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What are the best ways to document an accident investigation for root cause analysis?

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Accidents can happen in any workplace, but they can be especially costly and dangerous in industrial settings. That's why it's important to document and analyze the causes of accidents, so you can prevent them from happening again. In this article, we'll show you the best ways to document an accident investigation for root cause analysis, a method that helps you identify and eliminate the underlying factors that contributed to the incident.

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Guilherme Busato de Lima

Top Voice LinkedIn | Executivo de Gest?o | Executivo Industrial
Jo?o Vitor Lins Maciel

Engenharia | Qualidade | Gest?o de Projetos | Melhoria Contínua | Lean | Opera??es Industriais | Linkedin Top Voice
Ant?nio Miguel de Moura Paula

Engenheiro Mecanico Especializado em Manuten??o e Estratégias Operacionais | Gest?o de PCM | Análises de Falhas |…

1 Gather the facts

The first step in documenting an accident investigation is to gather the facts. You need to collect as much information as possible about what happened, when, where, how, and why. You can use various sources of data, such as witness statements, photos, videos, records, logs, diagrams, and measurements. You should also secure the accident scene and preserve any evidence that might be relevant. The goal is to create a clear and accurate picture of the event and its context, without making any assumptions or judgments.

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Guilherme Busato de Lima

Top Voice LinkedIn | Executivo de Gest?o | Executivo Industrial
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A melhor forma é fazer como os seriados de TV tipo CSI fazem quando v?o analisar um crime. Ter o máximo de evidências registradas tal qual estavam no momento do acidente ajudará a eliminar suposi??es ao longo da análise. Sempre que possível, além de fotos e vídeos, guarde materiais que julgar relevantes que possam contribuir para a análise. Por exemplo, uma luva quando o acidente foi na m?o... a forma como a luva se apresenta pode ajudar a entender a qual tipo de esfor?o ela foi submetida, o ponto de origem, etc., com isso será mais fácil entender a dinamica do acidente e por consequência facilitará os próximos passos que est?o relacionados a amálise propriamente dita.

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Ant?nio Miguel de Moura Paula

Engenheiro Mecanico Especializado em Manuten??o e Estratégias Operacionais | Gest?o de PCM | Análises de Falhas | Gest?o da Lubrifica??o | Manuten??o Preventiva e Preditiva.
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Em face de um acidente de trabalho, os passos s?o: - coletar o maior número de fatos e evidências do ocorrido; - fazer uma análise detalhada sem procurar o culpado e sim as causas principais que provocaram o acidente; - tomar a??es para que n?o aconte?a mais esse tipo de acidente com recomenda??es, treinamentos, a??es e mudan?as necessárias; -implementar as a??es e fazer o acompanhamento para verifica??o das efetividades e das mudan?as propostas. Tudo isso tem que ser escrito, a investiga??o, depoimentos, métodos de descoberta do fato causador, recomenda??es, planos de a??es e mudan?as geradas.

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Paulo Aranda Correia

Engenharia da Seguran?a no Trabalho
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Ao estar ligado à investiga??o de um acidente de trabalho após o seu incidente, devemos recolher os depoimentos das testemunhas, recolha de fotografias do local e se possível falar com os meios de assistência. Depois desta recolha penso que se deve focar nas causas do acidente para se ter uma real no??o do sucedido e aí tentar ir para uma melhoria. A recolha dos elementos deverá ser a mais eficaz, id?nea e objetiva pois poderá vir a dar lugar a ir a tribunal. A sua objetividade dará lugar a um bom relatório que vai perdurar no tempo e aí ser de uma clarividência no decorrer do tempo.

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2 Identify the causes

The next step is to identify the causes of the accident. You can use different tools and techniques to help you with this task, such as fishbone diagrams, 5 whys, fault tree analysis, or event tree analysis. These methods help you to organize and visualize the relationships between the factors that led to the accident, and to distinguish between the immediate, contributing, and root causes. The immediate causes are the direct triggers of the accident, such as human errors, equipment failures, or environmental hazards. The contributing causes are the underlying conditions that enabled or facilitated the immediate causes, such as poor training, inadequate maintenance, or ineffective policies. The root causes are the fundamental and systemic issues that allowed the contributing causes to exist, such as organizational culture, management practices, or regulatory gaps.

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Arnaldo Mattos

Sócio
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Sou de opini?o, que após identificar a causa e necessária a preven??o para que n?o mais venha ocorrer, com constancia, fatos semelhantes, apoiar e corrigir, para seguir avante sem trope?os ou atropelos.

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3 Recommend corrective actions

The final step is to recommend corrective actions to prevent the recurrence of the accident. You should prioritize the actions that address the root causes, as they are the most effective and sustainable solutions. You should also consider the feasibility, cost, and impact of each action, and assign responsibilities and deadlines for their implementation. You can use tools such as action plans, risk matrices, or SMART goals to help you with this step. The goal is to create a realistic and actionable plan that will improve the safety and performance of your workplace.

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Jo?o Vitor Lins Maciel

Engenharia | Qualidade | Gest?o de Projetos | Melhoria Contínua | Lean | Opera??es Industriais | Linkedin Top Voice
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o modelo de Reason enfatiza a importancia da análise de múltiplas camadas, conhecida como "fatia da cebola". Isso significa investigar n?o apenas os eventos imediatos de um acidente, mas também as camadas mais profundas de falhas e condi??es que contribuíram para ele. Essa abordagem holística permite identificar n?o apenas as causas diretas, mas também as raízes sistêmicas dos problemas, possibilitando a implementa??o de medidas preventivas mais abrangentes e eficazes. Outro aspecto fundamental do modelo de Reason é a ênfase na aprendizagem organizacional. Em vez de atribuir culpa ou responsabilidade individual, o modelo de Reason incentiva as organiza??es a adotarem uma abordagem de aprendizado e melhoria contínua.

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4 Write a report

Once you have completed the previous steps, you should write a report that summarizes your findings and recommendations. The report should be clear, concise, and consistent, and follow a logical structure. You can use a template or a checklist to guide you through the report writing process, and make sure you include the following elements: an executive summary, an introduction, a description of the accident, an analysis of the causes, a list of corrective actions, and a conclusion. You should also attach any supporting documents, such as data sources, diagrams, or evidence. The report should be reviewed and approved by the relevant stakeholders, and communicated to the appropriate audiences.

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5 Follow up and monitor

The last step in documenting an accident investigation is to follow up and monitor the progress and effectiveness of the corrective actions. You should track the status of each action, and verify that they are completed on time and as planned. You should also measure the impact of the actions on the safety and performance indicators, and compare them with the baseline and the target values. You should report any deviations, challenges, or successes, and adjust the actions as needed. You should also document any lessons learned, best practices, or feedback, and share them with your team and organization.

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6 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?

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What are the best ways to document an accident investigation for root cause analysis?

1

2

3

4

5

6

1 Gather the facts

2 Identify the causes

3 Recommend corrective actions

4 Write a report

5 Follow up and monitor

6 Here’s what else to consider

Industrial Engineering

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What are the best ways to document an accident investigation for root cause analysis?

1

2

3

4

5

6

1 Gather the facts

2 Identify the causes

3 Recommend corrective actions

4 Write a report

5 Follow up and monitor

6 Here’s what else to consider

Industrial Engineering

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