Workplace accidents occur each and every day all across and the Country. Each Year the Bureau of Labor Statistics publishes a statistical summary of injuries and illnesses (See summary below) that emphasizes this fact. The failure of people, equipment, supplies, or surroundings to behave or react as expected causes most of the accidents. Accident investigations determine how and why these failures occur. By using the information gained through an investigation, a similar or perhaps more disastrous accident may be prevented. Conduct accident investigations with accident prevention in mind. Investigations are NOT to place blame.

National Census of Fatal Occupational Injuries in 2007

A total of 5,488 fatal work injuries were recorded in the United States in 2007, a decrease of 6 percent from the revised total of 5,840 fatal work injuries reported for 2006. While these results are considered preliminary, this figure represents the smallest annual preliminary total since the Census of Fatal Occupational Injuries (CFOI) program was first conducted in 1992. Final results for 2007 will be released in April 2009.

Based on these preliminary counts, the rate of fatal injury for U.S. workers in 2007 was 3.7 fatal work injuries per 100,000 workers, down from the final rate of 4.0 per 100,000 workers in 2006, and the lowest annual fatality rate ever reported by the fatality census.

Key findings of the 2007 Census of Fatal Occupational Injuries:

• The number of fatal falls in 2007 rose to a series high of 835--a 39 percent increase since 1992 when the CFOI program was first conducted.
• Transportation incidents, which typically account for two-fifths of all workplace fatalities, fell to a series low of 2,234 cases in 2007.
• Workplace homicides rose 13 percent to 610 in 2007 after reaching a series low of 540 in 2006.
• The number of fatal workplace injuries among protective service occupations rose 19 percent in 2007 to 337, led by an increase in the number of police officers fatally injured on the job.
• Fatal occupational injuries incurred by non-Hispanic Black or African American workers were at the highest level since 1999, but fatal work injuries among Hispanic workers were lower by 8 percent in 2007.

Workplace Injuries and Illnesses in 2006

Nonfatal workplace injuries and illnesses among private industry employers in 2006 occurred at a rate of 4.4 cases per 100 equivalent full-time workers—a decline from 4.6 cases in 2005. Similarly, the number of nonfatal occupational injuries and illnesses reported in 2006 declined to 4.1 million cases, compared to 4.2 million cases in 2005. These findings were reported today by the Bureau of Labor Statistics (BLS) of the U.S. Department of Labor.

What is the purpose of this course?

This course introduces you to basic accident investigation procedures and describes accident analysis techniques. Throughout the course, you'll be taking what you've learned throughout the course to analyze a hypothetical accident!

The challenge to any accident investigator is to report the findings in a well-thought-out manner to ensure management will adopt recommendations for improving its safety management system, thus solving problems long-term. It's a common struggle trying to overcome long-held perceptions about safety and how accidents occur. Management perceptions and subsequent actions reflect both traditional and progressive approaches. Let's take a look at old and new management thinking about accidents.

Old Theory - Worker Error Old thinking about the causes of accidents assumes that the worker makes a choice to work in an unsafe manner.

It implies that there are no outside forces acting upon the worker influencing his actions and that there are simple reasons for the accident. Old thinking also considers accidents as solely resulting from worker error: A lack of "common sense." Actually, common sense, is an invalid concept. No one has common sense. Rather we will have unique sense based on individual experience, education, etc. Assuming common sense also allows management to place all blame for accidents squarely on the shoulders of the employee. The employee is "the problem." So, to prevent accidents, the employee must work more safely. This thinking results in blaming and short-term fixes that are inefficient, ineffective, and in the long run more expensive to implement and maintain.

New Theory - Systems Approach The systems approach takes into account the dynamics of systems that interact within the overall safety program.

It concludes that accidents are considered defects in the system. People are only one part of a complex system composed of many complicated processes (more than we realize). Accidents are the result of multiple causes or defects in the system. It becomes the investigator's job to uncover the root causes (defects) in the system. Fixing the system, not the blame, is the heart of the investigation. To prevent accidents, the system must work more safely. This line of thinking results in long-term fixes that are actually less expensive to implement and maintain.

What is an accident?

An accident is the final event in an unplanned process that results in injury or illness to an employee and possibly property damage. It is the final effect of multiple causes.

An "event," occurs when one "actor" (one person/thing) performs an "action" (does something). In this definition, a person or thing will do something that results in a change of state. Accidents are processes that culminate in an final event that causes injury or illness. An accident may be the result of many factors (simultaneous, interconnected, cross-linked events) that have interacted in some dynamic way.

Why conduct an "investigation"?

