Accident investigation.

Accident investigation

Accidents happen. How often have you heard that. All too often it is a cliche used to excuse or overlook potentially serious problems. Problems that can be avoided and should be corrected. Unfortunately, the saying is true. Accidents do happen. No matter how much attention is given to safety, incidents will occur where someone is hurt. Sometimes they are not serious. Sometimes they are. And sometimes, while the result is not serious, the potential for serious injury is significant.

Let's consider an example. A worker is injured while working on a bench grinder. In this case, a metal fragment is thrown into the eyelid of the worker. The clear safety shield on the grinder had been removed. The worker has the injury examined by the on-site health professional. It is determined that no serious damage occured and the worker returns to his job.

This incident could be viewed as "just one of those things," since no serious injury occured. Or it could be viewed that the worker was at fault because he "should have known better" than to run a grinder without the shield. But, perhaps there is a more important underlying cause.

Any time a serious or potentially serious accident occurs, it needs to be investigated. Incidents will often occur because of problems in the safety system. This system includes items such as training of operators, supervision, equipment, maintenance and materials used, among others. If safety is to be improved, any serious or potentially serious accident should be investigated to determine exactly what caused the problem. Investigation is the only way in which the problem can be understood. And the only way to truly avoid a duplication of the problem in the future.

As in our example, even if an accident results in no permanent injury, management has an obligation to determine why this accident occured. And take action to make sure it does not recur. Was it the operator's fault for not following safety rules? Was he even aware of the safety requirements? Is this the first time this kind of accident occurred? Did the maintenance department not get a repair done in a timely manner? Or was the supervisor lax in his responsibility?

Why investigate accidents?

There is a long list of reasons that accidents need to be investigated. The most obvious is to protect workers from further injury. The list goes on to include items such as to provide feedback on overall safety management and increase awareness within the labor force of safety needs.

Regardless of all the reasons for conducting accident investigations, they must be conducted with the right frame of mind. Only by investigating an accident can it be thoroughly understood. By understanding the underlying cause of an accident, its recurrence is most likely to be prevented. If an accident is investigated in such a way as to justify disciplining an employee, there is little likelihood that the true cause of the accident will be found.

The primary objective of any accident investigation should be to determine the real cause of the accident to prevent recurrence. If the investigation is conducted in such a way as to assign blame to an individual, it's unlikely that safety in the workplace will be improved. Any accident investigation will only be as good as the objectives of the investigator. If that objective is anything less than prevention of recurrence, the safety program will suffer.

Even motives that are less punitive, such as mitigating possible OSHA actions or satisfaction of insurance requirements, will undermine the benefit of accident investigation in a safety program. Accident investigations work as a feedback tool to reinforce lessons already learned, verify or cause modification of procedures already established and cause new procedures and equipment to be reviewed. Serious and potentially serious accidents serve to pinpoint the weak links in a company's safety program.

What should be done?

Du Pont Safety Services, a division of E.I. DuPont, has been involved in teaching safety to companies for 17 years. They have developed an investigation method to optimize the productive use of accident investigation. In their experience, this method applies to operations of all size.

Initial responsibility lies with the line supervisor and his/ her immediate supervisor. They must determine the potential seriousness of an accident and how extensive the investigation should be. Investigations take time. As a result, a decision to investigate an accident is an important decision.

Seriousness of an accident can be hard to judge. A good rule of thumb is the lost workday. That is, any accident that results or could have resulted in a lost workday is serious. Near misses can be difficult to judge. However, if there is a serious injury potential, investigation is called for. Examples might be as follows:

* A worker falls from a low scaffold while working on a piece of equipment and twists his ankle in the process. While this injury was not serious, it could have been a broken leg.

* A worker gets a small shock when turning on a piece of equipment. Any shock involving a voltage potential of more than 75 volts DC or 40 volts AC is considered dangerous.

* A worker gets lightheaded while working in an adhesive spray area. The worker stops work for a short period of time, then resumes without further problem. Any potential hazardous chemical leaks should be investigated before serious spill, fire or serious health hazards occur.

Incidents that are not serious should be reported but do not require the serious investigation of other accidents. Again, a good dividing line is the loss of a day's work. Examples include the following:

* While filing, a secretary receives a paper cut.

* A water pipe ruptures at a joint, spraying cool water over a worker. Water is tap water out of a city fed line.

* While cutting out a form, scissors slip and cut the worker's finger.

Non-serious accidents can usually be investigated with a very limited team. Often, this will be simply the supervisor and the injured party. If others are doing the same job, they should be included as well. Serious accidents are another matter. The teams involved with accident investigation here should include the designated safety manager, one or more upper level managers, as well as others with significant input. This might include personnel from maintenance, manufacturing engineering and other related departments.

How should investigations be conducted?

In the case of a serious accident, second level management will generally lead the investigation with the first line supervisor gathering background information such as maintenance records on the equipment, worker history, safety rules, information on training and posted notices, etc. In these cases, the second level manager should lead discussions, ensuring that all reports are completed and that positive conclusions are reached. This also ensures a higher degree of objectivity in the investigation.

An important aspect of accident investigation is that all present who participate in the investigation are relaxed and that a positive relationship exist in the investigation team. Remember, the objective is to prevent recurrence of the accident. Discipline is not one of the objectives. According to Du Pont, the investigation should follow five basic steps:

* Collect all the facts.

