In this program where going to look at how learning from the mistakes we make today can help us be safer tomorrow.
Accidents happen, we all know that and we know that accidents can happen to anybody including ourselves. That can mean pain, injury sometimes even death, so it's important to understand why these things happen, if we make each one learning experience we can prevent the same type of accidents from happening again. An accident can be cause by hazardous conditions or unsafe work practices, but even when the reason seems obvious the real root cause can often be something else that's where accident investigation comes in. In examining incidents systematical to determine its true causes , that information is then use to update policies, procedures or equipment to reduce the risks of that type of accident from ever occurring again. The point of accident investigation is not to assign blame or to get anyone in trouble, it's to prevent people from being injured in the same way in the future. But before we discuss the investigation let's talk for a minute about how we should deal with the incidents themselves.
Accidents and Near Misses
There are two types of workplace incidents, accidents and near misses.
Near Miss - is an incident which is under slightly different circumstances could have resulted in an injury or damage to equipment or materials. In other words an accident waiting to happen. Near misses can warn us about the problem before something more serious happens and it's much better to learn from near misses than from accidents. Unfortunately, we want always having near miss to warn us about a potential problem. If an accident does occur, our first concern should be that the people who are injured are being cared for.
If someone needs first aid and your qualified to give it that should come first then medical personnel should be called immediately. Once any victim are taking care of the appropriate supervisors and managers should be notified if they aren't already at the seen. The area should be secured so that no one else can get hurt, safety tapes is often use for this. this will also help to prevent people from tampering the evidence that the investigator will need to look at.
Investigations and Root Causes Analysis
An accident investigation will usually begin immediately after an incident. Interviewers may take places soon as the area is secured. It's important to remember that the investigators need your help, be honest and provide as much information as you can.
Even if you do not witness the accident investigators may want to talk to you, especially if you are familiar with the site or the task being performed at the time of the accident. Remember the information is being gathered to help determine the exact cause of the accident not to face blame on anyone. Determining the cause of an accident is not always easy. After all, most accidents have several contributing factors. This is why a root cause analysis can often help the situation.
A root cause analysis is an examination of the chain of events that lead to an accident. These events may have taken place days, weeks even months before the accident actually occur. So, it's important that the analysis be thorough. Potential factors that investigators will look for includes; faulty or poorly maintained equipment, lack of training or the absence of appropriate policies and procedures. Remember root cause analysis looks all of the factors that could have been triggered into an accident. Which is why it is a vital part of any accident investigation. During an investigation you should offer as much information as you can regarding the accident. This include any relevant facts about the workers who were involved, the site where the accident occurred and the working conditions at the site. A successful root cause analysis relies on detail, it will help with your familiar with the safety practices that are used in a work area where the accident occur. And don't worry about giving investigators too much information, they will sort it all out. You never know when some small fact will be the key to determining what really happen and why. Let's look at some examples:
A warehouse worker is standing on the top step of the ladder and falls off. It may appear to be an easy investigation it seems obvious that the ignore the rule about not standing on the top step of the ladder loss his balance and that's why he fell.
The worker's actions are certainly a factor but there can be other reasons this accident occur as well. In order to help prevent the same type of accident from happening again, we need to look deeper. What if the ladder he was on was the tallest one in the warehouse. We know a person fell off a ladder, we also know that he was standing on the top step by continuing the investigation we eventually discovered that he was using the tallest ladder in the warehouse. The worker's carelessness is a factor but the lack of proper equipment is the root cause of his accident. The warehouse needs a taller ladder so that workers can reach the highest materials without standing on the top step. Remember the ultimate goal of an accident investigation is to prevent this incident from happening again. Let's look at another example of root cause analysis.
A worker fixing a machine is suddenly shocked, we might conclude that since there was electricity involved the situation was inherently hazardous that there wasn't much that could be done to make this situation safer.
But it takes electricity to run a machine and there are procedures that allow electrically powered equipment to be work on safely so there are probably other factors to consider. For instance, should the system have been locked out? If so, why wasn't it? We need to look at whether the worker who was repairing the machine had been given training on lockout/tag out procedures. If he had received lockout tag out training we would also need to determine if the worker was following the procedures that he was taught. In this instance the investigator determine that the root cause of the accident was a lack of training, the worker never attend the lockout/tag out class he scheduled for and therefore he never knew the danger he was putting himself into. Now let's apply root cause analysis to a third situation, one that involve person protective equipment.
Falls are accidents that people don't always investigate fully, if a person falls we usually figure their loss their grip or their footing but if we'll take a closer look. In this case we discovered that the worker did not follow procedure by wearing his fall protection gear, we will then need to find out why. There are a number of reasons why is an employee might skip proper safety procedures. In attempt to increase their output a worker in a hurry can sometimes forget about safety. Ironically, if an accident occurs as a result, production will often slowdown or even stop all together. There are times when an accident has nothing to do with equipment, training or procedures. Often investigators find a missed communication is the root cause of an accident. Workers need to clearly hear and understand any instructions they received about the job their doing. If communication aren't clear or there's question about what should really be done instructions should be repeated so that everyone understands the proper procedure.
Learning from Accidents
So far, we've only look at the first goal of an accident investigation, determining the cause. Now let's look at the other goal, making sure that the same type of accident doesn't happen again. Remember when it comes to learning from accidents, there are four basic areas to look at; Policies, training, equipment and communication.
Proper training is always a key element in preventing accidents. If problems have existed with certain type of activities or situations in the past, everyone should be made aware of the potential hazards that are associated with those situations and be trained to handle them. If a situation is hazardous enough your facility may have to put new policies in the place or existing policies may have to be updated. This can often take the form of workplace rules or standard operating procedures that everyone must follow. Many actions are cause by faulty or misused equipment. In these cases the equipment may need be repaired, if repairs are not possible or if the correct equipment isn't being use new equipment may have to be purchased, which may also require additional training. If an accident was the result of faulty communication, people may need made aware the factors that can hearing what a co-worker is saying difficult and how to overcome this. In many cases, the solution to the problem can involve more than one of these four factors.
As you can see investigating accidents can be an involved process but the goal of an accident investigation to determine the cause of an accident and prevent similar accidents from happening again is worth the effort. Let's review what you can do to help.
- Report near misses they can teaches a lot about preventing accidents in the future. In the event of an accident remember people safety is the top priority.
- Cooperate with investigators their goal is to prevent more accidents from occurring.
- Provide investigators with as much information about an accident as you can. Remember that a root cause analysis is an examination of the entire chain of events that lead to an accident, so no detail is unimportant.
- If you are helping to investigate in accident look at all four major factors policies, training, equipment and communication.
A good accident investigation can solve the mystery behind any safety problem and give you chance to help you and your co-workers stay safe on the