Accident Investigation

Part I

INTRODUCTION TO THE ACCIDENT SEQUENCE

Accidents do not just happen-they are caused, and the key to accident investigation is to find the causes. The first step in finding the cause of an accident is to examine the sequence of events that led up to it. Discovering this sequence is the goal of many of the analytical techniques discussed later in the book. This part of the book includes many theories that have been developed to determine how accidents occur. Many have been and continue to be used, and many others have been disproven. This book will mention many theories, but will focus on those that are based on the accident sequence.

The objective of this book is to present an analytical approach to accident investigations-gathering evidence, using analytical techniques and ~e analytical process to determine the accident sequence, and using this Info .

rmatton to discover the causes and to recommend changes to prevent future accidents.

Ob· Jectives for Part I:

• Dnderstand that accidents have a sequence of events and be able to deter · thi mine · s sequence.

• Be familiar with several accident causation theories and know how each applies to the accident sequence.

Part I: Introduction to the Accident Sequence

2

• Be aware that most accidents have multiple causes.

• Be able to break down accidents and use an analytical approach to investigate them.

CHAPTER1

What is An Accident?

Nobody wants to answer the phone and hear the words, "There's been an accident." But what is an accident? There are many different ways in which that term is to describe something that should not have occurred. A child would say, "It was an accident. I didn't mean to break that window with my ball." However, in the realm of investigations, an accident is an occurrence in a sequence of events that produces unintended injury, death, or property damage.

Definition of Terms

Accident

There are many definitions for accident. Most books agree that an accident is an undesired event that causes injury or property damage (Bird and Germain 1985). Many companies use the term incident rather than accident because accident implies human error, whereas, according to the National Safety Council, "an incident is an unintentional event that may cause personal harm or other damage" (National Safety Council 2009, viii). The definition of accident that best captures the analytical approach to accident investigation is: "Th at occurrence in the sequence of events that produces unintended injury,

3

Part I: Introduction to the Accident Sequence

4

death, or property damage" (National Safety Council 2009, viii). Accidents are sequences of events. There are normal (positive) sequences where there is no accident and accident sequences, also called negative sequences. An accident is a result of a negative sequence of events. These definitions and others are listed in Exhibit 1.1.

Near Miss

The difference between an accident and a near miss is usually luck or chance. A near miss is an occurrence in a sequence of events that had the potential to produce injury, death, or property damage but did not. Near misses can and should be investigated the same way accidents are.

Accident Investigation

An accident investigation is a structured process that attempts to uncover the sequence of events that produced or had the potential to produce injury, death, or property damage so that causal factors can be determined and corrective actions can be taken. Any occurrence that has a sequence of events can be investigated by analytical techniques-first-aid cases, OSHA-recordable injuries or illnesses, fatalities, property damage, or near misses. The steps in an accident investigation are: analyzing the facts, developing an accident sequence, finding the causes, and recommending corrective action.

The next definitions have to do with the accident itself. Safety professionals use various terms for the basic terminology of the profession (Sorrell 1998); this book simplifies the definitions.

Causal Factors

The causes of the accident are called the causal factors. A causal factor is an event or circumstance that produced an accident. Other books may use the term root cause to mean something similar. Causal factors can be at the basic (worker or equipment) level, the intermediate (supervisory) level, and the upper management level. The causal factors of an accident answer the question, ''What happened?" After causal factors are determined through an

Chapter 1: What is An Accident?

analytical process, con-ective actions are developed to prevent similar types of accidents.

Corrective Actions

Corrective actions are the actions taken to prevent recurrence of the accident. Causal factors link to corrective actions to address all levels of causes and accountability ( see Exhibit 1.1, Definitions).

Exhibit 1.1 DEFINITIONS

Accident-The occurrence in a sequence of events that produces unintended injury, death, or property damage.

Incident-An unintentional event that may cause personal harm or other damage.

Near Miss-An occurrence in a sequence of events that had the potential to produce injury, death, or property damage but did not.

Accident Investigation-A structured process of uncovering the sequence of events that produced or had the potential to produce injury, death, or property damage to determine the causal factors and corrective actions.

Causal Factors-Events and circumstances that produced the accident. Causal factors incorporate "root causes," "basic causes," "immediate causes," lower level causes, upper level causes, and management causes. When discovering causal factors, it is important to analyze all causes at all levels.

Corrective Actions-The actions taken to prevent recurrence of the accident. Corrective actions are the "fixes" to prevent future accidents. These fixes should be performed at the appropriate level.

