Accident Investigation

CHAPTER14

Reporting and Follow-up

R eporting and documentation are important parts of the accident in,escigation process. There are many reporting styles and methods, but mchever way is chosen, it is important to ensure consistency in the reports.

The last step in the accident investigation process is to follow up to ensure that the corrective actions have been initiated and are being followed. Many companies forget this important step. An accident will not recur if its causal fmors are determined, corrective actions are developed, and the corrective mions are initiated and in place. A follow-up ensures this.

Reporting

The three types of accident investigation reports are listed in Exhibit 14.1. ~e first is a lot;-a medical log, accident log, or even the OSHA 300 log.

e second · fi d is a orm that has space to document facts causal factors, an con · ' ecuve actions Th third . . . rt All hr n · e 1s a written accident investigation repo . t ee

Pes should acciden convey the facts of the investigation, the causal factors of the

t, and the · "d N tnis corrective actions that will prevent future acc1 ents. ear ses can b . . e~ .d and thi e50.gated and documented in the same manner as acc1 ents,

s can be he] ful . P 1n preventing accidents .

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Exhibit 14.1

Accident Log-list of all accidents, injuries, and near misses.

Accident form-form used to collect information about an accide t the accident, and list the causal factors and corrective actions. n 'document

Accident Report-a document that includes the accident sequ analysis, cau sal factors, and corrective actions. ence, facts,

Accident Logs

Accident logs are simp ly lists of a company's accidents-injuries, property damage, and near misses. Medical dep artments usually keep a log of employees who visit the department. Th e safety d ep artment should at least keep logs of near misses, mino r accidents, and mino r property d amage, but any accident, near miss, property damage, o r injury can and p rob ably should be investigated in addition to recording it in a log. Accide nt logs can b e very comprehensive or very simple as illustrated in Exhibit 14.2.

lllo st companies are required to keep an 3OSHA 300 log. All recordable inj uri es, lo st workday in ju ri es, illnesses , and fat alities (as described by the OSHA Reco rdkeep ing Sta nd ard) are record ed h ere. Keeping this log is required by law, but it is not a sub sti tute fo r proper accident investiga tion, including developm ent of cau sal facto rs and corrective actions. The log is an excellent tool fo r determining trend s and p oss ible po ints of weakness in the safe ty program.

Accident Forms

Accident form s collect two types o f in fo rm ation:

1 · 1 d descriprion Facts: the date and time of the accident, the personne mvo ve , o f th e accident, and other valuable in fo rmation.

Analysi s: cau sal facto rs and co rrective action s.

't Chapter 14: Rrporti11g and Fa!low.1,p

e~hibi,:_tl;.:4_.z ____ Aim cmrn"nr., -------.,C ACCIDENT LOG '.J Injured Accident Causal Corrective

Name Body Part Description Factors Actions ~ J___::::::.::.=---t----, - --'---t-- =:.:__+ ~~~-

Some form s are v ery basic, while others can be many pages long and represent a fairl y comprehensive investigation. A form is an excellent first opportunity to record evidence and facts about an accident. A basic accident fonn is illustrated in E xhibit 14.3. Companies can develop customized forms to ensure consistency o f their accident investigations.

Accident Reports

Accident reports sh ould b e written for maj or accidents , injuries, fatalities, property damage, and even ne ar mi sses with potential for major injury or damage . A repo rt should include a description of the accident sequence, the fa cts and analysis, causal facto rs, and corrective actions. This professional document will b e u sed n o t only for documentation, but also to prevent future accidents by initiating the co rrective actio ns listed.

Accident rep orts sh o uld , at a minimum, contain:

Introduction . Discusse s the purpo se of the inve stigation and brie f background o f the facility and accident.

::_c

Parl l I ·: />rrt 't'fllmg A rcidmJs

Exhibit 14.3 ACCIDENT FORM

NA~IE OCCU l>A110N

DATE llM E

:..; -1,n!RE OF l.'\:Jl! RY BODY PART I NJURED

LOCATION

TAS t-: ATTIME OF INJt.: RY

ACCIDE.',"T DE.5CRIP11ON

G\L'S.,\L F:KTORS

CORR.ECTI\'E ACTJo;,,:s

PREPARED BY I DATE

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Chapter 14: Ivporting ,md Follow-up

Methodology. Di scu sses the accident investigation and the techniques used 10 determine the sequence of events, causal factors , and corrective

:1ccions.

Sequence of events (a thorough accident description). This is a chronological sequence of the accident events . A portion of the events and causal factor s chart may be included.

Facts and analysis. Results of analytical techniques, possibly divided into topic areas. This pan should flow logically into the next two pans.

Causal factors.

Corrective actions.

Conclusions and summary. A summary of the inve stigation and its outcomes (Vincoli 1994) (DOE 1999).

Report-Writing Tips

Be objective. State the fact s of the accident and assign causes and causal relationships. Do not assign blame.

\'Vritc in a style that everyone can follow , not like you are describing a technical procedure.

Do not include p eople's names in the report; they are not important at this level of documentation. J ob titles could be used instead of names.

Break the facts into topic areas such as training, management oversight, electrical sa fety, explosives, or machine maintenanc e. For the example sce nari o, the topic areas could be forklift activities, manage ment (sup ervisio n) , communication, and pos sibly ladder sa fety. The facts in these topic areas are listed and analyzed. If there are multiple topic areas, the responsibility fo r reporting on them can be assigned to different people.

ln sen gra phic s and tables into the report to convey the information more effective ly.

