Accident Investigation

Resources - Accident Investigation and Root Cause Analysis

Incident/Accident Analysis

Introduction

The process of analysis is extremely important in identifying and eliminating those conditions, behaviors and system weaknesses that result in workplace accidents. In this module, we'll be discussing the various concepts, principles and procedures related to the analysis process so that you can, hopefully, transform your workplace, as close as possible, into a "risk free" zone.

Fix the system not the blame!

If your safety program fails to eliminate workplace hazards, chances very likely an accident will result. When it does, it's important to conduct an effective accident investigation. Wait a minute! Did I say "investigation"? Well, wash my mouth out with soap. It's important that we get beyond accident investigation and perform an accident "analysis." In most workplaces, the term "investigation" implies that the primary purpose of the activity is to establish liability (blame). That may be why OSHA conducts their investigations, but to be most effective, you can't afford to get stuck in that rut. You've got to conduct this activity for the express purpose of improving your safety management system. The only way to receive any long-term benefit from accident analysis is to make sure system weaknesses are uncovered and permanently corrected.

Remember this graphic from the course introduction? The message is that there is a substantial cost to pay for each and every accident your company has.

Although accident investigation is a valuable and necessary tool to help reduce accident losses, it is always considerably more expensive to rely on accident investigation than hazard investigation as a strategy to reduce losses and eliminate hazards in the workplace. In some cases it may cost hundreds of thousands of dollars more as a result of direct, indirect, and unknown accident costs.

But, when the accident happens...it happens. And it's important to minimize accident costs to the company. This can be done if effective accident investigation procedures are used.

So, let's take a quick look at some basic concepts and then discuss the first steps to take in building an effective accident investigation program.

Accidents just happen...don't they?

Do they? Are they really unexpected or unplanned? If a company has 20 disabling injuries one year, and sets an objective to reduce the accident rate by 50% by the end of the next year, aren't they planning 10 accidents for that year? If they reach that goal, won't they be happy about it...content? "Hey, let's kick our feet up, pat ourselves on the back, and relax!" Is that really acceptable? (Just some food for thought) You can't ever afford to relax, or be content in safety.

Incident and Accident defined

What is the difference between an incident and an accident? We'll use the following definitions for these two terms in this module:

  • An incident is an unexpected event that may result in property damage, but does not result in an injury or illness. Incidents are also called, "near misses," or "near hits."
  • An accident is an unexpected event that may result in property damage, and does result in an injury or illness to an employee.

A typical accident is the result of many related and unrelated factors (conditions, behaviors) that occur sometime, somewhere that somehow all directly or indirectly contribute to the injury event or accident. It is estimated that there are usually more than ten factors that contribute to a serious accident. Other experts state that there is an average of 27 contributing factors. What's the point here? Explaining why an accident occurred may not be an easy task.

Plan the work...work the plan!

When a serious accident occurs in the workplace, everyone will be too busy dealing with the emergency at hand to worry about putting together an investigation plan, so the best time to develop effective accident investigation procedures is before the accident occurs. The plan should include as a minimum procedures that determine:

  • Who should be notified of accident.
  • Who is authorized to notify outside agencies (fire, police, etc.)
  • Who is assigned to conduct investigations.
  • What is the training required for accident investigators?
  • Who receives and acts on investigation reports.
  • What are the timetables for conducting hazard correction.

Accident Scenario: John's hurt bad... fell off a scaffold over at the worksite!

You've just been notified of an injury in the workplace and immediately swing into action. You grab your investigator's kit and hurry to the accident scene. By the time you get there, the EMT's are administering first aid. It's a serious accident so the victim is transported to the hospital. Now it's safe to investigate.

The first task is to secure the accident scene. The easiest way to do this is to place yellow warning tape around the area. If tape is not available, warning signs or guards may be required.

Just the facts, ma'm...just the facts

The next step in the procedure is to gather useful information about what directly and indirectly contributed to the accident. Interviewing eye witnesses to the accident is probably one of the most important techniques in gathering information, but there are many other tools and techniques too.

Gathering background information about the accident may be accomplished in many ways.

Of course you want to get initial statements through interviews with eye witnesses. They can give you much information about the circumstances surrounding the accident. You should tell those who you initially interview that you may conduct follow-up interviews if more questions surface. Interview other interested persons such as supervisors, co-workers, etc.

You should also review any records associated with the accident, including:

  • Training records
  • Disciplinary records
  • Medical records (as allowed)
  • Maintenance records
  • EMT reports
  • Police reports (rare)
  • Coroner's report (fatalities)
  • OSHA 200 Log (past similar injuries)
  • Safety Committee records
  • Take photographs of the scene.
  • Videotape the scene.
  • Make sketches of the scene.
  • Make observations about the scene.
  • Include measurements.

Remember you are gathering information to use in developing a sequence of steps that led up to the accident. You are ultimately trying to determine surface and root causes for the accident. It is not your job, as an accident investigator, to place blame. Just gather the facts.

