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 result or effect of a number of surface and root causes.
If your company is in the private sector, and a serious accident or fatality occurs, you may be required to report it to your State or Federal OSHA office.
OSHA Standard 1904.39, Reporting fatalities, hospitalizations, amputations, and losses of an eye as a result of work-related incidents to OSHA, details the specific requirements.
Within eight (8) hours after the death of any employee as a result of a work-related incident, you must report the fatality to the Occupational Safety and Health Administration (OSHA), U.S. Department of Labor.
Within twenty-four (24) hours after the in-patient hospitalization of one or more employees or an employee's amputation or an employee's loss of an eye, as a result of a work-related incident, you must report the in-patient hospitalization, amputation, or loss of an eye to OSHA.
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An accident isn't just an event that you can lump into one big category. In reality, there are many different types of accidents. Let's take a look at a partial list.
An effective accident investigation 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. The effective program will include the following elements:
The accident investigation process we will discuss in this course will make sense if you understand that ultimately, the purpose of the investigation is to improve the safety management system. Conducting the investigation for any other reason will likely result in ineffective solutions. In this course, we'll introduce a seven-step process for conducting accident investigations.
The first step in an effective accident investigation procedure is to secure the accident scene as soon as possible so that we can accurately gather facts. At this point, you are not yet interested in what "caused" the accident. Instead, you should focus on making the accident scene secure so that you can gather as much pertinent information as possible.
To secure the accident scene, simply use yellow caution tape, place warning cones, or post a guard to keep people away.
Don't start documenting the scene until it is safe to do so. As the accident investigator, you don't want to get in the way of emergency responders. It's also not safe to start if hazards have not been properly mitigated.
Once the accident scene has been roped off, it's important to immediately begin gathering evidence from as many sources as possible during an investigation. You want to gather data that will help you determine what happened, how it happened, and why it happened.
You won't be able to document the scene effectively unless you come prepared, so make sure you have put together an accident investigation kit for use during the investigation. As you'll learn, there are many ways to document the scene, so it may become quite difficult for one person to effectively complete all actions.
The most effective strategy is to document as much as possible, even if you don't think the information may be relevant. It's easy to discard clues or leads later if they prove to not be useful to the investigation. It's not at all easy to dig up material evidence late into the investigation.
After you have initially documented the accident scene, the next step is to start digging for additional details by conducting interviews. This activity is perhaps the most difficult part of an investigation. The purpose of the accident investigation interview is to obtain an accurate and comprehensive picture of what happened. Remember, you're conducting an accident investigation, not a criminal investigation. The last thing to do in the interview is to come down hard (be accusatory) on an interviewee.
So let's take a look at some effective techniques that will assure you get the facts. An important aspect of your job, as the interviewer, is to construct a composite story or "word picture" of what happened using the various accounts of the accident and other evidence. So, let's review some effective interviewing techniques:
So far, you have collected a lot of factual data and it's strewn all over your desk. The task now is to turn that data into useful information. You've got to somehow take this data and make some sense of it.
It's important to know that you're not gathering all of this information just to conduct an assessment of what was and was not present immediately prior to the accident. You're actually conducting an analysis to determine specifically how surface causes (behaviors and conditions), and the underlying root causes (system weaknesses) contributed to the accident. To better understand this, let's take a closer look at what the process of "analysis" is.
Webster defines analysis as the, "separation of an intellectual or substantial whole into its parts for individual study."
The accident is a complicated process of individual events leading up to and including the main event. When an accident occurs, we need to separate or "break down" the "whole" accident into its component "parts" for study to determine how they contributed to the accident: the main event.
The accident investigator's challenge is to effectively assess each event to identify the presence or absence of behaviors and conditions, and then analyze those behaviors and conditions in each event to determine if and how they contributed to the accident. To do this we need to make some basic assumptions about the factors that cause or contribute to accidents.
In developing a sequence of events, the challenge is to take the information gathered and arrange it so that we can accurately determine what initial conditions and/or actions transformed the planned work process into an unintended accident process.
Each event in the unplanned accident process is composed of an actor and an action, so let's take a look at each.
It's important to understand that when describing an event in writing, first identify the actor and then tell what the actor did. Remember, the actor is the "doer," not the person or object being acted upon or otherwise having something done to them. For instance, take a look at the event statement below:
In the example above, "Bob" is the actor and "unhooked" describes the action. First we describe the actor...Bob. Next, we describe the action...unhooking. The lifeline and harness, although "objects" are not actors because they are not performing an action. Rather, something is being done to them. Also note that the statement is written in active tense.
Our challenge at this point in the investigation process is to accurately arrange the events to determine their correct sequence leading up to the accident so that we can more effectively understand why the accident event, itself, happened. Once the sequence of events is developed, we can then study each event in the sequence to determine the related causal factors below.
To get a good idea of what the sequence of events looks like, review the short example below:
It's important the sequence of events clearly describe what occurred so someone who is unfamiliar with an accident is able to "see it happen" as they read the narrative.
Click on the image to the right to see how you can use cards to visually develop the sequences of events. Describe each single event on the front of the card and any additional source information on the back. Each card will indicate the actor and action. Attach any photos you take to the card. Arrange the cards on your desk or a wall in the proper sequence.
If an event is hard to understand, it may be that the description is too vague or general. The solution to this problem is to increase the detail. We can use two strategies to increase detail:
Well, that was a short, but informative, introduction to the idea of constructing the sequence of events. Just remember, the accuracy of your investigation will be greater by following this procedure. It is now time to answer your final quiz question and check your answers below.
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