When the unthinkable happens, take the steps to keep it from happening again.
By John Shirikian-Hesselton
The first definition listed for “accident” in most dictionaries is “an unforeseen and unplanned event or circumstance.” However, that is not what we normally think of when we hear “accident” in connection to a workplace setting. What generally comes to mind instead is the definition found further down the list: “an unfortunate event resulting especially from carelessness or ignorance.” Whichever the case, when an accident occurs in the workplace immediate action must be taken to ensure the unfortunate event doesn’t occur again and that something positive is taken from the situation.
Since an accident has already occurred, an investigation is needed to gather the information that will be used to identify what needs to be done to prevent a recurrence. By preventing a similar or even more devastating accident, the workplace is improving safety and in turn benefiting the company’s future bottom line.
During accident investigations the hazardous conditions, activities and sequence of events are being identified after the fact rather than as a proactive initiative. However, the focus of the investigations still needs to be prevention. Investigations are not performed with the intent to place blame or find a scapegoat. Employees need to understand this, and they should receive frequent reminders of this important distinction. If during an investigation it is determined that work policies were violated and corrective measures need to be implemented, these measures need to be taken because the procedures and/or policies were broken NOT because of the accident. This is often a difficult concept to embrace, but it is important and needs to be addressed with employees. It cannot be overstated how essential it is that investigations be conducted as FACT-finding not FAULT-finding activities.
U.S. OSHA commented on accident investigations in its “Safety & Health Program Management Guidelines” indicating that the employer’s primary purpose for investigating accidents “is so their (accident) causes and means for preventing repetitions are identified.” The Guidelines also remark that “Although a first look may suggest that “employee error” is a major factor, it is rarely sufficient to stop there. Even when an employee has disobeyed a required work practice, it is critical to ask, ‘Why?’ A thorough analysis will generally reveal a number of deeper factors, which permitted or even encouraged an employee’s action. Such factors may include a supervisor’s allowing or pressuring the employee to take shortcuts in the interest of production, inadequate equipment, or a work practice which is difficult for the employee to carry out safely. An effective analysis will identify actions to address each of the causal factors in an accident or ‘near miss’ incident.”
The bottom line is that the output of the accident investigation process should not end with merely identifying violations of employer safety rules. The final report should focus on identifying safety management system weaknesses and/or unsafe conditions. Handling the accident investigation process in this fashion ensures the accident analysis process is a “profit
center” activity for the company. It will result in long-term returns that are substantially greater than the investment put into the process.
This strategy is also shared by the Canadian Centre for Occupational Health and Safety (CCOHS), a Canadian federal government agency based in Hamilton, Ontario. CCOHS supports the vision of eliminating all Canadian work-related illnesses and injuries.
CCOHS states on its website: “It is with a passion for and commitment to worker health and safety that CCOHS equips working Canadians with the information needed to reduce hazards and eliminate risks in the workplace, that all may enjoy a healthy and safe environment!” To help employers and workers learn from accident situations, CCOHS provides accident investigation information for employers and employees on its Web site, which states: “When accidents are investigated, the emphasis should be concentrated on finding the root cause of the accident rather than the investigation procedure itself so you can prevent it (the accident) from happening again. The purpose is to find facts that can lead to actions, not to find fault. Always look for deeper causes. Do not simply record the steps of the event.”
CCOHS also provides information on accident investigation training courses on its website at www.ccohs.ca/ccohs.html.
Accident Investigation Plans
To get started it is essential to have an established written Accident Investigation Plan. The plan should clearly state the entire accident investigation step-by-step procedures and responsibilities. Key areas that need to be addressed include:
• Training employees on immediate accident reporting.
• Training employees on Emergency Notification Procedure. The first priority is always safety and medical attention. Train on how to summon help and notify key personnel. Everyone must be moved to safe areas before taking any other actions.
• Identify whom to notify of accidents. This varies depending on the nature of the accident. The person responsible for handling emergency care should not be the individual responsible for contacting key company personnel, family members, media, etc.
• Identify who is authorized to communicate with outside agencies (fire, police, media, OSHA) once the initial emergency is under control. There should be one emergency control person to minimize confusion and miscommunication. Prepare beforehand statements that only preauthorized personnel will read to the media.
• Determine who will conduct investigations. Key individuals can be called on for technical assistance, but you will need a core team of employees trained on accident investigation techniques. All employees need to understand the accident investigator’s role.
• Develop a follow-up process to ensure recommendations from the investigation are communicated to all employees, implemented and monitored for effectiveness. Include periodic reviews of accident reports by the safety committee.
