Introduction:

One of the biggest failings in the safety profession is effective accident and high potential near miss incident investigation. Generally, accident investigations are carried out poorly and are mostly fault finding exercises. This sends a negative message to the workforce, and constantly reinforces the fallacy that management is always almost perfect, and never do anything wrong. It is always the injured employee who is at fault. Effective investigations get to the root causes of the system breakdown that caused the accident, or near miss incident. Sometimes this opens a can of worms!.

 

Objective:

The objectives of this workshop are to:

• Explain the importance of accident and near miss incident

investigation.

• Teach how to investigate accidents and undesired events.
• Clarify how to identify the immediate and root causes of an accident.
• Explain what remedial measures are.
• Show how to get to the accident facts.
• Explain what happens after an accident.
• Teach attendees how to score a completed accident investigation form.
• Revisit the rules and golden rules of accident and near miss incident investigation.
• Teach how to interview accident victims.
• Show how a thorough investigation can sometimes reveal complex underlying factors.

 

The workshop includes:

• A comprehensive workshop book.
• Attendee participation exercises.
• The hands-on “Impala Platinum” case study.
• Ranking of accuracy of accident investigation forms.
• How to identify high risk acts and conditions.
• Risk assessment exercises.
• Round table discussions.
• Witness interviews (role play).

 

Program Contents:

 

Day 1 – Session 1 (90 MINS)

 

1. Welcome and Introduction
2. Emergency procedure
3. Ground rules
4. Participants’ introduction
   • Learning objective (Student Exercise)
5. Workshop details
   • Aims, objectives, and outcomes.
   • Workshop schedule for 5 days and 4 sessions per day
6. Syllabus review
   • Baseline Accident Investigation – tank entry (Students exercise)

 

Day 1 – Session 2 (90 MINS)

1. Definitions
2. Understanding the terms:
   1. Accident, injury,
   2. Key points of an accident
   3. Accident statistics internationally
   4. Near miss incident
   5. Safety myth busted.
   6. Authority, Responsibility and Accountability

• Students’ exercise – “Whose Job, is it?”

 

1. Safety Philosophy
   1. Accident ratios (Presentation)
   2. Heinrich
   3. Bird
   4. Petersen
   5. The Columbia Case Study
   6. Conclusion
2. What causes accidents? (Team project)

 

 

Day 1 – Session 3 (90 MINS)

 

1. Loss Causation Model

• Failure to identify the hazards and assess the risks (HIRA)
• Weaknesses in the SMS
• Accident root causes
• Immediate cause of energy exchange
• Luck factors
• Energy transfers
• Types of energy transfers (Presentation)
• Examples

1. Accidental loss
2. Types of loss

• Direct
• Indirect/Hidden
• Totally hidden.

1. The Logical Sequence Accident Investigation Method

 

 

Day 1 – Session 4 (90 MINS)

 

1. High Risk Behavior and Conditions – (Presentation)
2. Student exercise high risk behavior and conditions
3. Accident Root Cause
   • Defining root cause
   • Root cause analysis defined.

 

DAY 2:

 

DAY 2 – Session 5: (90 MINS)

 

1. Safety in the Shadows
   • Near Miss Incidents – (Presentation)
2. Property damage accidents
3. Natural causes

 

 

DAY 2 – Session 6 (90 MINS)

1. Risk Assessment in an instant (Presentation Risk Assessment)

1. • Pre-task Risk Assessment- example
   • HIRA
   • Hazard Identification

1. • Risk analysis (Presentation)
   • Probability and severity quantified.
   • Risk matrix and its use

• Risk evaluation
• Risk profile

1. Risk register
2. Action plans
3. Students risk assessment exercise (Team Project)

 

 

DAY 2 – Session 7 (90 MINS)

1. Teams report back on risk assessment exercise.
2. Team 1
3. Team 2
4. Team 3
5. Team 4

1. Team 5
2. Feedback and discussion of risk assessment exercise
3. Safety Management Systems Risk Assessment Standard exercise

DAY 2 – Session 8 (90 MINS)