What happened next?

Now you've gathered tons of information about the accident, and it's piled high on your desk. What do you do with it? It's important that you read through the information initially to develop an accurate sequence of events that led up to and included the accident.

It's important, here, to note that one of the symptoms of conducting accident investigations to determine liability is that not much analysis is conducted once liability can be established. On the other hand, in a fix-the-system culture, analysis is in-depth and the question of liability does not surface until after system weaknesses have been determined. If non exist, then, and only then, is the question of appropriate discipline discussed.

What caused the accident?

The next step is to determine cause. This step may be difficult because you are first searching for the surface causes of the accident, and then, from the clues you uncovered, ultimate the system weaknesses or root causes. Remember, just like the leaves on the plant to the left, surface causes are usually pretty see to see and not too difficult to uncover. However, you may find it takes a great deal more time to accurately "dig up" the underlying safety management system weaknesses, that contributed to the accident.

Surface causes. The conditions and behaviors directly or indirectly producing the accident. A readily apparent reason for an accident/incident that usually appears early in an accident/incident investigation. A long-lasting corrective action does not come from a surface cause. A surface cause leads to a root cause. Primary surface causes directly cause the accident and usually involve the victim an some object or behavior. The secondary surface cause are conditions or behaviors that indirectly contribute to the accident. Secondary surface causes can occur anytime, by any person in the organization, and at any location. Conditions are objects or "states of being." Behaviors describe some sort of action, activity. Examples:

  • Unguarded saw (condition)
  • Horseplay (behavior)
  • Not using hearing protection when required (behavior)
  • Slippery floor (condition)
  • Inadequately trained employee (condition)

Root causes. Underlying system weaknesses that indirectly produce the primary and secondary surface causes leading to the accident incident/accident. The system weaknesses always exist prior to the surface causes that produced the accident. They are the programs, policies, plans, processes, and procedures in any of the seven elements or activity areas in a safety management system. It takes more in-depth investigation and results in long-lasting corrective action that can prevent repetition of the accident. A root cause may be referred to as a "basic" cause in some accident investigation references. Here are some examples of root causes:

  • Inadequate or missing safety training plan.
  • No clearly stated supervision.
  • No inspection procedures.
  • Inadequate hazard reporting process.
  • Inadequate purchasing policy.
  • No progressive discipline process.

Time to report

Now that you have developed the sequence of steps leading up to, and including the accident, and determined surface and root causes, it's time to report your findings. Some employers also ask accident investigators to make recommendations for corrective action, so be prepared for that.

Most companies purchase accident investigation forms. That's fine, but some forms leave little room to write the type of detailed report that is necessary for a serious accident. If you use such a form, make sure you attach important information like the sequence of events, and findings which include both surface and root causes.

A better idea is to develop your own report form that includes the following five sections:

Section One: Background Information. This is the who, what, where, why, etc. It merely tells who conducted the inspection, when it was done, who the victim was, etc: Just a fill-in-the-blank section.

Section Two: Description of the Accident. This section includes the sequence of events you developed to determine cause. Just take the numbers off, and make a nice concise paragraph that describes the events leading up to, and including the accident.

Section Three: Findings. This section includes a description of the surface and root causes associated with the accident. List the surface causes first, and then it's associated root cause. Remember, your investigation is to determine cause, not blame. It's virtually impossible to blame any one individual for a workplace accident. Don't let anyone pressure you into placing blame.

Section Four: Recommendations. This section may be part of your report if requested by your employer. Recommendations should relate directly to the surface and root causes for the accident. For instance, if one of the surface causes for an accident was a slippery floor, the related recommendation should address eliminating that hazard through:

  • Elimination
  • Substitution
  • Engineering controls
  • Barriers and enclosures
  • Administrative and Work Practice controls
  • Personal protective equipment
  • Intermim measures

After making recommendations to eliminate or reduce the surface causes, you use the same procedure to recommend actions to correct the root causes. If you fail to do this, it's a sure bet that similar accidents will continue to occur.

Section Five: Summary. In this final section, it's important to present a cost-benefit analysis. What are the estimated direct and indirect costs of the accident being investigated? These represent potential future costs if a similar accident were to occur. Compare this figure with the costs associated with taking corrective action?

Source: OSHAcademy

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Copyright ©2000-2016 Geigle Safety Group, Inc. All rights reserved. Federal copyright prohibits unauthorized reproduction by any means without permission. Students may reproduce materials for personal study. Disclaimer: This material is for training purposes only to inform the reader of occupational safety and health best practices and general compliance requirement and is not a substitute for provisions of the OSH Act of 1970 or any governmental regulatory agency. CertiSafety is a division of Geigle Safety Group, Inc., and is not connected or affiliated with the U.S. Department of Labor (DOL), or the Occupational Safety and Health Administration (OSHA).