Accident Investigation
CHAPTER13
Recommending Corrective Actions
T he subject of thi s chapter seldo m receives the attention it deserve s. The purpose of an accident inves tiga tion is to prevent recurrence of the sa me accident or a similar accident and to correct problems in the safety program
50 that other types of accid ents can be avoided. The important steps of any accident investigation are gathering evidence, discovering and analyzi ng th e accident sequence, determining causal factors, and fi nding corrective actions imt will prevent future accidents. The last three steps arc linked to the steps before them : Once all of the facts are ga thered and analyzed, the accident sequence is determined. Once the accident sequence is determined, rnu sa l facmrs become clear. And once the causal factors are established, correcthre actions can be developed.
Causal Factors
A causal factor is an event or circ um stance th at he lped to cause an accid ent. An investigator must exam in e causa l factors at al.I levels-manage mern, •·orker, engineering (design), and policy-in order to to provide corrective actio ns and accountabili ty for tho se corrective actio ns . Use an evcnrs and cau 5al factors chart to develop the ca usa l factors, and ensure that none arc
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140
missed. All poss ible cau sal fa ctors should be li sted . . , n o matter ho
seem, so that when co rrecave actions are developed th . w minor th . . , e 1nve · ev
pos mve th at all o f the causal factor s hav e been addressed. stlgator can b~ T eaching a worker who has been involved in an .
accident to sa fely will probably prev ent that worker from rep . Work mo, eattng the . e causal fa ctors frequently go b eyond the worker level. If the accident, but
li · d · · th causal fa . po cy issue o r a e s1gn issue , en the corrective act1· Ctor 1s a . . on must be d
at th at level m o rder to av01d future accidents. An a .d . a dressed ca ent mvesti .
a chance to look at failures in the safety program and c ganon is . . orrect them It .
a rune to place blame or attnbute human error but to I k · is not the human error. ' 00 at what caused
Corrective Actions
Although companies use different terms to describe fixing the problems that cau sed accidents, "recommendations" and "corrective actions" seem to b e the mo s t widely used. A corrective actio n, if implemented, should " fix" a cau sal factor-prevent it from causing another accident. Corrective actions can take the form of engineering redesigns, task redesigns, policy or procedure change s, and equipment changes, among others. Any action that can b e taken to prevent future accident s is a corrective action, as shown in E.mibit 13.1.
T o be effective in preventing future accidents, corrective actions should be implemented u sing the three-step process shown in Exhibit 13.2.
1. Develop the corrective actions after the investigation produces causal fac tors.
· f 1 • organizing and 2. Track the corrective actions. A database 1s use u ,or tracking in fo rmation about the co rrective actions.
. . h been followed as 3. Follow up to ensure that the co rrective acno ns ave . . not
ini tiated. If a corrective actio n is n o t used, accident prevenuon is ens ured.
Chapter 13: Rerommmdi11g Corrective A r/ions
. . .1 ORRECTIVE ACTIONS TO PREVENT ACCIDENTS
l H=RDS l G8
Develop corrective actions to prevent
accidents
Developing Corrective Actions
A corrective action should fix a problem and prevent accidents. All causal haors should have at least one corrective action (DOE 1999).
lips for Developing Corrective Actions
' Every accident should h ave at least one causal factor.
' Develop at least one corrective action for each causal factor.
' Communicate corrective actions clearly.
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Exhibit 13.2
THREE-STEP, PROCESS FOR CORRECTIVE A CTIONs
Develop corrective
(
actioa~~:.;..~~vent
CORRECTIVE ACTION PROCESS
Track corrective actions Follow up corrective
actions
i\lake causal factors and corrective action s ve ry specific so that the worker, superviso r, or manager knows exac tly w h at the problem is and how to fL, it. " Hwnan error" as a causal factor and " training" as the corresponding corrective action, fo r example, are too ge n e ral to be of use. Examples of usefu17 specific corrective actions are " D esign a metal guard that prevents contact with the blade " ; "Provide e lectrical training for all maintenance worke rs, incl uding loc kout/tagout procedures"; and "lncrease the corporate in spec tor's audit scheduJ e to include warehouse activiries." The more specifics included in the corrective action, the better the chance that accidents \vl.ll be preve nted.