Accidents versus Incidents

There has been much debate from safety professionals on the relevance of the terms accident and incident. Many companies use the term incident to lessen the impact of human error or fault in the meaning. Many companies and even governmental agencies have switched to the term incident and thus perform

5

Part I: Introduction to the Accident Sequence

6

incident investigations. Other companies use the concept of an incident as more of property or equipment damage. There is not much use in trying to contemplate the differences, and just embrace whichever one works for your

company or industry.

The same accident investigation processes and analytical techniques can be used no matter what term is used to describe the unintended injury, death,

or property damage.

Near Misses How do near misses fit into the accident investigation process? A near miss is an occurrence in a sequence of events that had the potential to produce injury, death, or property damage but did not. In aeronautical terms, when airplanes almost collide or fly too close to each other, then it is a near miss or you could say a near hit-they nearly hit each other. In these instances you want a far hit.

The concept of a near miss is widely confused among employees and these instances usually do not get properly reported. The best concept that can be used to describe a near miss is when someone sees you do something and says, ''You were lucky," or '"( ou dodged a bullet on that occasion. That almost got you that time." These are all instances that resulted in a near miss.

What is the difference in an accident and a near miss? Again, sometimes the only difference in a near miss and an accident is a matter of inches or seconds and luck or chance. If the blade was one inch to the left, then it would have been a fatality. According to the definitions, the only difference between these two terms is the severity that one was hurt, or damage was done. The moSt

important issue is to determine the potential of injury, death, or property damage for these instances. The biggest problem with near misses is the procedure for how these near misses are reported. If near misses are not reported, then they cannot be investigated; thus, the potential for an accident still exists.

These near misses are extremely important to understand and ensure that all employees understand the importance of prompt reporting of these instances. Near misses usually fall into the categories that will eventually ruro into an accident. How companies handle and react to near misses is the keY to preventing these hazards and issues before they become accidents. Praise

Chapter 1: What is An Accident?

and recognition for reporting near misses, instead of fault-finding accusations, will start a trend in more reporting of near misses, thus making near misses a proactive management tool to ensure a sincere message of trying to fix problems and prevent accidents (Clark 2010).

Property Damage and Equipment Damage Accidents

Property damage and equipment damage accidents are also sometimes as confusing as near misses and also often unreported. One of the issues with this type of accident is the monetary damage. Similar to near misses, how much monetary damage is enough to prompt a response or reporting? A broken hand tool might not get reported; however, a vehicle crash might get reported. These are also based on potential, in that even though there was no injury or death, there was still loss, but there was potential for injury as well. Just take a look at forklifts in plants: how many do you see that are all scratched and dented? I wonder how many of those were reported.

Small versus Big Accidents

Many professionals get bogged down by the issue of big accidents versus small accidents. All accidents, no matter how big or small, can and should be investigated. It starts with a hazard or a hazardous situation. The bigger the hazard or hazardous situation or act/ omission, then the more likelihood of loss. There are instances where a near-miss accident had more potential than an injury accident; however, through chance and luck it was just a small accident or a near miss. That near miss must be investigated, causal factors found, and corrective actions taken to prevent a much bigger accident and loss the next time, if conditions remained the same. Just because the accident was a small one this time, if conditions and acts are not corrected, then a big accident will come later. Near misses, property damage, and injury accidents can all be investigated.

Risk and Accidents

There has been much debate over these terms over the years. There is risk in everything we do. Risk is the amount of probability of occurrence and severity of occurrence that is inherent in everything we do. There are also hazards

7

Part I: Introduction to the Accident Sequence

8

that increase the amount of risk in our everyday life. Zero accidents is a goal that every company and every person should strive to meet. While most companies strive to reduce hazards and hazardous situations and reduce the amount of risk, there are risky situations that arise every day at the workplace.

Summary

There are many types of accidents, near misses, and even property damage events that need to be investigated. The type of accident makes no difference. First aid injuries or fatalities and catastrophes are basically all the same. The theories apply to both the small accident and the large accident and even near misses. There is a sequence of events for all, and while some are more complicated than others, they are basically the same. Many of the near misses are categorized as a near miss because of luck more than safety controls. No matter what size of the accident (even near misses), they all have causal factors that caused the accident. They key to accident investigation is to identify the causal factors and correct them to prevent accident recurrence.

REVIEW QUESTIONS I

1. What is an accident?

2. Why should near misses b~ investigated?

3. What is the difference in an accident, near miss, and property damage accident? ,

4. What are causal fac;tors?