The answer to this question is key to the success of the entire program. Does your organization conduct accident investigations for the same reason as OSHA? To determine the purpose of a process, it's important to look at the "output" of that process. The fatality investigation report is the output of the investigation process, so let's take a look at the sample given in OSHA Instruction CPL 2.113, Appendix C:

MEMORANDUM FOR: Regional Administrator FROM: Area Director SUBJECT: Notification of Results of Fatality Investigation The following information supplements the OSHA-170, regarding investigation of the accident at Farmers Gin Company, Inc., which occurred on June 15, 1995. Establishment Information: Farmers Gin Company, Inc., located at Grainfield Road, Grossfield, USA, has no previous inspection history. The company has a work force of 32 employees and operates on a seasonal basis, usually June to November. Family Involvement: The next of kin information was obtained from the company and the CSHO telephoned to verify the information and advise the family that an investigation is in progress. The standard information letter was sent. There has been no further Contact from the family. Union Involvement: There is no union at this location. Proposed Action: Issue citations for serious and other violations of machine guarding, open floor holes, hazard communication and recordkeeping with a penalty total of $5,475. A 5(a)(1) letter outlining the hazards to be corrected which were not clearly addressed by 29 CFR 1928 Safety and Health Standards for agriculture and for which other OSHA Standards are not applicable will also be mailed to the company. The six month date for this case is December 15, 1995

The message contained in this document is that, as required by the OSHA Act of 1970, OSHA agencies conduct accident investigation primarily to determine if violations in OSHA law caused the accident: To establish employer liability - place blame, if you will. This is OSHA's mandate. This is not your organization's mandate.

The employer's mandate: Analyze to fix the system...Don't investigate to fix the blame

Unfortunately, some employers believe that the investigation process ends once liability has been established. The problem, here, is that once the purpose of the analysis process has been achieved, analysis stops. When employers investigate to place blame, effective analysis to fix the system generally does not generally occur.

According to OSHA's Safety & Health Program Management Guidelines, the employer's primary purpose for investigating accidents is primarily, "so that their causes and means for preventing repetitions are identified."

OSHA goes on to say this about the investigation process:

"Although a first look may suggest that "employee error" is a major factor, it is rarely sufficient to stop there. Even when an employee has disobeyed a required work practice, it is critical to ask, "Why?" A thorough analysis will generally reveal a number of deeper factors, which permitted or even encouraged an employee's action. Such factors may include a supervisor's allowing or pressuring the employee to take short cuts in the interest of production, inadequate equipment, or a work practice which is difficult for the employee to carry out safely. An effective analysis will identify actions to address each of the causal factors in an accident or "near miss" incident."

Bottom line. The output of the employer's accident investigation process should not end with merely identifying violations of employer safety rules. The end product should identify safety management system weaknesses. In the most effective employer accident investigations, the question of liability is addressed only if an honest evaluation concludes no safety management system weaknesses exist.

Are accidents always unplanned?

We like to think that accidents are unexpected or unplanned events, but sometimes, that's not necessarily so. Some accidents result from hazardous conditions and unsafe behaviors that have been ignored or tolerated for weeks, months, or even years. In such cases, it's not a question of "if" the accident is going to happen: It's only a matter of "when." But unfortunately, the decision is made to take the risk.

A competent person can examine workplace conditions, behaviors and underlying systems to predict closely what kind of accidents will occur in the workplace. Technically, we can't say an accident is always unplanned. Like any system, a safety management system is designed perfectly to produce what it produces. Consequently, written safety plans may be (unintentionally) designed such that they create circumstances that cause accidents.

In companies that decide to take the risk, it's likely their attitude about accidents is that, "accidents just happen; there's nothing we can do about them." Of course, that's an unacceptable notion in any effective safety culture. Employers with a healthful attitude about accidents consider them to be "inexcusable," and demand that hazards be corrected before they cause an accident.

Accidents and incidents

Accidents are part of a broad group of events that adversely affect the completion of a task. These events are incidents. For simplicity, the procedures discussed in this course apply most appropriately to accidents, but they also applicable to all incidents in general.

Characteristics of an effective accident investigation program

• The program will be guided by standard written procedures. It's important to make sure procedures are clearly stated and easy to follow in a step-by-step fashion.

• Clearly assigned responsibility for accident investigation. It's up to the employer to determine who conducts accident investigations. Usually a supervisor, management/labor team, or safety committee member conducts the investigation. Whoever conducts the investigation, needs to understand his or her role as an accident investigator. Usually, two heads work better than one, especially when gathering and analyzing material facts about the accident. We recommend a team approach.

• All accident investigators will be formally trained on accident investigation techniques and procedures. Investigators may attend accident investigation training presented by OSHA, private educational institutions, or in-house training conducted by a qualified person.

• Accident investigation must be perceived as separate from any potential disciplinary procedures resulting from the accident. The purpose of the accident investigation is to get at the facts, not find fault. The accident investigator must be able to state with all sincerity, that he or she is conducting the investigation only for the purpose of determining cause, not blame.

• The accident investigation report will be in writing and will make sure that the surface causes and root causes of accidents are addressed. Most accident reports are ineffective precisely because they neglect to uncover the underlying reasons or factors that contribute to the accident. Only by digging deep, can you eliminate the hazardous conditions and work practices that, on the surface, caused the accident.

• The accident investigation report will make recommendations to correct hazardous conditions and work practices, and those underlying contributing factors that allowed them to exist. In many instances, the surface causes for the accidents are corrected on the spot, and will be reported as such. But the investigator must make recommendations for long-term corrections in the safety and health system to make sure those surface causes do not reappear.

• Follow-up procedures to make sure short and long-term corrective actions are completed.

• An annual review of accident reports. A couple of safety committee members evaluate accident reports for consistency and quality. They must make sure root causes being addressed and corrected. Information about the types of accidents, locations, trends, etc., can be gathered.

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