Recommending Corrective Actions that Eliminate Hazards
There are usually several ways to fo< a problem, a nd some ways are m~re likely to prevent acciden ts than oth e rs . Try to choose a corrective ac~oo th ·u li · f h d reducoon at ,vi e mm ate a h azard when p ossible. Two types o azar ,rd Slrategl es \vork well to d evelop co rrec tive action s and fix prob1ems-haz
Chapter 13: Recommending Comrlive Arliom
d which is w idely used and accepted in the safety area and
I prece eoce, . . ' con"0 f om epidemiology called 'IIJ"'Y control.
reg)' taken r ''"' d ntrol precedence shows the order in which hazard control
'fhe hazar co d A h f th Ii . Ii . Id b e considere . t t e top o e st is e rrunating the hods shou . _
rnet that usually involves design or redesign. The next step is . .
hj Z . c minimum ri sk or, m som e cases, substtrute a less hazardous design ,or . 10 . N tis to design in sa fe ty d evices such as guards, although they do ltenal. l ex
rn duce or eliminate the hazard but simply cover it up. Warning d evices, 110
\~enal protective equipme nt, procedures, and training also do not eliminate P" d the hazard so they are toward the b ottom of the list. If none of orre uce ' . . . . Jheearlier steps works, the last choice is to _accept the nsk. Accepting the nsk is usuall}' n ot considered a correcttve action and 1s not used m accident mmcigacions (System Safet y Society 1997) . There has already been one acci dent and having another is n ot acceptable. Exhibit 13.3 outlines the h1zard control precede nce.
Exhibit 13.3 HAZARD: coNTROL PRECEDENCE
PRIORITIES IN SEEKING A HAZARD CONTROL SOLUTION
1. Design to eliminate hazard conditions.
2. Design for minimum risk.
3. Design in safety devices.
4. Design separate warning devices. 5. Develop operating procedures (including protective clothing,
equipment, and devices) and train personnel to use them.
6. Develop administrative rules.
7. Require management to accept risk. ~is precedence emphasizes building safety into the system. a.nd minimizing reliance on human input. Safety as part of the design makes it integral to the 'Ystem· (System Safety Society 1997, 1-3).
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Part fl /_· Pm'f'11ti11gAmdmtJ
The seco nd hazard reducti o n strategy, based 00 epiderniolo con:1'~1, w:1s developed by William Hadd o n.Jr. (1970) and lis ~ · and !n)llt} for tnJUC)' control: ts ten 5ftategi~
1. Prevent the creation of the ha zard in the first place. E xample- D th~ ~1~nufacrure of p~rticularly hazardous vehicles such ~s O not al!o.. numbtkes, o r all-terrain ve hicles. motorcycles,
2. RedHce the amOl(JJt of the_ hazard bro~~ht into being. E xample: Allow th , handguns o nl y tO p o lice and military units. c_:i.Jcof
3. Prevent the release ef a hazard that alrratfy e..,7Sts. Example: Im rove th power of motor vehicles. p e bnkmg
4. Modify the release ~r spah·al _d1Stn'bution of release of the hazard from JI; Jci;rrt Example: Use child restramts and seat belts in motor ve hicles.
5. Separate, 1/1 litm or space, the hazard and that which IS to be protrrtrd. Exam 1c: Remove roadside trees and poles. p.
6. S eparale the hazard and that which is to be protrcted I!) intt,pos,iion of O
ma:rr..;: bam·er. Exa mple: Install air bags in passenger vehicles.
7. Af.odify basic relevant qualities ef the hazard. Example: Eliminate sharp points and edges on ve hicle exteriors.
8. i\1ake 1llhal is to be protected more resistant to da111agefro11J the hazard faamp!e: Require physical conditioning before participation in sports th arprod uce conditioning -re lared injuries.
9. Begin lo counter the dafllage alreatf.y dom l!J the mvironnu!llal hazard E:umple: Increase the u se of s moke detectors and carbon monox.ide de trctors.
10. Stabilize) repair, afld rehab1iitale the oiject ef the da111agt. Example: Proiide prosthetic d evices for amputees .
(Adapted from Haddon 19;~
Haddo n 's list is made up o f ba sic injury control strategies as oppasrcl 10
workplace hazard control stra tegies . The list provides a basic und ersr:uidmg of how to prevent inju ry. Find out more about injury control by rr.id!n.? Haddon ( 1970) and Robens on (1998).
