The accident investigation is a key component of an effective safety process, but very few investigations achieve their intended purpose. All too often the focus of an investigation is finding someone responsible for an incident, but it should really be about finding facts, finding real causes, and finding the fixes that will prevent the incident from happening again. For an accident investigation to be successful, it must lead to proactive safety improvements and injury prevention.
This article will help everyone involved in an investigation as management, employees and investigators understand their roles in the process and will also learn how to recognize common mistakes made during investigations and how to make the right changes that can prevent injuries and improve workplace safety
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The Importance of Accident Reporting
A good accident investigation can lead to solutions that will prevent the recurrence of common workplace incidents and quite possibly a more serious injury. Many incidents will never be successfully investigated, however, because they will never be reported.
An employee who cut his hand works for a company that gives awards for not getting hurt, so he doesn’t want to report his injury and ruin the prize for everyone else. A near-miss incident in which a large pipe almost hits a pedestrian won’t be reported because nobody was hurt and the workers involved think they solved the problem themselves.
A burn injury that occurred when an employee passed by a hot workstation won’t be reported either. The employee’s best friend got hurt last year and had a very unpleasant experience from the investigation. We don’t want to drive injuries underground by emphasizing bad measuring systems. We need to make sure that everyone understands that there are lessons to be learned from all incidents, so report them alleven close calls.
We need to learn how to conduct proper and professional investigations. The focus of an accident investigation is finding facts, finding real causes, and finding the fixes that will keep it from happening again. Everyone plays a role; it’s a team effort: employees, management, and the investigators must all understand their roles and responsibilities.
The Employee’s Role and Responsibilities
Say a co-worker in a machine shop suffers a pretty severe hand injury. What should you do? Always remember to call for help first. Call 911 or however you activate your emergency response system.
After the injured person is taken care of, there will be a lot of confusion and very little direction. This is why it is important for everyone to know how to react when the unexpected happens. Once the victim gets help, we need to preserve the scene. We need to install caution tape or some type of barricade, just like you’ve seen done in crime scenes on TV. An undisturbed scene can reveal a lot of information. For example, if a light curtain or proximity sensor were disturbed during the clean-up, it may be impossible to determine if they were working correctly before the injury.
Employees who witnessed the incident or who work in the immediate area must be prepared to describe what they have seen because they are likely to be interviewed. It is also important to remain calm because factual recall following a traumatic incident can be unpredictable, especially as time passes. Take a moment to reflect on your observations; write down details such as machine settings, positions of people and equipment and anything else you feel may be important.
During the interview, keep your observations factual. Don’t speculate, guess or make assumptions about what you think happened.
Don’t try to hide or cover up details that may make yourself or others look bad.
If you follow these guidelines, you’ll do just fine and you’ll provide valuable information.
Management’s Role in the Investigation
Management must be willing to let the investigative process happen and provide the resources and support for the effort. Of course, we cannot provide infinite resources to every investigation. Decisions must be made on a case-by-case basis as to how much time, effort, and money we are going to apply to any given incident.
Some factors that will help make this decision are the complexity, potential, and severity of the incident.
A burn injury is not very complex and should not require many resources to conduct a proper investigation, while a complex chemical plant explosion will require more resources. So complexity must be the first factor considered when deciding how many resources to allocate.
Next, we must consider the potential of the incident. The near-miss with the large pipe had a high potential for serious injury, therefore requiring significant resources even though no injury took place. A minor cut with a box cutter, while important, has much less potential and is not very complex; therefore, fewer resources are required.
Often, the near miss which could have been fatal rarely gets investigated, while the minor cut draws a five-person team searching for the perfect knife or cut-resistant glove.
This is poor utilization of our resources; we should always apply our greatest resources to the most complex and high-potential incidents.
Finally, management is responsible for considering and approving the proposed solutions and then ensuring they are implemented.
The Role of Investigators
The people with the most visible role in the process are the investigators. They will examine the facts and evidence, conduct interviews, determine true causes and make recommendations for corrective actions.
The investigation team should represent a cross-section of the organizational structure, from the shop floor workers who are the experts on the work involved to upper management, so all perspectives can be considered.
Members should be selected because of their technical skills and critical thinking abilities. Members of the investigation team must be fair and objective.
Each investigation is an opportunity to find true causes and real solutions. Many investigations go wrong at the start because investigators make assumptions based on preconceived ideas or incomplete information.
A good investigator will start by documenting the evidence and the facts, then analyzing them to determine what happened and ultimately, why it happened.
An important part of the investigator’s job is helping everyone understand and believe that the investigation is looking for solutions, and not simply seeking to hold someone responsible and move on.
Regardless of the circumstances, investigators must make a special effort to not play the “blame game. Finding someone to blame may be faster and easier, but all it does is divert attention away from the real problems.
A heavy load is borne by the investigation team to maintain a high level of integrity and utilize critical thinking skills that draw conclusions from the evidence and facts.
Gathering Data & conducting Interviews
To start gathering data, we must first document the scene. The investigator will observe and take notes on the state of the scene, what evidence is there and where it is located.
He may take measurements and photographs as a way to preserve the evidence. Examining the scene can provide many useful facts and should be done in a thorough and methodical manner, making sure to document all evidence before releasing the scene.
Conducting interviews with witnesses and knowledgeable employees is another way to gather valuable information, but it must be done carefully.
