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)
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.
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:
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1. An accident is _____.
a. the final event in a series of eventsAn 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.
2. This type of accident is likely to occur if a worker carries a box that is too heavy.
a. OverexertionOf 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 businessTraditional 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.
4. Traditional causation theory assumes accidents are caused by _____.
a. a lack of trainingThe systems approach to causation takes into account the dynamics of multiple variables that interact within the overall safety management system.
5. In the systems approach, accidents are assumed to be caused by _____.
a. a lack of common senseWhy 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:
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.
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. processAs 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:
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.
7. OSHA conducts accident investigations to primarily determine _____.
a. the employer's system weaknesses processUnfortunately, you may have the impression that the purpose of your investigation is the same as OSHA's mandate. Here's the problem with that:
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:
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 causesAn 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.
Throughout the remaining course modules, we'll discuss a proven seven-step process for effectively investigating accidents. The seven steps are:
9. What is an important characteristic of an effective accident investigation program?
a. Surface causes are corrected on the spotRead 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.