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Course 702 - Effective Accident Investigation

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Safety guides and audits to make your job as a safety professional easier

Developing Solutions

Educate management on the benefits.

Effective Recommendations

An accident investigation is generally thought to be a "reactive" safety process because it is initiated only after an accident has occurred. However, if we propose recommendations that include effective immediate corrective actions and system improvements, we may transform the investigation into a valuable "proactive" process that helps to prevent future injuries. In this module we'll explore tips and tactics for making effective recommendations that "sell" safety improvements.

Once you have developed engineering and administrative controls to eliminate or reduce injuries, the challenge becomes convincing management to make changes. Management will most likely understand the importance of taking corrective action and readily agree to your ideas. However, if management doesn't quite understand the benefits, success becomes less likely. Your ability to present effective recommendations becomes all that more important. This module will help you learn how to put together "an offer they can't refuse," by emphasizing the long-term bottom-line benefits of the corrective action you are recommending.

Why Decision-makers Don't Respond Quickly

When recommendations are not acted upon, it is usually because the decision-maker does not have enough information to make a judgment. To speed up the process and to improve the approval rate, you must learn to anticipate the questions the decision-maker will ask in order to sign off on the requested change. This being the case, the more pertinent the information included in the presentation, the higher the odds are for approval.

Do it Right!

It's important to divide your recommendations into the categories below:

  1. Immediate or short-term corrective actions to eliminate or reduce the hazardous conditions and/or unsafe behaviors related to the accident.
  2. Long-term system improvements to create or revise existing safety policies, programs, plans, processes, procedures and practices identified as missing or inadequate in the investigation.

Some employers may assign the responsibility for making recommendations to safety directors or other managers. However, you, as the accident investigator, may be required to take on this very important responsibility. Consequently, it's a good idea to know where to start, and how to write strong recommendations.

One tip up front: If you find the responsibility is yours, be sure to get the help of experts if you are unsure how to proceed. OSHA consultants, other safety professionals or your workers' compensation insurer can be a great source for help.

The Hierarchy of Control Strategies

The Hierarchy of Controls
(Click to enlarge)

Let's discuss the six hazard control strategies that I've grouped into the two categories described in module 7.2. As a safety professional, you need to be familiar with these basic strategies. You can be sure they'll be on the exam :-)

Higher Priority Strategies that Control Hazards

1. Elimination: Totally eliminate the hazard. (no hazard - no accident) Why is this control strategy our top priority? Employing an elimination control has the potential to completely remove the hazard. We're somehow changing a thing/condition in the workplace. And as we all know...

No hazard, no exposure = no accident.

2. Substitution: Substitute the hazard with a less hazardous condition, process or method. Some basic examples are substituting a toxic chemical with a non-toxic chemical or replacing an old poorly-designed machine with a new model.

3. Engineering controls: See if any of the strategies below are used in your workplace.

  • Design: Example - Design a tool so that it reduces the likelihood of a strain or sprain.
  • Redesign: Example - Change the design of a machine so that dangerous moving parts or electrical circuits are out of reach.
  • Enclosure: Examples - Place a hood over a noisy printer. Place a machine guard around a dangerous moving part.

It's important to note that OSHA expects the employer to first try to eliminate, substitute or engineer the hazard so that it can no longer cause a serious injury. For instance, if a machine is producing unacceptable noise, OSHA would expect the employer to first eliminate or reduce the noise level to acceptable levels using one or more of these three strategies. In this instance, an engineering control such as enclosure might work.

Lower Priority Strategies to Control Exposure and Behaviors

4. Warnings: Signs and labels that tell employees to "Keep Out," "May cause eye irritation" etc., are used to warn employees about hazards. Note: Employees do not necessarily follow "posted" rules and warnings. They usually only follow "enforced" rules and warnings. Think about that the next time you're driving down the highway. Do you drive at the posted speed limit, or the enforced speed limit? Enough said.

5. Administrative controls:This control strategy also attempts to reduce exposure by limiting the duration of exposure to a hazard. To do this, the employer may employ job rotation and schedule work/breaks. This is also accomplished through improving work procedures and practices. Example - Develop and use a safe work procedure for preventative maintenance on air conditioning equipment.

6. Personal protective equipment (PPE): Some jobs require PPE by law. PPE places a barrier between workers and the hazard. This control strategy is used in conjunction with the other control strategies. It should not be used to replace them. When other controls do not adequately eliminate or reduce hazards, PPE may be needed in addition to those strategies. Remember, PPE does not eliminate or reduce the hazard itself, it merely sets up a barrier between you and the hazard. And, to be successful, it is highly dependent on the employee's behavior.

The final three control strategies are less effective than elimination, substitution, and engineering controls in the long term because they do not remove the hazard, itself. Rather, they merely attempt to reduce exposure to hazards by controlling behavior - attempting to change "things we do or don't do."

