Accident Investigation

UnitVII.pdf

Home >Engineering homework help >Accident Investigation

Course Learning Outcomes for Unit VII

Upon completion of this unit, students should be able to:

7. Describe managerial practices for ensuring implementation of corrective actions. 7.1 Identify corrective actions based on the hazard control precedence. 7.2 Apply the corrective action process to a completed accident investigation.

Reading Assignment

Chapter 6: The Analytical Process

Chapter 13: Recommending Corrective Actions

Access the resource below, and read pp. 10-11:

Occupational Safety and Health Administration. (2015). Incident [accident] investigations: A guide for employers. Retrieved from https://www.osha.gov/dte/IncInvGuide4Empl_Dec2015.pdf

In order to access the resource below, you must first log into the myWaldorf Student Portal and access the Business Source Complete database within the Waldorf Online Library. To reduce the amount of results you receive, it is recommended to search for the article by title and author.

Holden, R. J. (2009). People or systems? Professional Safety, 54(12), 34-41.

Access the resource below, and read Developing Conclusions and Judgements of Need to “Prevent” Accidents in the Future (pp. 2-87 to 2.91):

U.S. Department of Energy. (2012). Accident and operational safety analysis: Volume I: Accident analysis techniques. Retrieved from http://energy.gov/sites/prod/files/2013/09/f2/DOE-HDBK-1208- 2012_VOL1_update_1.pdf

Vanderhoof, W. (2006). Improving risk management. Occupational Hazards, 68(12), 35-36.

Unit Lesson

The main purpose of an accident investigation is to prevent the same, or a similar, accident from happening (Oakley, 2012). This means that when an investigation is completed, corrective actions need to be identified and implemented. If the investigation has been done by applying accident causation theory and effective accident analysis techniques, many causal factors may be revealed. A corrective action should then be identified for every causal factor (Oakley, 2012). This does not mean that every corrective action must be implemented.

Since a hazard is something that can cause injury or illness, corrective actions that eliminate hazards should be the first priority. For example, if an employee suffers an eye injury while operating a piece of production

UNIT VII STUDY GUIDE

Recommending Corrective Actions

https://www.osha.gov/dte/IncInvGuide4Empl_Dec2015.pdf

UNIT x STUDY GUIDE

Title

machinery, and the investigation reveals that the required eye protection was not worn, a corrective action could be to enforce the use of eye protection. However, note that using eye protection does not eliminate the hazard. Corrective actions can be categorized by their relative effectiveness. Most safety practitioners use a hazard control precedence list to select control measures. There are many versions of these lists, but what they have in common is that they start with controls that eliminate the hazard through design or engineering. Controls further down the list are less effective and include administrative methods such as work practice controls and training. Personal protective equipment (PPE) is typically at the bottom of these ordered lists and is used as a control only when other methods are not feasible (Oakley, 2012; Oregon Occupational Safety & Health Administration [OSHA], n.d.).

In our eye injury example, we should look for ways to redesign the equipment or provide barriers that prevent flying particles from striking the worker before we resort to PPE. Many organizations use PPE to control hazards without first considering other methods because it is the least expensive option. PPE as a sole control measure also makes it easier to simply blame the injured employee for not following the rules when the real cause of the injury may be poor equipment design.

In Unit IV, we discussed four levels of accountability that can be applied to accident causal factors: worker, supervisor, management, and corporate. Using these same levels when identifying corrective actions helps shift the focus from simple employee error to systemic failures that may have contributed to the event. If our injured worker failed to wear the proper PPE, perhaps the training was inadequate. This would involve a corrective action at the supervisor or management level.

Once again, we return to our accident scenario of Bob slipping in water on the floor and breaking his leg. In earlier units, we created an events and causal factors chart and used change analysis, barrier analysis, fault tree diagrams, and fishbone diagrams to identify causal factors. We are now ready to determine corrective actions. First, we list our causal factors and determine levels of accountability.

CAUSAL FACTOR ACCOUNTABILITY

Worker Supervisor Management Corporate

Wet floor sign not placed X X

Wet floor sign not available X X

Wet floor not cleaned up X X X

Maintenance request to repair pipe not submitted

X X

Poor communication among workers and supervisors

X X

It should not be a surprise that much of the responsibility for the conditions that led to the accident lies with supervisor and management. The next step is to write corrective actions that eliminate or control hazards and reflect the appropriate level of accountability.

CAUSAL FACTOR RECOMMENDED CORRECTIVE ACTION ACCOUNTABILITY

Wet floor sign not placed Establish clear policy on placement of accident prevention signs.

Corporate

Communicate accident prevention sign policy to all employees.

Management & Supervisor

Enforce sign policy. Supervisor

Wet floor sign not available

Procure wet floor signs. Management

Wet floor not cleaned up Establish policy on spill cleanup. Corporate

Maintenance request to repair pipe not submitted

Train supervisors in maintenance responsibilities. Management

Poor communication among workers and supervisors

Establish communication policy that ensures all messages are acted on.

Corporate

UNIT x STUDY GUIDE

Title

Note that there are no corrective actions assigned to the worker involved. The investigation revealed that the worker’s actions (or lack of actions) were directly related to inadequate policies and procedures. It is appropriate that the corrective actions are assigned to the levels above the workers. If the recommendations are implemented and the accident happens again, it is possible that some of the accountability would then fall to the worker, but the investigation of the second accident would still need to determine if the corrective actions were, in fact, adequately implemented. In other words, why did the new barriers fail?

Keep in mind that proposed corrective actions are likely to differ depending on the investigator, the thoroughness of the investigation, and the analytical techniques used. Can you identify additional corrective actions for Bob’s broken leg scenario? There is no single, perfect solution.

It is rare that the safety practitioner has the last word in deciding which corrective actions are actually implemented (that is one reason we call them recommendations). The decision makers in your organization may not be satisfied with just being told that implementation will prevent a recurrence. Be prepared to answer questions such as follows: (Oregon OSHA, n.d.):

 What are the potential costs to the organization if the hazard is not eliminated?

 What are the potential costs to the organization if the hazard is eliminated?

 How soon will the corrective action pay for itself?

 What is our return on investment (ROI) if corrective actions are taken?

OSHA has an online tool that can be used to estimate the cost of injuries and their impact on profitability. You can access the tool at the following link: https://www.osha.gov/dcsp/smallbusiness/safetypays/estimator.html

In an ideal world, all levels of the organization’s management would see the wisdom of the corrective actions, and money for full implementation would be available. Even when presented with cost-benefit data, organizational managers may be reluctant to expend the necessary resources, or those resources may simply not be available. It is important to be able to offer some alternatives to the ideal corrective actions. If engineering controls are not feasible, administrative or work practice controls are still better than no controls.

You may have heard the saying that no job is complete until the paperwork is done. This is true, too, with the accident investigation process. In the next unit, we will discuss the importance of the written accident investigation report and the follow-up process.

References

Oakley, J. S. (2012). Accident investigation techniques: Basic theories, analytical methods, and applications (2nd ed.). Des Plaines, IL: American Society of Safety Engineers.

Oregon Occupational Safety & Health Administration. (n.d.). Conducting an accident investigation. Retrieved from http://www.orosha.org/educate/materials/Accident-Investigation-110/9-110print.pdf