparing the events leading up to it to a set of dominoes.
The first domino (event) sets the stage and starts the accident sequence. When it falls, it pushes the next, and that pushes the next, until the last domino (accident or injury) is toppled
there are 5 actions that comprise the sequence
*ancestry & social environment
*fault or person
*unsafe act
*unsafe condition
The 5 actions that comprise the sequence to Heinrich’s domino theory -
- ancestry & social environment
- fault or person
- unsafe act
- unsafe condition
- Injury
- What are the two most important factors in determing the causes and corrective actions for accidents
Unsafe Acts
Unsafe Conditions
- Three factors that influence the outcome of an event used in Haddon’s matrix theory
- human factors
- equipment factors
- environmental factors
Haddon’s also has three distinct phases -
pre-injury, injury, post-injury
see chart p 29 - draw in here
Three phases of accident investigation
The investigative phase -
the analytical phase
the recommendation phase
Three phases of accident investigation - and their definitions
investigative - gain knowledge, discover facts, interview, document
analytical - analyze knowledge?What happened?
Recommendation - Develop corrective actions - how can it be prevented
Know what starts the analytical phase of accident investigation
Once the accident sequence is determined the analytical techniques are used to determine the causal factors and corrective actions
Know what is problem with using the root cause concept
One problem with using the root cause concept is that the term “root cause” has many meanings among safety professionals.
conflicting definitions:these various definitions reduce the effectiveness of the term “root cause”
Main focus of an accident investigation
Fixing a problem or problems is the main focus of accident investigation.
Four components of an accident investigation program - 4 components
1formal written accident investigation policy
2 training in emergency response
3 training in accident investigation
4 an accident investigation kit
- What 2 actions emergency response personnel should take first
- SECURE THE SCENE -
2. PROVIDE CARE TO THE INJURED
10 items that should be included in an accident investigation kit
tools personal protective equipment cameras tape measures gloves lights security tape tweezers evidence bags
*** chart p 46
INVESTIGATIVE TOOLS ADMINISTRATIVE/RECORDING TOOLS
barricade tape camera
cones graph paper
tape measure witness statement forms
flashlights/spotlights notepad and clipboard
evidence tags analytical technique forms
evidence bags copy of the accident investigation policy
tweezers
gloves (latex & work)
PPE
binoculars
- Name 4 types of evidence
Physical Evidence
Paper Evidence
People Evidence
Photographic Evidence
Physical Evidence - Hardware and solid material related to the accident
Paper Evidence - Any type of written documentation related to the accident
People Evidence - The evidence that is gathered from people, usually in the form of statements or interviews
Photographic or picture evidence - media that can document the scene and transfer knowledge
- Know which type of evidence is least likely to be damaged in an accident
“Paper evidence is the least likely of the “four P’s” to be damaged or contaminated”
- Know when witnesses should be interviewed
witnesses should be interviewed as soon as possible after the accident, but for the injured individual medical care should take precedence over interviews
- Know how long you should collect evidence
In most accident investigations evidence collection continues until the accident sequence is determined.
Evidence collection should continue until you have enough information to document the accident sequence, determine causal factors and develop corrective actions.
- 3 categories that physical evidence is broken into
visual
testing
placement or puzzle evidence
- visual evidence includes information that can be gathered by looking at the scene
- testing evidence must be analyzed in a laboratory
- placement or puzzle evidence that has broken into pieces(exploded) and must be reassembled to determine how accident occurred
- Factors are important when taking photos of accident evidence
*take pictures as soon as possible
include a reference guide ie ruler
*keep a picture log -
coordinate angles and directions in picture log
start taking pictures at a distance
*take pictures of smoke (black petroleum, white organics)
*take enough photographs so that a person who has not seen accident site can understand accident sequence
p 54
a few good photographs are better than many ad photographs
take photos of scene before ou move anything
better - videotape are before, during and after moving an object
photograph anything that will be removed or will disappear eventually
p55
photo tips
*take big picture photos - shows environment/relationships/distances between people and equipment
*include a reference object in picture if purpose is to show relationships ie ruler or person
*keep a photo log to ID pictures and note their purpose (photo#,object or purpose of photo, location picture was taken from, direction of the shot and time picture was taken
*get up high if possible
What analytical process is ?
“An accident investigation is the process of breaking down information into pieces until the investigator understands what happened; then he or she can analyze the pieces to determine ways to prevent the accident from recurring.
definition of analytical p describes the systematic thought process of breaking down information
What is goal of causal analysis?
to find all of the causes including the systemic causes - not just the immediate or superficial causes.
5 why technique is?
ASKING “WHY” five times to get to the root of a problem.
What type of causal factors exist at the
worker or equipment level
EQUIPMENT FAILURES INADEQUATE TRAINING INEXPERIENCE HUMAN ERROR work performed, equipment operates
What type of causal factors exist at the
supervisor level -
INADEQUATE HANDLING OF: *JOB SAFETY ANALYSES *COMMUNICATION *SCHEDULING LACK OF PROPER SUPERVISION supervisor level - describe how work is to be done
What type of causal factors exist at the
management level -
BUDGET ISSUES
COMMUNICATION
POLICIES/PROCEDURES
management level - dictates policies and procedure
What type of causal factors exist at the
corporate level -
PROBLEMS FOUND & CORRECTED AT THIS LEVEL PREVENTS ACCIDENTS
corporate level - dictates culture, philosophy and style of company
Know what hazard is -
HAZARD - A hazard is something that has the potential to cause injury, and hazards are correctable.
Know what failure is
FAILURE - A failure is something that goes wrong with personnel, equipment, or the environment.
A failure may or may not have the potential to cause injury (if it does it is also considered a hazard).
Failures are usually caused by faulty design, a defect, inadequate maintenance, limits that were exceeded or environmental effects.
Three phases of accident investigation
Investigative
Analytical
Recommendtion