As long as employees "behave" or comply with the warning signs, administrative controls and wear PPE when required, these control strategies will work. However, human beings are natural risk-takers, and it's "normal" for us to want to work in the most efficient manner. Sometimes safe work procedures are not perceived as efficient, so we may not want to use them.

Therefore, managers must regularly supervise employees to make sure they comply with warning signs, procedures and PPE requirements. Think about the "Murphy's Law" principle below. It certainly applies to safety. Here's an important principle to remember:

"Any system that relies on human behavior is inherently unreliable."

The Hierarchy of Controls, when used separately or in combination, may be quite effective in eliminating or greatly reducing the probability of a future similar accident. However, to make sure long term risk reduction is achieved throughout the entire company, safety management system improvements must be made, so let's discuss this important topic.

Recommend System Improvements

The surface causes for accidents actually represent the symptoms of underlying safety management system weaknesses. This cause-effect relationship is so important to understand that I'll say it again: the behaviors and conditions that caused the accident are, themselves, usually the effects of deeper root causes. This is a fact.

Consequently, your first assumption, as an accident investigator, should be that root causes have contributed to an accident, and your job is to find them. Your first basic assumption should never be that an accident is simply the result of surface causes. Once in a while, you'll find that an accident was solely the result of a "personal failure," but that won't be often: in fact, it will be rare in most organizations.

Therefore, make every effort to improve safety management system components to ensure long term workplace safety in your company. As we learned in the last module, the most successful accident investigator is actually a systems analyst. Making safety management system improvements might include some of the following examples:

  • including "safety" in a mission statement;
  • improving safety policy so that it clearly establishes responsibility and accountability;
  • changing a work process so that checklists are used that include safety checks;
  • including hands-on practice as part of the safety training program;
  • revising purchasing policy to include safety considerations as well as cost; and
  • changing the safety inspection process to include all supervisors and employees.

"GIGO" or "QIQO"?

Here's another idea to think about. When managers do not respond to a recommendation, it may be that they do not have enough useful information to take action. You've probably heard of the GIGO principle -- "If you put garbage in, you'll get garbage out." That also works on the flip side. Quality in - Quality out or "QIQO". Useful information presented to management is more likely to result in decisions that take effective action to make long-lasting positive improvement.

Six Key Questions

To help make sure your recommendations include quality short-term corrective actions and long-term safety management system improvements, answer the following six primary questions. Doing this will help you be able to answer any questions management may have at the time you present your recommendations, and it will help you justify taking action by appealing to management's need to fulfill their obligations.

Answer the following six questions to help develop and justify recommendations.

  1. What exactly is the problem?
    • What are the specific hazardous conditions and unsafe work practices that caused the problem?
    • What are system components - the inadequate design or implementation of safety management programs, policies, plans, processes, procedures and general practices that allowed the conditions and behaviors to exist?

Answer the following six questions to help develop and justify recommendations.

1. What exactly is the problem?

  • What are the specific hazardous conditions and unsafe work practices that caused the problem?
  • What are system components - the inadequate design or implementation of safety management programs, policies, plans, processes, procedures and general practices that allowed the conditions and behaviors to exist?

Six Key Questions (Continued)

2. What is the history of the problem?

Have similar accidents occurred previously? If so, you should be able to claim that the probability for similar accidents is highly likely to occur. What are previous direct and indirect costs for similar accidents? How have similar accidents affected production and morale?

  • Describe how it has affected direct, budgeted or insured costs related to past injuries or illnesses.
  • How has it affected indirect, unbudgeted or uninsured costs related to loss of efficiency and/or productivity and employee morale?

3. What are the solutions that would correct the problem?

What are the specific engineering, administrative and PPE controls that, when applied, will eliminate or at least reduce exposure to the hazardous conditions? What are the specific system improvements needed to ensure a long term fix?

4. Who is the decision-maker?

Who is the person who can approve, authorize, and act on the corrective measures? What are the possible objections that he/she might have? What are the arguments that will be most effective in overcoming objections?

Six Key Questions (Continued)


5. Why is the decision-maker doing safety?

It's important to know what is motivating the decision-maker. Is the decision-maker doing safety to fulfill one or more of the following imperatives?

  • Fulfill the legal obligation? You may need to emphasize possible penalties if corrections are not made. Common in a fear-driven culture.
  • Fulfill the fiscal obligation? You may want to emphasize the costs/benefits. Common in an achievement-driven culture.
  • Fulfill the social obligation? You may want to emphasize improved morale, public relations. Common in a humane corporate culture.

Employer motivation will determine the nature of the objections to the recommendations you submit. What are possible objections the decision-maker might raise? Whatever they might be, it's important you understand their motivations so that you are better prepared with responses that satisfy the decision-maker's needs.

