The best metaphor for how accidents are investigated is a simple maze. If a group of people are asked to solve the maze as quickly as possible and ask the "winners" how they did it, invariably the answer will be that they worked it from the Finish to the Start. Most mazes are designed to be difficult working from the Start to the Finish, but are simple working from the Finish to the Start. Like a maze, accident investigations look backwards. What was uncertain for the people working forward through the maze becomes clear for the investigator looking backwards. (Source: DOE)
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 result or effect of a number of surface and root causes.
- An "event," occurs when one "actor" (one person/thing) performs an "action" (does something).
- A person or thing (equipment, tools, materials, etc.) will do something that results in a change of state.
- An accident may be the result of many factors (simultaneous, interconnected, cross-linked events) that have interacted in some dynamic way.
Accidents and Incidents
Workplace accidents are part of a broad group of events or occurrences leading to a physical or psychological injury. Workplace incidents adversely affect the completion of a task but do not result in a employee injury. For simplicity, the procedures discussed in this course apply most appropriately to accidents, but they are also applicable to all incidents in general. Think of it this way:
Accidents cause injuries: incidents do not.
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.
- Struck-by. A person is forcefully struck by an object. The force of contact is provided by the object.
- Struck-against. A person forcefully strikes an object. The person provides the force or energy.
- Contact-by. Contact by a substance or material that, by its very nature, is harmful and causes injury.
- Contact-with. A person comes in contact with a harmful substance or material. The person initiates the contact.
- Caught-on. A person or part of his/her clothing or equipment is caught on an object that is either moving or stationary. This may cause the person to lose his/her balance and fall, be pulled into a machine, or suffer some other harm.
- Caught-in. A person or part of him/her is trapped, or otherwise caught in an opening or enclosure.
- Caught-between. A person is crushed, pinched or otherwise caught between a moving and a stationary object, or between two moving objects.
- Fall-To-surface. A person slips or trips and falls to the surface he/she is standing or walking on.
- Fall-To-below. A person slips or trips and falls to a level below the one he/she was walking or standing on.
- Over-exertion. A person over-extends or strains himself/herself while performing work.
- Bodily reaction. Caused solely from stress imposed by free movement of the body or assumption of a strained or unnatural body position. A leading source of injury.
- Over-exposure. Over a period of time, a person is exposed to harmful energy (noise, heat), lack of energy (cold), or substances (toxic chemicals/atmospheres).
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 which decide to take the risk, it's likely its attitude about accidents is, "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 hazards be corrected before they cause an accident.
Old Theory - Worker Error
Old thinking about the causes of accidents assumes that the worker lacks common sense or 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 considers accidents as solely resulting from worker error: A lack of "common sense." Actually, common sense, is an invalid concept. In reality, no one has common sense. Rather, we each develop a unique and hopefully "good sense" based on individual experience and education.
- When we assume common sense is a valid concept, it allows us to more easily place blame for accidents squarely on the shoulders of the employee.
- The Common sense excuse for accidents infers the employee is "the problem." To prevent accidents, the employee must work more safely.
- Thinking that accidents are due to a lack of common sense results in 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 multiple variables that interact within the overall safety management system.
- It assumes accidents are due to defects in the safety management system.
- People are only one part of a complex system composed of many complicated processes.
- 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.
Why Conduct the Accident Investigation (AI)
Why should you conduct an accident "investigation"? The answer to this question is key to the success of the entire AI process. Here's an important principle to understand:
To determine the purpose of a process, look at the final "output" of that process.
What does that mean? It means that to understand what the purpose of the accident investigation process is, you've got to look at the findings in the final report. So, let's contrast the findings in an OSHA AI report with what should be the findings in your AI report.
Why OSHA Conducts an Accident Investigation
As you are surely aware, OSHA conducts many accident investigations each year. You can review accident summaries at the OSHA Fatality and Catastophe Investigation Summaries webpage.
Remember, the findings in an 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
The following information supplements the OSHA-170, regarding investigation of the accident at _____ Company, Inc.
Proposed Action: (The output!) 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.
As you can see, the output was a recommendation to cite and fine the employer. The message in the above OSHA report is that, as required by the OSHA Act of 1970, OSHA conducts accident investigations to primarily determine if the employer violated OSHA standards. OSHA establishes employer liability, places blame, and administers "penalties" (punishment). This is OSHA's mandate:Establish liability and issue penalties as appropriate.
This is not your organization's mandate.... read on...
Investigate & Analyze to Fix the System... Not the Blame
Unfortunately, some employers believe that the investigation process ends once the blame has been established. Here's the problem with that belief:
Once the purpose of the analysis process has been achieved, analysis stops.
When employers investigate to place blame, analysis stops and the employer does not continue an effective analysis process to fix root causes in the safety management system.
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."
|"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 the root causes: the safety management system weaknesses. In the most effective employer accident investigations, the question of liability (fault, blame) should be addressed only if an honest post-investigation evaluation concludes that no safety management system weaknesses contributed to the accident.
Effective Accident Investigation Program
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 the following:
- Usually a supervisor, safety manager, or management/labor team conducts the investigation. 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.
- The 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.
- The accident investigation report will make recommendations to correct hazardous conditions, 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 are being addressed and corrected. Information about the types of accidents, locations, trends, etc., can be gathered.
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