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Course 702 - Effective Accident Investigation

The Basics

A maze where you must start from the finish and find your way to the start
Start the investigation at the finish and work backwards.

The best metaphor for investigating accidents is a simple maze. For instance, if you ask several people to solve a maze as quickly as possible and ask the "winner" how they did it, invariably the answer will be that they worked it backwards, from the finish to the start. Most mazes are difficult working from the start to the finish, but are simple working from the finish to the start. Like a maze, accident investigations look backward. What is uncertain for people working forward through a maze becomes clear to the investigator who looks backwards from the accident. (Source: DOE)

What is an Accident?

An accident is the final event in an unplanned series of unique events that results in an injury or illness to an employee and may include property damage. It is the final result or effect of a number of surface and root causes.

  • An "event," occurs when one "actor" (a person or thing) performs an "action" (does something).
  • A person or thing (equipment, tools, materials, etc.) will do something that results in a change.
  • 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 an employee injury. For simplicity, the procedures discussed in this course apply most often to accidents, but they can also apply to all incidents. Think of it this way:

Accidents cause injuries: incidents do not.

Read the material in each section to find the correct answers to each of the questions. After answering all questions, click the "Check Quiz Answers" button to see your score and a list of missed questions. To correct a question, return to the question, review the material, change your answer, and return to the last section page. Click the "Check Quiz Answers" again to recheck the results.

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1. An accident is _____.

a. the final event in a series of events
b. the end result of expected outcomes
c. the expected outcome of unexpected events
d. the final planned event after a series of expected events

Accident Types

Safety Memo - The Accident Cascade.

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 their clothing or equipment is caught on an object that is either moving or stationary. This may cause the person to lose their balance and fall, be pulled into a machine, or suffer some other harm.
  • Caught-in: A person or part of them 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 they are standing or walking on.
  • Fall-to-below: A person slips or trips and falls to a level below the one they are walking or standing on.
  • Overexertion: A person over-extends or strains themselves 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:
  • Overexposure: Over a period of time, a person is exposed to harmful energy (noise, heat), lack of energy (cold), or substances (toxic chemicals/atmospheres).

2. This type of accident is likely to occur if a worker carries a box that is too heavy.

a. Overexertion
b. Bodily reaction
c. Fall-to-below
d. Fall-to-surface

Are Accidents Always Unplanned?

Employees cleaning windows using boatswain chairs and fall protection
Accidents are unplanned, or are they?

Of course,accidents are unexpected, unplanned events, and unintentional. However, some accidents occur after being ignored or tolerated for weeks, months, or even years. In those cases, the decision is intentionally made to take the risk.

Technically, we can't say an accident is always unplanned. Because the safety management system is designed perfectly to produce what it produces, managers can design and deploy policies, processes, procedures and practices that almost guarantee accidents will happen, especially "when the going gets tough." Safety may no longer be prioritized as "number 1."

As an example, if a work crew is behind schedule, they might be pressured by management to hurry and take unsafe shortcuts to make sure they make deadlines. "Hurry" is one of top reasons accidents occur.

Companies that decide to take the risk, likely have an opinion that "accidents just happen; there's nothing we can do about them." Of course, that's an unacceptable idea in an 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.

3. Companies that have healthful attitudes consider accidents _____.

a. to be just the cost of doing business
b. as unavoidable
c. to be inexcusable
d. as beyond their control

Traditional Causation Theory

Employee wearing a safety vest and hard hat and pointing to his head
If he just had common sense.

Traditional accident causation theory implies that there are few outside factors contributing to accidents acting upon the worker and that there are simple reasons for the accident. It considers accidents as resulting solely from worker error: A lack of "common sense." Actually, common sense is an invalid concept. Actually, common sense is not so common. Rather, we each develop a unique and hopefully "good sense" based on our individual education, training, and previous experience.

  • When we assume employees lack common sense, it allows us to more easily place blame squarely on the shoulders of employees when an accident occurs.
  • The Common sense excuse for accidents infers employees are "the problem." Therefore, "the fix" is to get employees to somehow use common sense: that's an important part of the fix, but much more is required.
  • Thinking that accidents are due to a lack of common sense results in short-term fixes that address only surface causes.
  • In the long run this approach is more expensive to implement and maintain.

4. Traditional causation theory assumes accidents are caused by _____.

a. a lack of training
b. a lack of common sense
c. poor employee attitudes
d. a lack of careful planning

Systems Causation Theory

A chart showing the different elemenst of a health and safety system
Assume the system needs fixing.
(Click to enlarge)

The systems approach to causation takes into account the dynamics of multiple variables that interact within the overall safety management system.

  • The primary assumption the investigator has is that accidents are due to defects in the safety management system.
  • Fixing the system, not the blame, is at the heart of the investigation.
  • Discipline is not appropriate if the safety management system has somehow "failed" employees.
  • Individual behaviors are only one part of a complex system composed of many variables.
  • Accidents are the result of multiple weaknesses or defects in the system.
  • It is the investigator's job to uncover the root causes (defects) in the safety management system.
  • To prevent accidents, system structure, processes, and outcomes must be designed and deployed better.
  • This line of thinking results in long-term fixes that are actually less expensive to implement and maintain.