The process used to investigate accidents goes well beyond merely completing a form or two. It involves well-defined methodology and requires a commitment of time and resources. Developing and using sound accident investigation procedures and techniques has a far-reaching impact outside the accident investigation arena. Once learned and understood,
the thought process engaged during an investigation can be beneficially applied to many other work activities such as work setup activities and job safety analysis.
It is important that all levels of accidents are investigated. The same investigation techniques need to be applied even in situations with no personal or physical injuries or damages. Many work sites refer to this type of incident as “near-miss” or “near-hit,” referencing the fact that injury or physical damage was “nearly hit” or “just missed.” Whatever it is called, all
incidents need to be included in the accident reporting and investigating process. All incidents must be reported as soon as possible. Covering this topic during employee orientation shows it is important and will help establish an effective accident reporting system.
Accident investigations are used to determine causes and to identify corrective actions to eliminate or control the related hazards. As previously mentioned, to be effective the investigation needs to focus on fact-finding. The purpose is to identify how and why failures occur. Emphasis needs to be placed on identifying all possible causes and not on fault-finding. Investigations looking to place blame will cause more harm than good.
If investigators are looking to place blame they will lose all credibility, making it difficult to gain workers’ confidence and cooperation, and hampering information and fact-finding efforts. This does not mean that employee and employer responsibilities, oversights and mistakes will be overlooked. They need to be identified and recorded in a factual manner as part of the investigation to be dealt with at the appropriate time in the appropriate forum. It is paramount to the investigation to identify in a factual manner what happened and also identify what failed.
There are many factors that combine to cause accidents. The theory of “multiple causation” states that it is the random combination of various factors that results in accidents. The accident report must do more than just identify unsafe acts or hazardous conditions that surrounded an incident. It needs to identify the facts that will be used to eventually discover all the contributing causes. To accomplish this, information must be gained so those performing the investigation can flush out all contributing and root causes. It is not enough to stop at the first suspected cause; the investigators must keep asking why, what and how until all possibilities are exhausted.
Once all medical, safety and health issues have been handled at the accident scene and damage control is finalized, the accident site must be secured for the duration of the investigation. The entire scene should be placed under the control of one authorized individual to ensure nothing is moved or changed without approval. All evidence should be preserved. Diagrams and photos should be obtained before anything is disrupted. There are numerous companies offering training on the proper way to handle this part of an investigation. It is important to maintain the privacy of any victims. Photos that would be considered grim should be minimized and, if taken, kept strictly confidential. (Some U.S. State OSHA websites have on-line accident investigation programs.)
Witnesses are an important part of any investigation. It is necessary to interview anyone who may have heard or seen anything that could be pertinent to the incident. Interviews should be handled as soon as possible following the incident to ensure the information is fresh, and before individuals discuss what they saw or heard with others. As people discuss the incident they may unintentionally become influenced by what others think they heard or saw. Prior to being interviewed, witnesses should be separated and asked to refrain from discussing the accident. Interviews should always be held privately.
How and where an interview is conducted is also important. Witnesses should never feel threatened or pressured. They need to feel comfortable and be allowed to speak freely without being influenced or led by questions. They should never be forced back to the scene until they are comfortable returning to the area. Re-enacting the accident may be a useful technique but only when the witnesses feel ready to do so.
All elements of the investigation need to be handled professionally and consistently. The accident investigation system should be a preplanned process. To ensure the best possible information, anyone performing investigation activities needs to have authority and training. Whether interviewing a witness or reviewing the accident scene, certain key
techniques are required and training is necessary. It is not fair to anyone to just hand someone a clipboard or a camera and expect that a good investigation will result.
The best investigation will be useless if the findings are not evaluated and changes are not implemented. As mentioned, there are many causes to any accident. Anyplace the chain to the final event is severed will prevent the accident as it originally occurred. Most of the time the investigation analysis will yield a number of changes that, if made, will prevent a recurrence of the accident. It is a best practice to implement as many changes as possible to ensure the scenario that caused the accident can’t recur. However, before anything is changed it is essential that all new scenarios are verified to ensure they are not creating new hazards. If not careful, a more dangerous condition may be created unintentionally due to a change put in place to correct a hazardous situation that was identified during an accident investigation.
It is a good practice to have an accident investigation kit prepared and ready for use. This ensures that time is not wasted looking for items either getting to the scene or once at the scene.
Joan Shirikian-Hesselton is an independent Occupational Safety and Health consultant. She has more than 30 years of experience in Occupational Safety and Health in both the public and private sectors, including a decade of dedicated experience in the precast/prestressed concrete industry. She is a past NPCA Safety, Health & Environmental Committee chair, and she has worked with U.S. OSHA as a Special Government Employee.