1. Why are accidents not reported? (Team project)
2. Why are near miss incidents ignored?
3. Encouraging reporting
4. Safety Culture
   • Safety Culture Presentation – (Silver Bullet)
5. Purpose of accident investigation
6. Who should investigate?
7. Sources of information
8. Root cause analysis methods
   • Problem solving
   • Fishbone method
   • Why? Why? Why?
   • Uncovering the root causes
9. Ten rules of accident investigation

 

DAY 3:

DAY 3 – Day 3 – Session 9 (90 MINS)

1. Team quiz 3
2. Management Functions applicable to Accident Investigation
3. The Politics of Accident investigation (Opening a can of worms)
4. Review of important topics
5. Feedback and clarification on learning objectives
6. International standards on injury classification and reporting
7. LTI
8. DI
9. Minor injury
10. Recordable
11. Reportable
12. Reportable machinery failures
    • Injury classifications exercise (Student exercise)

 

 

DAY 3 – Session 10 (90 MINS)

1. Team presentations on Loss Causation Model
2. Each team demonstrates the Loss Causation Model using all team members.
3. Winning team

 

DAY 3 – Session 11 (90 MINS)

1. Safety Management Systems
   • SMS Presentation (Presentation)
2. Sections
3. Elements
4. Minimum standards
5.  Minimum standard details
6. ISO 45001
   • Review and evaluation of SMS standard on Accident Investigation (Team exercise)
7. Open question time

 

DAY 3 – Session 12 (90 MINS)

1. Interviewing techniques
2. Question types
3. Interviewee types

 

DAY 4:

DAY 4 – Session 13 (90 MINS)

• Team quiz 4
• Team exercise – interviewing techniques
• Role play

 

DAY 4 – Session 14 (90 MINS)

1. Investigation form

• Review of Accident Investigation form features

1. Remedial measures
2. Review of the guide Accident Investigation Made Simple (AIMS)

• Case study-team project – Overhead Electric Pole accident

 

DAY 4 – Session 15 (90 MINS)

1. Feedback on case study

• Review and evaluation of Team 1 findings
• Review and evaluation of Team 2 findings
• Review and evaluation of Team 3 findings
• Review and evaluation of Team 4 findings
• Review and evaluation of Team 5 findings

1. Ideal solution
2. Action plans

 

DAY 4 – Session 16 (90 MINS)

1. Team quiz 4
2. Review of case study Impala Platinum

• Description of the event

1. Case study Impala Platinum– teams’ investigation of event
2. Determining the:

• Losses
• Energy exchanges
• Immediate causes analysis
• Root cause analysis
• Controls that failed.
• Risks not identified.
• Action plans

 

1. Team presentation of findings

• Review and evaluation of Team 1 findings
• Review and evaluation of Team 2 findings
• Review and evaluation of Team 3 findings
• Review and evaluation of Team 4 findings
• Review and evaluation of Team 5 findings

DAY 5

Day 5 – Session 17 (90 MINS)

1. Team quiz 5
2. Evaluation of quality of accident investigation reports
3. Evaluation Supervisor A

• Strengths/final score

1. Evaluation Supervisor B

• Strengths/final score

1. Review of Teams’ scores
2. Will the remedies fix the problem?
3. The ideal solution
4. Winning team

Day 5 – Session 18 (90 MINS)

1. Remedial measure
2. If it won’t fix the problem – don’t do it!
3. Action plans
4. Follow up.

 

Day 5 – Session 19 (90 MINS)

1. Review of important topics
2. Feedback and clarification on learning objectives
3. Open question time
4. Student of the workshop award
5. Conclusion
6. Workshop evaluation

 

Day 5 – Session 20 (90 MINS) Checklists & Vital Tips

1. Presentation of certificates
2. Thanks
3. Close

Target Audience:

Supervisors and front line management often have to investigate accidents in their own divisions and this workshop will equip them with the tools and knowledge to enable them to do so effectively. Safety professionals will also benefit from this “out of the box” approach to investigations.