Accident
Investigation
Featuring Root Cause Analysis
BY Joe Garcia
Whether you have an accident
investigation process already in
place, don’t have one, or are in the
midst of creating one, here are a
few ideas on why accident
investigation is important
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GOVERNMENT ENTITY EXPOSURES
t
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GOVERNMENT ENTITY EXPOSURES
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PUBLIC ENTITY CHALLENGES
• Control Expenses and Risk
• Insurance
• Legal
• Out of Pocket
• Delivery of Services
• Minimize Disruptions
• Continue Traditions
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GOVERNMENT ENTITY LOSS
TRENDS BY DEPARTMENT
4%: Fire Dept./Association
Response - Auto accidents
Inadequate(NFPA)Delays/water
Failure to respond
Employment Practices
12%: Park & Recreation
Falls
Swimming pools
Defective Sports Equip. issued
Sports injuries
Sexual Abuse
Employment Practices
Workplace Harassment
19%: Administrative Offices
Slip, Trip and Fall
Employment Practices
Workplace Harassment
Public Officials Liability
24%: Public Works/Road & Bridge
Auto maintained roads
Sewer Backups
Contact w/ heavy equipment
Missing/damaged traffic signs
Unprotected excavations
Damage to utilities in ROW
Employment Practices
41%: Law Enforcement/Jails
Pursuit & Response accidents
Use of force
False arrest
Domestic violence
Search and seizure
Employment Practices
Inadequate medical services
Inadequate supervision/surveillance
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GOVERNMENT ENTITY LOSS
TRENDS BY LINE OF COVERAGE
8%: Property
Fire Losses
Wind/Tornadoes
Theft/Vandalism
16%: General Liability
Slip/Trip and Falls
Park and Recreation
Public Works
Street/Road Defects
Security Issues (physical assaults)
1%: Inland marine (equipment)
Fire (fueling)
Operator Error
Theft/Vandalism
Inadequate Maintenance
31%: Employment Practices
Discriminatory Hiring Practices
Workplace Harassment
Hostile Environment
Wrongful Termination
Failure to Promote
Inconsistent Disciplinary Measure
ADA Accommodations
26% Automobile Liability
Law Enforcement
Public Works
Fire Department
18%: Law Enforcement/Jails
Pursuit & Response accidents
Use of force
False arrest
Domestic violence
Search and seizure
Employment Practices
Inadequate medical services
Inadequate supervision/surveillance
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BENEFITS OF ACCIDENT INVESTIGATION
A process to determine the underlying causes that
can lead to an accident
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BENEFITS OF ACCIDENT INVESTIGATION
(Continued)
•
•
•
•
Prevention of future, similar losses
Contribution to the bottom line
Reduction of human pain & suffering
Continuous improvement of operational and safety
procedures
• Raises Safety awareness level
• Reaffirms its commitment to the safety and well-being
of its employees
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PURPOSE OF ACCIDENT INVESTIGATION
• Minimize the potential for recurrence of similar
accidents/losses
• Identification of the accident cause and surrounding
circumstances
• Determine what adverse effects resulted from the accident
• Effective implementation of corrective action
• Educate employees in the accident causation hazards and
related control methods
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WHAT IS ACCIDENT INVESTIGATION?
• A process to determine the underlying causes that can lead to an
accident
• This information is used to identify and take preventive action
• Accident Investigation is a basic component of loss prevention
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WHY DO ACCIDENT INVESTIGATIONS FAIL?
A process to determine the underlying causes that
can lead to an accident
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ACCIDENT INVESTIGATION TAKES
TEAMWORK
Seat
Of
Power
Directors/Manager
Department Heads
Department Supervisors
Non Management Employees
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ACCIDENT INVESTIGATION TAKES
TEAMWORK (Continued)
• Takes everyone working and watching together
• Identifying Hazards
• Finding controls that fit
• Discovering emerging trends
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ROLES AND RESPONSIBILITIES
• Top Management
• Safety Director / Coordinator
• Supervisor / Front Line Manager
• Safety Committee
• Accident Review Team
• Employee
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WHY ACCIDENT INVESTIGATIONS
FAIL (Continued)
•
•
•
•
•
•
•
Lack of management support
Lack of time to complete
Lack of accountability
Lack of motivation
Not clear on procedures
Lack of skills & knowledge
Investigation stopped short and didn’t reveal the root
causes of the accident
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WHICH ACCIDENTS NEED TO BE
INVESTIGATED?
• Injury
• Illness
• Property damage
• Process interruption
• Near miss
Answer: ALL OF THE ABOVE
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PRE-PLANNING PROCESS
• Clearly defined roles and responsibilities
• Training of key staff members
• Uniform procedures established
• Communications established
• Necessary equipment and forms on hand
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DEFINITION OF KEYWORDS
• Accident - The undesired event that results in personal injury or
property damage
• Incident – An incident is an unplanned, undesired event that adversely
affects completion of a task
• Near Misses – Near misses describe incidents where no property was
damaged and no personal injury sustained, but where given a slight
shift in time or position, damage and/or injury easily could have
occurred
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ACCIDENT CAUSATION
95% of Accidents have two or more “causes”
People
Equipment
Entity Policy/Mgt
Accident
Crash
Incident
Injury
Environment
Materials/Other
Cause
Department Policy
Effect
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ACCIDENT INVESTIGATION
TAKEAWAY (Continued)
• Eliminate the hazard
• Substitute a Less Hazardous material or Process
• Use Engineering Control
• Use Administrative Controls
• Personal Protective Equipment
• Training of Employees
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ACCIDENT INVESTGATION
TAKEAWAY
• Documented facts only
• Determine if the corrective actions apply to more than
one employee, more than one job function, more
than one shift, etc.
• Prioritize corrective actions based on future accident
potential
• Submit both interim and permanent corrective
actions, if necessary
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ACCIDENT INVESTIGATION
TAKEAWAY
• Ensure that permanent corrective actions don’t get
“lost in the shuffle.”
• Evaluate the effectiveness of implemented corrective
actions:
• By interviewing employees
• Accident experience
• Review of policies
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CLAIMS REPORTING & INVESTIGATION
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ACCIDENT INVESTIGATION
CONCLUSION
• Accident investigations are the single most important tool for
identifying the causes of accidents for both employee injuries
and incidents involving the general public.
•
All incidents at your entity and on your properties, even those
that do not involve injury, should be investigated.
•
A thorough investigation can help discern the root cause of the
event and generate suggestions to correct it.
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ACCIDENT INVESTIGATION
CONCLUSION
The data collected by accident investigations over a period of time,
can identify loss trends that might not be immediately obvious from
analyzing a single or handful of accidents. This can lead to:
• Lower insurance premium
• Lower cost from legal issues
• Lower out of pocked expenses that insurance does not cover
• Better moral from the public and employees
• Finding improvement needs from department policies or a
process
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Questions
Joe Garcia
Risk Control Specialist
303-531-3888