University Kuala Lumpur MFI

(FWB 23102 Welding Safety Management) ACCIDENT INVESTIGATION 1. Getting Started Definition: An investigation is a search for the truth, in the interests of justice and within the constraints of the law. P.G Nendick. Objectives: To obtain accurate and full information about the circumstance and the causes of the accident. To prevent the occurrence of similar accident in the future, to uncover new hazards and to devise adequate control measures.

2. Reasons of Investigation. There are reasons for thorough and effective investigation of accident, namely: a) On humanitarian basis because no one likes to see people killed or injured. b) The accident may have resulted from breach of law by some one with the possibility of civil proceeding being instituted by injured party against his employers. c) Required by enforcing authority (OSHA and FMA) d) The accident may result in lost of production. e) May effect on the morale of the workforce. f) Search for prevention solution and improve safety standard. g) to process workers' compensation claims 3. Investigation Accident investigations fall into two main categories: a. Internal investigation Whenever an occupational injury/illness becomes "OSHA Recordable" a formal accident investigation will be held. This investigation will be conducted within 72 hours after the incident, if possible. The line manager is the best position to investigate the accident, but the injured employee's supervisor can begin to set up the accident investigation soon after the accident. b. External investigation The first type of external investigator that may be encountered is one representing a Statutory Authority. That is a person representing a Government Agency, which administers legislation, which embraces the activity being undertaken at the workplace involved.

University Kuala Lumpur MFI

(FWB 23102 Welding Safety Management) 4. Steps involved in investigating an accident. The accident investigation process involves the following steps: Report the accident occurrence to a designated person within the organization Provide first aid and medical care to injured person(s) Investigate the accident Identify the causes Report the findings Develop a plan for corrective action Implement the plan Evaluate the effectiveness of the corrective action Make changes for continuous improvement 5. Looking into the cause of an accident Accident Causation Models Many models of accident causation have been proposed, ranging from Heinrich's domino theory to the sophisticated Management Oversight and Risk Tree (MORT). Figure 1: Accident Causation

The simple model shown in Figure 1 attempts to illustrate that the causes of any accident can be grouped into five categories: Task Here the actual work procedure being used at the time of the accident is explored Material To seek out possible causes resulting from the equipment and materials used. Environment The physical environment and especially sudden changes to that environment. Personnel The physical and mental condition of those individuals directly involved in the event must be explored. Management Management holds the legal responsibility for the safety of the workplace and therefore the role of supervisors and higher management must always be considered in an accident investigation. 2

University Kuala Lumpur MFI

(FWB 23102 Welding Safety Management)

6. Gathering facts. The steps in accident investigation are simple: the accident investigators gather information, analyze it, draw conclusions, and make recommendations. Injured workers(s) The most important immediate tasks--rescue operations, medical treatment of the injured, and prevention of further injuries--have priority and others must not interfere with these activities. When these matters are under control, the investigators can start their work. Physical Evidence Before attempting to gather information, examine the site for a quick overview, take steps to preserve evidence, and identify all witnesses. positions of injured workers equipment being used materials being used safety devices in use position of appropriate guards position of controls of machinery damage to equipment housekeeping of area weather conditions lighting levels noise levels Eyewitness Accounts There are two types of witness: Eyewitness - person who actually see the accident happen. Circumstantial witnesses those who did not actually see the accident but who can contribute valuable information Interviewing There are certain proven technique for a successfully interview, the following elements form the basic approach to investigation interviewing Conduct the interview in private at the workplace. Put the interviewee at ease, dont hurry things. Ask the interviewees version pf what happened Only ask necessary questions. Dont ask leading questions. Close the interview on a positive note. Thank the witness. Background Information Often an overlooked source of information can be found in documents such as technical data sheets, maintenance reports, past accident reports, formalized safe-work procedures, and training reports. Any pertinent information should be studied to see what might have

University Kuala Lumpur MFI

(FWB 23102 Welding Safety Management) happened, and what changes might be recommended to prevent recurrence of similar accidents. 7. Analyzing and Deciding on the Cause. Accident analysis is carried out in order to determine the cause or causes of an accident or series of accidents so as to prevent further incidents of a similar kind. It is also known as accident investigation. It may be performed by a range of experts, including forensic scientists, forensic engineers or health and safety advisers. A. Sequence Accident analysis is performed in four steps: I. Fact gathering: After an accident happened a forensic process starts to gather all possibly relevant facts that may contribute to understanding the accident. II. Fact Analysis: After the forensic process has been completed or at least delivered some results, the facts are put together to give a "big picture." The history of the accident is reconstructed and checked for consistency and plausibility. III. Conclusion Drawing: If the accident history is sufficiently informative, conclusions can be drawn about causation and contributing factors. IV. Counter-measures: In some cases the development of counter-measures is desired or recommendations have to be issued to prevent further accidents of the same kind. B. Methods There exist numerous forms of Accident Analysis methods. These can be divided into three categories: I. Causal Analysis uses the principle of causality to determine the course of events. Though people casually speak of a "chain of events", results from Causal Analysis usually have the form of directed a-cyclic graphs-the nodes being events and the edges the cause-effect relations. Methods of Causal Analysis differ in their respective notion of causation. II. Expert Analysis relies on the knowledge and experience of field experts. This form of analysis usually lacks a rigorous (formal/semiformal) methodological approach. This usually affects falsify-ability and objectivity of analyses. This is of importance when conclusions are heavily disputed among experts. III. Organizational Analysis relies on systemic theories of organization. Most theories imply that if a system's behaviour stayed within the bounds of the ideal organization then no accidents can occur. Organizational Analysis can be falsified and results from analyses can be checked for objectivity. Choosing an organizational theory for accident analysis comes from the assumption that the system to be analysed conforms to that theory.

8. Investigation Report. The report should provide a condensation of fact about the accident. Those who use accident information are interested in either general or specific information or both.

University Kuala Lumpur MFI

(FWB 23102 Welding Safety Management)

A good report will consist of four (4) sections namely:

Identifying Information Accident Description Cause Analysis. Recommendation

9. Why are some accidents are not reported. Red tape dont report accident s just to avoid paperwork Ignorance not familiar with OSHA reporting specification Embarrassment people do not report an accident because they are embarrassment bye their part in it. Record spoiling some accident are reported just to preserve a safety record such as zero accident.