5. In the systems approach, accidents are assumed to be caused by _____.

a. a lack of common sense
b. safety management system defects
c. defects in human behavior
d. hazardous conditions inherent in the workplace

Why Conduct the Accident Investigation

One employee pointing a finger at another employee
You're guilty!

Why should you conduct an accident "investigation?" The answer to this question is key to the success of the entire process. Here's an important principle to understand:

To determine the actual purpose of a process, look at its final output.

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 recommendations in the final report.

  • If the recommendations include identifying the employee(s) at fault, the purpose of the process is to place blame.
  • If the recommendations focus on identifying and correcting root-cause system safety management system weaknesses, the purpose of the process is to fix the system.

Let's contrast the recommendations in an OSHA accident investigation report with what should be the findings in your report.

6. To determine the actual purpose of an accident investigation, look at its _____.

a. process
b. findings
c. OSHA requirements
d. recommendations
Image of an OSHA Inspector
OSHA inspects to identify violations.

Why OSHA Conducts Accident Investigations

As you are aware, OSHA conducts thousands of accident investigations each year. You can review accident summaries at the OSHA Fatality and Catastrophe Investigation Summaries webpage.

Remember, the proposed actions of an OSHA investigation report is the final output. So, let's look at the sample report given in OSHA Instruction CPL 2.113, Appendix C:

Findings of the Investigation Report
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 _____ Company, Inc.

Proposed Action: (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 proposal 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" (consequences). This is OSHA's mandate: Establish liability and issue penalties as appropriate.

OSHA's mandate is not the same as your organization's mandate.

7. OSHA conducts accident investigations to primarily determine _____.

a. the employer's system weaknesses process
b. the managers who have failed to comply with rules
c. if the employer violated OSHA standards
d. if the employer has complied with equity requirements

Fix the System - Not the Blame

Workers speaking to each other and reviewing a checklist
Work together to fix the system.

Unfortunately, you may have the impression that the purpose of your investigation is the same as OSHA's mandate. Here's the problem with that:

When the purpose of an investigation is achieved,
the analysis stops.

Once you determine who is to blame for the accident, the analysis process is considered complete: it stops and you don't continue the process to fix the root causes in the safety management system.

According to OSHA's Safety and Health Program Management Guidelines), your primary purpose for investigating accidents is to identify their causes and provide means for preventing repetitions.

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 your accident investigation should not merely identify violations of safety rules and assign fault. The end product should identify the underlying root causes: the safety management system weaknesses such as inadequate supervision, training, physical resources, or psychosocial support. Effective accident investigation reports do not address the question of fault. Competent managers (safety, human resource, and supervisory) address the possibility of fault only if the completed accident report cannot identify safety management system weaknesses that contributed to the accident.

8. The end product of an accident investigation should identify the _____.

a. surface causes
b. root causes
c. primary causes
d. actual causes
Conducting Effective Investigation - Montana State Fund

The Accident Investigation Program

An effective accident investigation program is guided by standard written procedures. Procedures are clearly stated and easy to follow in a step-by-step fashion. Click on the button to see important characteristics common in the most effective accident investigation programs.

  • At least two competent persons investigate. Two persons usually work better at gathering and analyzing material facts about the accident.
  • Accident investigators are properly trained on techniques and procedures.
  • The investigation report is written, and address surface causes and root causes of accidents.
  • The accident investigation report makes recommendations to correct hazardous conditions and unsafe work practices, and improve underlying SMS weaknesses.
  • The purpose of the accident investigation is to determine the facts, not the blame. Discipline is a separate issue properly addressed by management/human resources only if contributing root causes have not been uncovered.
  • Surface causes for the accidents are corrected on the spot or as soon as possible. Long-term system improvements are completed in a timely manner.
  • Competent persons evaluate accident reports annually for consistency and quality.
  • Safety personnel annually review and evaluate the investigation program.
  • Information about the types of accidents, locations, trends, etc., is analyzed to improve investigations and prevent future accidents.
  • Everyone is informed of corrective actions and system improvements. Training is conducted as needed.

The Seven-Step Process

Throughout the remaining course modules, we'll discuss a proven seven-step process for effectively investigating accidents. The seven steps are:

  1. Secure the accident scene
  2. Document the accident scene
  3. Conduct interviews
  4. Develop the sequence of events
  5. Conduct surface and root cause analysis
  6. Determine the solutions
  7. Write the report

9. What is an important characteristic of an effective accident investigation program?

a. Surface causes are corrected on the spot
b. It is designed to determine fault
c. Only third-party investigators are used
d. The focus is on determining liability

Check your Work

Read the material in each section to find the correct answer to each quiz question. After answering all the questions, click on the "Check Quiz Answers" button to grade your quiz and see your score. You will receive a message if you forgot to answer one of the questions. After clicking the button, the questions you missed will be listed below. You can correct any missed questions and check your answers again.

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Updated 7/12/2021