* Determine the causes.

* Recommend methods to avoid future accidents of the same nature.

* Communicate the recommendations.

* Act on the recommendations and ensure they are followed.

Timeliness is important in all accident investigations. They should be completed as soon as possible after the accident occurs. This may be within minutes of its occurrence. In other cases, gathering relevant background information may require additional time. Certainly, formal inquiry and fact finding should begin immediately after the accident. The more time that is allowed to pass after the accident, the more likely that pertinent details will be lost. Also, time delays can allow those involved to create stories that will hide a serious safety problem.

Conditions in the area of the accident should be left unchanged until the investigation is complete. Pictures can be used as a means of preserving an accident scene. It's important that nothing related to the incident be destroyed or thrown out. In collecting the facts, the accident investigation team should inspect the location and equipment used, talk to the injured person and, if possible, talk to others who were in the area when the accident occurred. They should also review the written procedures for the area, training records, maintenance records and other pertinent documents. They should also determine what instructions were given by supervision and whether others that do the same job use the same techniques. Throughout the fact finding period notes should be taken.

Investigators need to be good listeners and lookers during the initial phase of the investigation. Don't ask questions that can be answered "yes" or "no." Get an understanding of how the job is done and what is required. In talking to workers, watch for actions and eye movement that confirm (or don't confirm) the information being related. When reviewing the work area around the accident, pay attention to people factors as well as physical aspects of the area. Ask yourself "What would happen if...?" questions. In spite of the many physical factors, data shows that over 90% of all accidents are caused by unsafe actions by people. After reviewing the accident area, talk to the injured employee. Let them tell what happened. Don't interrupt. If possible, conduct this interview at the accident site so that the employee can demonstrate what happened. It may be valuable to have a qualified coworker present to comment on the job as well.

During the interview, avoid questions that point blame to the worker. Rather than asking "Didn't you know you had to use goggles?" ask questions such as "Describe the training you received for this job?" or "What are the safety requirements for this job?" When talking to witnesses, look for facts. Do not request judgments. Make sure that the objective of preventing recurrence, not finding fault, is understood.

What's next?

Once the facts are gathered, the team can convene to review the facts and draw conclusions. Conclusions such as carelessness, bad judgement, poor attitude, etc., are not acceptable. Conclusions should be ones which provide management with an avenue for action.

Looking back at our first example, the worker may have known he needed eye protection, either the shield or goggles. But perhaps he had reported the problem with the grinder to his supervisor and no repair had been made. And he had not been issued any goggles. He was being pushed to get a job done that required use of the grinder for a few moments, and he went ahead and did the job. For expedience. Conclusions here might be as follows:

* Safety training was adequate.

* Posted safety procedure was not followed in order to save time.

* Supervision did not issue adequate safety equipment to the worker.

* Maintenance had not completed the equipment repair in a timely manner.

* Supervision was overemphasizing productivity (possibly because of pressure from second or third level management).

As this shows, immediate and underlying causes are often interrelated. While the immediate cause usually involves only the worker, it is the weak link in the chain that begins with safety management. Immediate causes can include such things as using the wrong tool, not following established procedures, disregard for risk or taking a shortcut in order to save time. They can also include such things as an oil spill that was not cleaned up, faulty wiring or a trip hazard in an aisle. Immediate causes are the easy ones to see. However, if the investigation stops here, little will be done to prevent recurrence.

Underlying causes are the ones that enable the immediate cause to exist. They include items such as poor training, lack of enforcement of rules, poor maintenance, lack of proper storage space and overemphasis on productivity. These causes are more difficult to correct because they require changes in safety management.

And then?

Once the causes are identified, recommendations for corrective action can be made. These should be practical, as simple as possible and tell management what to do. In the example given, a recommendation that "all employees read posted procedures," would accomplish little. However, a recommendation that "supervisors should discuss the injury and remind them of what can happen to them if they do not observe safety rules," would be a positive action. From our example, one recommendation might be that "all safety related repairs will take priority over other maintenance items." Remember, management must "manage," not just direct.

Once the recommendations are made, it is the responsibility of the leader of the team to ensure that recommended actions are taken. This includes follow up with various involved areas. If corrective action requires time, some type of progress reporting procedure should be established. Recommendations that involve changes in the safety culture will require the longest period and, perhaps, the most detailed follow up.

Summary reports may be of value to other departments in the organization. These would include brief descriptions of what happened, causes of the accident and recommended actions. By compiling this information on a periodic basis, valuable information on the overall safety program of a company can be obtained. These can provide background information and direction for upper level management decisions.

Summary

Successful accident investigation requires cooperation of everyone involved. If it is viewed as a "witchhunt," it will soon cease to be a productive tool. Attempting to find fault with an individual, punish someone or cover up a problem will cause workers to refuse to cooperate. First line supervisors carry a significant burden in meaningful accident investigation. Negative perceptions can be avoided by 1) attending to the well being of the workers involved in the accident, 2) having compassion for the injured persons, 3) not blaming anyone for what happened, 4) recognizing persons who acted properly in the situation and 5) correcting unsafe conditions immediately.

How a company reacts to safety problems that do occur will tell the workforce much more about the company's commitment to safety than all the signs, training programs and speeches management can give.