Make sure the person being interviewed is comfortable and explain the purpose of the interview and the investigation.
During the interview, we need to pay special attention to the words we use and the questions we ask. There are a few simple words to use during the initial stages of an interview to establish basic facts: who, when, and where.
For example, who did you see operating the pipe cart at the time of the incident? When did you notice the pedestrian on the walkway? Where was the pipe cart operator standing?
Who, when, and where are three simple fact-finding words that help us to establish critical information.
Another word that is useful is “what, but we have to use this word with caution because it can sometimes ask for speculation rather than fact. For example, asking a witness “what happened? will solicit an opinion as to what they think happened, while asking “what did you see? limits the scope to only what they witnessed first hand.
“How and “why are very powerful words, but they don’t serve us well during the initial stages of an interview. Both call for an opinion or speculation rather than fact.
In addition, the word “why can create an accusatory tone and can be inflammatory. For example, “why did you stick your hand in the machine? or “why didn’t you follow procedures? This kind of questioning can be counterproductive and places witnesses and co-workers on the defensive.
Investigators must learn to sift through contradictory statements, assumptions, hearsay, and misperceptions to get to the truth. A properly conducted investigation makes this much easier, while a poorly conducted one makes it almost impossible.
We begin to analyze how and why the incident occurred so we can determine the underlying causes. To analyze the causes, we must consider the “components of riskhazards, control systems, and employee actions.
Hazards are everywhere and it always best to remove or engineer out the hazards, but all hazards cant be removed or engineered out of existence.
Since we cant eliminate hazards such as a set of stairs or the points of operation on a machine, we use control systems to control the risk. Control systems are everything we do to keep the incident from happening.
We design and build for safety, install guards, write procedures, train employees, inspect the workplace and observe workers. Just because we have all these systems in place does not mean they are working.
Lastly, we must consider the human factor of employee actions. For example, if an employee decides to carry a large box that blocks his view and blindly walks down the stairs, resulting in a missed step and fall, our control systems cannot prevent that.
If an employee removes the guard and tries to clean the machine while it is running, our control systems can’t prevent that either.
Evaluating Components of Risk
An employee slips on some fluid in a walkway.
- Asking how and why can help us understand how the hazard came to be there.
- Why is the fluid there? We learn that it leaked from a nearby container.
- How did it leak? Upon examination, it was found that a valve was leaking.
- Why was the valve leaking? It was installed without a gasket.
- Why didn’t he know where to find the gasket? The parts area is a big mess and the only guy who seems to be able to find anything is on vacation.
- Notice we asked how or why about five times to identify some causes of the hazard. If we had just stopped at identifying the hazard as fluid on the floor or at the leaking valve, we would have missed out on some important information.
When looking at our control systems, we find that there was no review or approval process for locating the container near the walkway. While there were safer locations in containment areas, it was placed there for convenience.
Oil on the floor has been noted by employees and during inspections before, but the cause of the leak was never determined or correcteda weak corrective action system.
We have found that our control systems are pretty weak.
Finally, we must look at the employee actions. The action of the employee was to step in the fluid. Why did the worker step into the fluid? Because she didn’t see that it was there.
Why didn’t she see it? She was not paying attention to her path of travel.
Why wasn’t she paying attention? She was from another department where walkways were always kept clear and clean, so she assumed the walkway would be safe.
Without looking at each of the three components of risk, we may have failed to find the real causes that must be corrected.
In almost all cases, if the sole recommendation to prevent recurrence is to counsel and retrain the employee to be more careful and pay close attention, you’re most likely wasting your time.
We need to look at the hazard, the control systems, and the actions of employees so we can understand the multiple causes of an accident. Only then can we find the solutions that will keep it from happening again.
Priority of Controls
After we have made a list of solutions, we must decide which ones to implement. We need to follow a priority of controls and the highest priority solution is to eliminate the hazard.
If that’s not possible, the next choice is to use engineering methods to control exposure to the hazards. For example, we can install machine guards or proximity sensors.
If engineering controls wont work, we can consider administrative controls. For example, we can restrict access to an area or we can improve a work procedure.
The last choice, and least effective one, is to rely on retraining and PPE to protect employees from a hazard.
While blaming the employee may be the number one mistake made by an investigation team, it is also clear that employee action is one of the components of risk that must be examined. If the hazard cannot be eliminated and the control systems are strong, correcting employee action through discipline may be the most appropriate solution.
If it looks like your investigation is heading in this direction, then be careful to honestly evaluate your control systems. If supervisors are looking the other way and other workers admit they dont follow procedure, then you dont really have a strong control system.
On the other hand, a habitual risk-taker who ignores rules takes chances and places himself and others in dangerous situations must be dealt with, not only for his safety but ours as well.
Implementation and Follow UP
Once solutions are decided upon, a corrective action list should be generated and all action items completed. If the report goes in a file and collects dust nothing happens!
Part of the investigation process must include a means to follow up on the action items generated to achieve a resolution. Follow up afterward to determine how the changes are working, and if any unforeseen problems are occurring.
Because everyone plays a role in a successful investigation, everyone must also be involved in the solutions. Communicate to all involved the solutions that were selected, how and when they will be implemented, and why other solutions were not chosen.
If procedures or processes will be changed, be sure to get input and suggestions from those employees who perform the tasks.
In the real world, keeping people involved goes a long way towards a successful solution.