Li nk causal factors to corrective actions with a simple table.

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Acci dent Trendi ng

One of the btest advancements in the ~ccid en t investigation process is acciden din T nding is the process of usmg a database to analyze accid t rren g. re . . ent trends

and find out what areas. Jobs, ~as ks, o r programs a re h avtng the most accident! and wh y. For example, the discovery tha t o n~ d ~partment is responsible for more medical calls than another m ay b e_ a n .mdicato ~ that a major acciden t could occur in that de partmen_r. If tre_n~m g m fo rma tt ~n such as this is UScd to make changes to reduce accide nts, tt ts calle~ proacttve trending. Accident and medical logs are excellent sources fo r tre~ding data. The more infomu.tion recei ved about an accident, the more tre n ding o pportunities there will~.

Many companies use tre ndin g to create colorful graphs and chans without actually focusing on problem areas and correcting the problems. It is important to remember that accident trending will no t p reve nt accidents unless cotrcctn-c actions are taken. If a tre nd is found-su ch as that electricians seem to be receiving three times as many shocks this y:ar as last-the reasons (perhaps tool or procedure changes) mus t b e d ete muned a nd corrective actions taken.

Another problem with trending is that it m ay oversimplify accident analysis because, to keep things simple and m ake pretty charts, co mpanies mar choose to follow only a few root causes an d base all o f their trending on these causes. Unfortunately, this type of trending does n ot help to prevent problems. The root causes chosen by the companies-human erro r, procedures not followed, management failure, supervision not adeq uate-are too broad to have useful corrective actions. For examp le, if a comp an y find s tha t 60 percent of che causes o f its accidents are " manage ment failure," w hat will the corrective actions be? Give managemen t more training? T raining in what? The cause 1s too vague. If this happen s, trending analysis will h ave lost its purpose.

Besides documenting information about types o f a ccidents and which depanmems have the most accidents, trending a nd accident analysis on be used to show how many accidents occur on each d ay o f the week or month; how many happen to each gender, age g ro up , or d e p artment; how many happen at certain times of day o r on ce rtai n shi fts ; h o w many happen to long-.term versus sho n -tenn employees; how man y h appen to people doing 2. certa.1n ~e of work or using a particular p rocedure ; w hich causal factors arc responsible for the most ac cidents; w hic h corrective actio n s are moS r oftetl

Chapter 14: JVport111g and FolloD'- IIP

ecommende<l; eve n w h a t p osition em p loyees were sta nding _o ~ sitting in w ~e n :n accide nt occu rred and w h a t b.o d y p a ~t s are m os t o ft en _miured . Trc ndu~g ;s an impo rta n t too l fo r preven ting acCJde nt s a nd correcttng weaknesses 10 cl1e safety p rogra m.

Follow-up Steps Check that the corrective action has been completed correctly. If a corrective ac tion d a ta b ase is u sed, m a ke a notatio n in th e database wh en the corrective ac tio n h as b ee n c o mple ted.

Make certain the corrective action works to preve n t accidents. A n ew procedure must b e tes ted to ensure that th e pro ble m was co rrected a nd accident s will be preve nted .

Ensure tha t the corrective action is being used. If a new p rocedure was wri tten, yo u will know tha t the co rre ctive ac tio n was co mple ted; however , the mo re impo rtant issu e is that the n ew procedu re is ac tually b e ing u sed .

Be proactive. A follo w -up is an exce lle nt o ppo rtunity ro o b serve h azards in the fie ld . \V h e n p e rforming the foll ow-up , check to see if a n y o th e r h:izards could cause an ac cid e n t. A ny h azard tha t h as the p o tential to cau se in jury, illness, o r damage sh o uld be analyzed a nd co rrec ted . A lso keep in mi nd that a correc tive ac tion could h ave b een co m p le te d correctl y, b ut the changes it cau sed to the sys tem m ay h ave created addi tio nal hazards that must now b e corre ct ed . For exam p le, requ iring main tenance ,vorkers to wear exte nsive p ersonal p ro tective equipment m ay lead to h eat- related illnesses in wann wea ther. The fo llow-u p is the last line o f defense in th e :iccidcm investigation process. This step sho uld en sure a safe and health y wor kplace free o f hazard s.

Su mmary

Documentation is a n im p o rta nt part of the accide n t investiga tio n p ro cess. The three types of d ocu me ntation used are accident logs, accident forms, and accident reports. All types of accide nt investigation documentation should convey th e fact s o f th e im ·es tigation , the cau sal factors of the accident, an d

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th e corrective actions that will preve nt future accidents. Once accidents are logged in to a computer database, trending can be used to prevent accidents and correct weaknesses in the safety program. The prevention of accidents is base d on th e initiation, completion, and use of corrective actions, and a fo llow-up ensure s that these steps are performed. (Please see the Appendix fo r a samp le Accident Investigation form.)

REVIEW QUESTIONS 1. What are the three types of accident investigation documentation?

2. What should be included in an accident investigation report?

3. What are some trending categories?

4. What is proactive trending?

5. What is a follow-up?

6. For the example accident scenario, prepare and document a full accident report that includes the introduction, methodology, accident sequence, facts , analysis, causal factors , and corrective actions, conclusions, and

summary.