  • List the possible decision-maker objections.
  • List the arguments that are most likely to be successful against those objections.
  • As a last resort: Review employer obligations under administrative law.

Six Key Questions (Continued)

6. What will be the cost/benefits of corrective actions and system improvements?

  • What are the costs that might result if/when OSHA inspects? Answer this question to address the legal obligation your employer has.
  • What is the estimated investment required to take corrective action, and how does that contrast with the possible costs if corrective actions are not taken? Answer this question to address the fiscal obligation your employer has.
  • What is the "message" sent to the workforce and the community as a result of action or inaction? Answer this question to address the social obligation your employer has.

It's important to have the answers to all of these questions ready for the decision maker.

The maintenance supervisor may be able to help you estimate the investment required for recommended corrective actions.

More ideas to consider:

  • These options must also eliminate or reduce the hazards and the exposures;
  • Try to include at least three (real world) but only one or two for this exercise;
  • Briefly list low/high cost solutions that eliminate the problem now/soon;
  • Briefly list low/high cost solutions that reduce the problem now/soon;
  • Briefly list the advantages and disadvantages of each solution.

Estimating Direct and Indirect Costs

The direct and indirect accident costs represent the "benefits" (money saved) if we adopt the recommended actions. The benefits are realized because we will not have to pay the costs over the foreseeable future. To help estimate direct and indirect costs, you can use OSHA's Safety Pays software. This is an excellent software tool that determines direct and indirect accident costs. It also calculates the business volume required to cover those costs. The data is based on 52,000 lost-time claims submitted to a major workers compensation insurance carrier.

What is the ratio between direct (insured) and indirect (uninsured) costs in your scenario?

The indirect costs for accidents will usually be greater than the direct costs. Indirect costs can range from 1 to 20 times greater than the direct costs, depending on the severity of the injury. For every $1 spent in direct costs, you' ll pay an additional $1 to $20 in indirect costs. For every one dollar spent in direct costs, you'll pay $1.50 in indirect costs. To determine the ratio between the indirect and direct costs, use the following equation:

Let's say an employee injured his hand (requiring surgery) while working around the machinery in our scenario. If the indirect (uninsured) accident cost totals $160,000 and the direct (insured) cost is $40,000, the ratio of indirect to direct costs will be 4 to 1. This ratio just happens to be the average ratio between indirect and direct accident costs in the USA.

Ratio Between Total Accident Costs to Direct Costs

This ratio is a little more dramatic than contrasting the indirect costs with direct costs. It helps emphasize the fact that direct costs are actually just the tip of the iceberg. To determine this ratio, use the following equation:

In this case, if the indirect (uninsured) cost totals $160,000 and the direct (insured) cost is $40,000, the ratio of total costs to direct costs will be $200,000/$40,000 = 5:1. What will XYZ have to earn in sales to pay back this lost money? Well, if XYZ has a 5% profit margin, they'll have to earn 20X the total accident cost, or $4 million in sales!!!

Return on the Investment (ROI)

To determine ROI, it's necessary to estimate the amount of the initial investment required to complete corrective actions and safety system improvements. Once the initial investment is determined, use the equation below to determine ROI.

Let's say our investment to train all employees on lockout/tagout procedures, machine guarding and PPE while working around machinery will be $20,000. If our total accident cost is $200,000, our ROI will be 1000%!!! Now that's a return.

Provide Options

Another good recommendation strategy is to provide the decision-maker with alternative corrective actions. This will increase the probability that the decision-maker will choose one of the alternatives. Your options might follow the logic below:

  1. First option -- If we had all the money we needed, what could we do? Eliminate the hazard with primarily engineering controls. Additional administrative controls if required.
  2. Second option -- If we have limited funds, what would we do. Eliminate the hazard with primarily administrative controls. Engineering controls if required.
  3. Third option -- If we don't have any money, what can we do? Reduce exposure to the hazard with administrative controls and/or PPE.

Well, how was that? Pretty tough... but the whole idea is to help you get through the rough parts now, so that you will be able to develop and present an effective recommendation to top management the first time! It is time to take the review quiz, so let's go.


Before beginning this quiz, we highly recommend you review the module material. This quiz is designed to allow you to self-check your comprehension of the module content, but only focuses on key concepts and ideas.

Read each question carefully. Select the best answer, even if more than one answer seems possible. When done, click on the "Get Quiz Answers" button. If you do not answer all the questions, you will receive an error message.

Good luck!

1. When making recommendations, we need to propose immediate _____ actions and _____ improvements.

2. Which of the following is an administrative control?

3. Which hazard control strategy is considered most effective?

4. Which of the following is considered an immediate corrective action?

5. How does the "GIGO" principle apply to safety system improvements?

Have a great day!

Important! You will receive an "error" message unless all questions are answered.