Now that you have accurately assessed and analyzed the facts related to the accident and developed effective corrective actions and system improvements, you must report your findings to those who have the authority to take action. In this module, we'll cover the procedure for effectively reporting the facts.
Never forget that your primary objective, as an accident investigator, is to uncover the surface causes and the contributing root causes. It is not be your job to conduct the investigation to establish who is to blame: that's playing the OSHA game if you do. In fact, if your analysis of the facts surrounding the accident has uncovered root-cause system weaknesses, justification for employee discipline does not exist because management has not fulfilled its OSHA-required responsibilities. Your challenge is to be as objective and accurate as possible.
Your findings, and how you present them, will shape perceptions and subsequent corrective actions. If your report arrives at conclusions such as"Bob should have used common sense," or "Bobbie forgot to use PPE," it won't be effective at all. If your report concludes with accusatory statements, it will be unlikely result in system improvements that permanently eliminate the surface causes. It's also likely that similar accidents will occur. Bottom line: If the accident investigation doesn't help to fix the system, it has most likely been a waste of time and effort. Okay, we'll' get off our soapbox. Let's look at the report.
Click the button to see examples of OSHA Fatal Fact reports that address both surface and root causes. Notice, no mention of who is to blame in the reports.
OSHA's Fatal Facts describe cases that are representative of employers who failed to identify and correct hazardous working conditions leading to fatalities at their worksites. The documents offer ideas on how to correct these hazards and educate workers about safe work practices.
One of the reasons an accident investigation might fail to help eliminate similar accidents, is that the report form is poorly designed. Some poorly designed forms actually make it quite difficult to get beyond identification of only surface causes: root causes are often ignored.
Let's take a look at one format that is designed to emphasize root cause analysis. Take a look at a sample accident report. This is a report format similar to that used by OSHA accident investigators in conducting workplace accident investigations, but it goes further. This form includes the identification of safety management system weaknesses and recommended improvements. You may want to print this form while we discuss the various sections.
This section contains background information that answers questions about who the victim is, and the time, date, location of the accident, as well as other necessary details. Make sure you obtain all of this information for possible later reference.
This section presents a descriptive narrative of the events leading up to, including and immediately after the accident. It's important that the narrative paint a vivid "word picture" so that someone unfamiliar with the accident can clearly see what happened.
Take a look at a sample Section II Description of the accident.
The findings section describes the hazardous conditions, unsafe behaviors and the system weaknesses your analysis has uncovered. Each description of a surface or root cause will also include justification for the finding. The justification will explain how you came to your conclusion.
Unfortunately, the most common failure found in accident reports is that they address only surface causes. Consequently, similar accidents recur. These report forms may have a format that "forces" the investigator to list only surface causes for accidents. The form does not "report" the system weaknesses associated with each surface cause. Consequently, the investigator believes the job is done without ferreting out the system weaknesses representing the root causes.
Other forms may actually require the investigator to indicate the status of employee negligence. Now, how can the accident investigator assure an interviewee or any other employee that the purpose of the analysis process is to "fix the system -- not the blame," when the report form shouts "negligent"?
To complete this section, just state the facts: The hazardous conditions, unsafe behaviors, practices, and inadequate or missing programs, policies, plans, processes and procedures that produced them. Be sure to write complete descriptive sentences. Not short cryptic phrases.
Take a look at this sample Section III: Findings and Justifications.
If root causes are not addressed properly in Section III of the report, it is doubtful recommendations in this section will include improving system inadequacies. Effective recommendations will describe ways to eliminate or reduce both surface and root causes. They will also detail estimated costs involved with implementing corrective actions. Let's take a closer look at effective recommendation writing. Review this sample Section IV. Recommendations.
This section contains a brief review of the causes of the accident and recommendations for corrective actions. In your review, it's important to include language that contrasts the costs of the accident with the benefits derived from investing in corrective actions. Including bottom-line information will ensure that your recommendation will be understood and appreciated by management.
The accident investigation report should be considered an open document until all actions have been completed. These include, but are not limited to:
That's it. Finish that last quiz question below and check your results!
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