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)
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.
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:
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.
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 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.
The systems approach takes into account the dynamics of multiple variables that interact within the overall safety management system.
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:
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.
As you are surely aware, OSHA conduct many accident investigations each year. You can review accident summaries at the OSHA Fatality and Catastophe Investigation Summaries webpage.
Remember, the findings in 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.
Unfortunately, some employers believe that the investigation process ends once the blame has been established. Here's the problem with that belief:
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."
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 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.
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:
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