ERC Refinery Project HSE Training Program
Accident Investigation
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Accident Investigation
An unfortunate and unexpected
event.
A typical accident is the result
of many factors that all come
together at the same time.
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Accident Investigation
• Conducting a thorough
accident investigation can be
an essential component of
being an effective supervisor.
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Reasons to Conduct
Accident Investigations
• To prevent recurrence.
• To comply with policies and
regulatory requirements.
• To help maintain employee
awareness of the importance
of safe, healthy work habits.
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Supervisor’s Responsibility
Investigations are usually the
supervisor’s responsibility.
• Supervisors have a better
understanding of operations
and equipment.
• Employees may be willing to
speak more freely with their
supervisor.
• Supervisors have a personal
stake in accident
investigations.
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Accident Notification
• Supervisor’s can only
investigate accidents they
know about.
• Supervisors need to make
sure their employees
understand the notification
process.
• Cover notification
procedures in new hire
orientations and post
conspicuously in the work
area.
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Managing the Accident Scene
• Survey the scene.
• Treat the injured.
• Control remaining hazards.
• Isolate the site to protect
people and preserve
evidence.
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Conducting An Accident Investigation
An investigation contains
three steps:
1. Gather as much
information as possible.
2. Analyze the facts to
determine what the causes
were.
3. Make recommendations for
corrective measures to
prevent future accidents.
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Accident Investigation
Accident investigations
should begin as soon as
possible.
Because Once the accident
occur:
1- Operations are disrupted.
2- Memories fade.
3- Employees are at risk.
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Gathering Information
• Time and location of
accident.
• Environment
• Check that nothing was
moved, repositioned, turned
off, or taken from the scene
• Sources of information:
• Witnesses
• Physical evidence at the scene
• Existing records
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Finding The Witnesses
• Arriving at the scene PROMPTLY
is essential for the investigator.
• Ask questions to identify
employees that attended the
accident.
• Workers in adjacent areas may
have information on sights,
sounds, weather conditions,
lighting, noise, and other factors
related to the accident.
• Limit contact between witnesses.
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The Interview Process
• Get written statements
• Reassure the witness
• Let the witness tell the story
• Begin with open-ended
questions.
• Don’t ask leading questions
• Summarize
• Ask for recommendations
• Close on positive note
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Physical Evidences
• Sketches
• Valuable reference after conditions
have been returned to normal.
• Use reference points to show the
position of objects if it’s practical.
• Photographs
• Documents position and objects
condition.
• Take photos of anything that could
possibly be important.
• Ensure proper authorization is in place
prior taking pictures (confidentiality,
trade secret issues, etc.)
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Documenting Accident Investigation
Report forms should include the following:
• General information (basic facts about the accident, who,
what, when, where, why, how and so forth).
• Summary (a brief description of what happened).
• Analysis (a description of what caused the accident and
why it happened).
• Recommendations (suggestions to eliminate or control
recurrences).
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Existing Records
Utilize records to ensure thorough investigation
of:
• Employee records.
• Equipment records.
• Job or task records.
• Previous accident investigation reports.
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Recommendations
Recommendations are usually found within the following:
• Training programs.
• Inspections.
• JHAs.
• Employee performance observations.
• Safety meetings.
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Confidentiality of Reports
• Do not release any accident report to outside entities
without appropriate approval.
• Do not speak to outside insurance representatives or
outside attorneys unless approved by appropriate
management.
• Do not permit any photos to be taken outside the scope of
the investigation.
• Do no speak with the media. Instruct the media to call the
project manager for information.
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UNSAFE ACT
• Unsafe acts are made by
people; they are not made
by systems or by faulty
equipment. People make
unsafe acts.
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Unsafe Conditions
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Questions
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Thanks
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