Remember this graphic from the course introduction? The message is that there is a substantial cost to pay for each and every accident your company has. Although accident investigation is a valuable and necessary tool to help reduce accident losses, it is always considerably more expensive to rely on accident investigation than hazard investigation as a strategy to reduce losses and eliminate hazards in the workplace. In some cases it may cost hundreds of thousands of dollars more as a result of direct, indirect, and unknown accident costs. But, when the accident happens...it happens. And it's important to minimize accident costs to the company. This can be done if effective accident investigation procedures are used. So, let's take a quick look at some basic concepts and then discuss the first steps to take in building an effective accident investigation program.

• An incident is an unexpected event that may result in property damage, but does not result in an injury or illness. Incidents are also called, "near misses," or "near hits."
• An accident is an unexpected event that may result in property damage, and does result in an injury or illness to an employee.

When a serious accident occurs in the workplace, everyone will be too busy dealing with the emergency at hand to worry about putting together an investigation plan, so the best time to develop effective accident investigation procedures is before the accident occurs. The plan should include as a minimum procedures that determine:

• Who should be notified of accident.
• Who is authorized to notify outside agencies. (fire, police, etc.)
• Who is assigned to conduct investigations.
• Training required for accident investigators:
• Who receives and acts on investigation reports.
• Timetables for conducting hazard correction.

Accident Scenario: John's hurt bad... fell off a scaffold over at the worksite! You've just been notified of an injury in the workplace and immediately swing into action. You grab your investigator's kit and hurry to the accident scene. By the time you get there, the Emergency Medical Team (EMT) is administering first aid. It's a serious accident so the victim is transported to the hospital. Now it's safe to investigate.

The next step in the procedure is to gather useful information about what directly and indirectly contributed to the accident. Interviewing eyewitnesses to the accident is probably one of the most important techniques in gathering information, but there are many other tools and techniques too.

Gathering background information about the accident may be accomplished in many ways.

• Training records
• Disciplinary records
• Medical records (as allowed)
• Maintenance records
• EMT reports
• Police reports (rare)
• Coroner's report (fatalities)
• OSHA 300 Log (past similar injuries)
• Safety Committee records

• Take photographs of the scene.
• Videotape the scene.
• Make sketches of the scene.
• Make observations about the scene.
• Include measurements.

Remember you are gathering information to use in developing a sequence of steps that led up to the accident. You are ultimately trying to determine surface and root causes for the accident. It is not your job, as an accident investigator, to place blame. Just gather the facts.

Now you've gathered tons of information about the accident, and it's piled high on your desk. What do you do with it? It's important that you read through the information initially to develop an accurate sequence of events that led up to and included the actual injury event. See what an accident investigation sequence of events might look like. OSTN Online Safety Training Course 702, Effective Incident/Accident Investigation, covers this topic in more detail on this subject.

It's important, here, to note that one of the symptoms of conducting accident investigations to determine liability is that not much analysis is conducted once liability can be established. On the other hand, in a fix-the-system culture, analysis is in-depth and the question of liability does not surface until after system weaknesses have been determined. If system weaknesses did not in any way contribute to the accident, the question of discipline may be discussed.

What caused the accident? The next step is to determine surface causes. This step may be difficult because you are first searching for the surface causes of the accident in each step. This can take some time. From the clues you uncovered during this phase of the analysis, you'll be able to determine the system weaknesses or root causes. Remember, just like the leaves on the plant to the left, surface causes are usually pretty easy to see and not too difficult to uncover. However, you may find it takes a great deal more time to accurately "dig up" the underlying safety management system weaknesses that contributed to the accident.

Surface causes. The conditions and behaviors directly or indirectly producing the accident. A readily apparent reason for an accident/incident that usually appears early in an accident/incident investigation. A long-lasting corrective action does not come from a surface cause. A surface cause leads to a root cause. Primary surface causes directly cause the accident and usually involve the victim and some object or behavior. Secondary surface cause are unique conditions or behaviors that indirectly contribute to the accident. Secondary surface causes can occur anytime, by any person in the organization, and at any location. Conditions are objects or "states of being." Behaviors describe some sort of action, activity. Examples:

• Unguarded saw (condition)
  
• Horseplay (behavior)
  
• Not using hearing protection when required (behavior)
  
• Slippery floor (condition)
  
• Inadequately trained employee (condition)

Root causes. Underlying system weaknesses that indirectly produce the primary and secondary surface causes leading to the accident incident/accident. The system weaknesses always exist prior to the surface causes that produced the accident. They are the programs, policies, plans, processes, and procedures in any of the seven elements or activity areas in a safety management system. It takes more in-depth investigation and results in long-lasting corrective action that can prevent repetition of the accident. A root cause may be referred to as a "basic" cause in OSHA accident investigation reports.

• Inadequate or missing safety training plan.
  
• No clearly stated supervision.
  
• No inspection procedures.
  
• Inadequate hazard reporting process.
  
• Inadequate purchasing policy.
  
• No progressive discipline process.

So, what causes unsafe behaviors?

Now that you have developed the sequence of steps leading up to, and including the accident, and determined surface and root causes, it's time to report your findings. Some employers also ask accident investigators to make recommendations for corrective action, so be prepared for that.

Most companies purchase accident investigation forms. That's fine, but some forms leave little room to write the type of detailed report that is necessary for a serious accident. If you use such a form, make sure you attach important information like the sequence of events, and findings which include both surface and root causes.

A better idea is to develop your own report form that includes the following five sections:

Section One: Background Information. This is the who, what, where, whey, why, etc. It merely tells who conducted the inspection, when it was done, who the victim was, etc: Just a fill-in-the-blank section.

• Engineering controls
  
• Work Practice controls
  
• Administrative controls
  
• Personal protective equipment

It's crucial that, after making recommendations to eliminate or reduce the surface causes, you use the same procedure to recommend actions to correct the root causes. If you fail to do this, it's a sure bet that similar accidents will continue to occur.

Section Five: Summary. In this final section, it's important to present a cost-benefit analysis. What are the estimated direct and indirect costs of the accident being investigated? These represent potential future costs if a similar accident were to occur. Compare this figure with the costs associated with taking corrective action? You may want to address return on investment also. Information on cost benefit analysis and return on investment are is presented in OSHAcademy Course 702.

Well, there it is. Remember, an effective accident investigation program will help to prevent similar accidents from happening and minimize accident costs. OK, ace detective, it's time to take the quiz.