Chapter I J: lvro111111md111g Corrrrlire Artio,11
king Corrective Actions rrac • e ac tion s has bee n developed , th e action s mus t be
e l of correct1v , . . . . once a ~ied . le does no good to conduct an c x~e Uent ~cc1d~nt m vesagat10n , 1~ipkm:sal facror s, and develop u se ful corrective actions 1f yo ur company t111d ca h corrective actions o r impl e ments th e m very s lowly. fails ro irnplemenl t ;e that corrective actions are act ed on is to track them. The best way to e n su
Tips for Tracking Corrective Action s
Establish a timetable for each co rrective action. If all the a~tions are assi~ed to a specific department or individual, they are u sually imp lemented m a timel}' manner. Consider using a database to track corrective ac ti o n s. Include field s for a description of the action, an anticipated completion dat e, and the p a rty responsible for carrying out the action.
Conduct a follow-up to make sure the corrective actions are in p lace a nd working correctly. Thi s will be discussed further in C hapte r 12.
Exa m p le Scenario
Exhibit 13.4 shows th e completed events and causal factors analysis for th e for klift -and -ladde r accident. The causal factors found for th.is acc ide nt are bck of barricades; management's failure to plan, schedule, and communicate 1he job; th e corpora te culrure o f getting jobs done quickly (including upper management's lac k of e nforce m e nt of policies and proced ures); and failure tO follow policies a nd procedures. Th e events and causaJ facwrs analysis, barrier analysis, and c ha nge analysis earlier in this b ook make it clear that this accident 15
more compli cated than jus t a "fo rgo t ro barricade' ' iss ue. If th e accident invesrigato r had a nal yzed o nl y the barricade iss ue, m any important prevention st
eps woul<l have b ee n mi ssed. Ex hibit t 3.5 lists the causal factors a nd som e co rrcc ci\·e action s that may preve nt recurre nce of thi s accident . Try to li.nd tnorc causal fac tors and corrective actions th at could prevent accidents like this.
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A
Exhi bit 13.4 SCENARIO EVENTS AND CAUSAL FACTO
New wing of wa rehouse finished. 1/6/ 11
Bill received promot ion to
f------, wa rehou se supervisor.
1/23 /11
Bill arrived at work.
2/ 5/ 11 , 7:35
Bill retrieved a ladder.
2/ 5/ 11,7:41
Chapter 13: R.i'ron1111e11di11g Correrllve Artio11s
SCENARIO EVENTS AND CAUSAL F~
C Forklift hit
ladder. 2/ 5/11
7:45
Forklift driver loaded last load of the
day. 2/5/ 11, 7:44
Bill fell off ladder. 2/ 5 / 11
7:45
Forklift driver immediately
notified medical. 2/ 5/11
7 :46
Par1 Ir ': Pm"t11t111t ,..lmdtnJJ
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Exhibit 13.5
CAUSAL FACTORS AND CORRECTIVE ACTIONS FOR EXAMP LE SCENARIO
CAUSAL FACTORS
1. Lack of barricades
2 Management failure to plan, schedule, and communicate job
3. Corporate culture to get jobs done quickly (upper management's lack of enforcement of policies and procedures)
CORRECTIVE ACTIONS 1. Train worke~s ands~
how to barricade aisles.
2. De~elop managemen~ train management on planning, ;~::~~~nt~,
5 ~ d communicating
3. Develop a~ auditing system~ for su pervisors, managers, and corporate employees that include enforcing policies and procedures~
4. Forklift policies and procedures not 4 . Tra in supervisors and forklift d;;;;; followed. on policies and procedures and
develop en forcem ent audits.
The example scenario is an example of manage ment and policy failur e. Since the accident occurred while someone was pe rforming a non-recurring job, engineering fiires are not appro priate, bul there may be ha zard elimination strategies thar could be used. Can rou think of a ny?
Summary
Correctfre actio ns-the actio ns that will prevent recurrence of the accident- are the backbone of the accident in ves tigation. Corrective actions must be based on the causal factors, developed cl earl y :md objectively, tracked u~cil completion, and followed up w ensure that they a re in place and wo rking correctly. If a corrective action is not mitiared, it can not prevent :1.ccidencs. Corrective actions should be developed at all level s of accountability arid ar th
e highest Jeyel of hazard control precede nce possible to en sure th at rhe hazard is controlled.
Chapter I J: fvrommmdmg Comm,., A rno,u
REVIEW QUESTIONS
I. What is a corre ctive action?
2. What is the relationship between a causal factor and a corrective action7
3. Haw must a corrective action be w ritt en?
4• Us! the hazar d control precedence.
5 Why should a company track corrective actions?
6. For the example scenario, try to fi nd more causal factors and corrective w:ions tha t will prevent accid ents.
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