Accident Investigation

CHAPTER15

Leaming from Accidents

While no company wants to have accidents, once they occur, it is important to learn from these accidents. One of the worst mistakes to make for a company is to repeat an accident. Accidents are opportunities to fix the safety program, correct hazardous situations, train employees on the correct behavior, and ensure systemic problems are corrected. While an accident is dreadful, we must learn from them.

The key concept of a safety program and the accident investigation program 15 ro prevent accidents and/ or prevent recurrence of an accident. No one wants to get hurt, but actions/inactions and conditions will dictate an accident. All 'd aca ents are caused, and there are many consequences of accidents. The heallh and safety of personnel is the utmost priority, but other issues include funcuonal c bili' f · fin · al 11 bein apa ty a ter los s, public image and reputation, anc1 we -

g 0oss of sales), and also civil or criminal legal action.

Lessons Learned "If it ca 0 happen h ' 1 " Thi · the co at t 1s ocation then it can happen anywhere. s 1s

ncept of 1 ' essons learned. One of the most important elements of

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accident in vcs t.igat.ion that ha s been discussed is to fi an . . gure Out Wh happened and how to prevent It. One of the bigge st mistakes of an . at

. k d kin y acc1de is not learning from your rrusta ·e s an ma · g the same mist k . nt . h aeagainAu companies need to not 1us1 fix t e problem areas and prev ·

' ent recurren b)' correcting the problems, but actually develop a system to lea f ce

. rn rorn th accidents. A lesso ns learned program will ensure that accidents a e , . . re corrected not just at o ne locat1on, but at all locations. Also a lessons lea d f

. . rne rorn a smaller accident can hdp avoid a larger accident from happening. "If ~-e were really good at learrung from o ur mistakes, two similar accidents would never occur" Qanson 2009) .

One of the biggest failures of companies is not communicating the problems, causes , issues, rrustakes, and / or failures of an accident to the other divisions of the company. If a company has multiple locations, then these issues could cause an accident anywhere. Communication is the key. Luckily, communication is much easier now, and accident information can be e-mailed immediately to other off-s ite locations.

There are many different ways to disseminate lessons learned information, and many companies e-mail out each cause and corrective actions to all. Others put together a weekly or monthly newsletter to disseminate the accident information. Communication is the key component.

Review Board

Another important aspect is to have an accident review board to review the accide nt report to check for quality, consistency, and ensure the faccs , causal factors, and corrective actio n s are correct. There are many types of re view board s. The be st review boards are made up of all levels of employees, from floor level (hourly workers), supervisors, to management. Th ere are othe r forms of review boards such as union review boa rd s

d ' h principle an management review board s. These all work on t e same . to review the report , validate the depth of analysis and inve sugauon '. h k h . · ns will fix c ec · t e cau sal factor s, and ensu re that the correcuve acuo . . h . . . . . . n effecu,e t e problem. Exhibit 15.1 gives a quick checklist for building a

acc id ent review board.

Chapter 15: Ltami11gfro111 Arcidents

Jl,<liibi t 15.l EFFECTIVE ACCIDENT REVIEW BOARD ~------

Building an effective accident review board

l) Choose the right accident review _board members, and the members should be knowledgeable in the analyacal techniques and causal factors analysis.

Z) Develop a consistent review process that yields consistency.

3) Root out system risk and look for systemic problems / causes.

4) Ensure that action items are completed.

Adapted from Hughes 2011.

Opportunities to Improve the Safety Program

While accidents are a negative path in a sequence of events and/ or an unplanned event, once an accident happens, the sequence is over. Now it becomes an opportunity to improve the safety program. An accident utilizes the concept of basic safety principles of identify, analyze, and control the hazards. The accident identified the hazard, and hopefully the accident investigation will ana lyze and control the hazards so there is no recurrence of the accident. Thus, it provide s an opportunity to improve the safety program. While many safety professionals are dedicated to using proactive safety techniques, once a near miss or accident occurs, it becomes an opportunity. It has either already caused an accident or almost did.

Prevent" S . mg ysterruc Problems One of h f find is the systemic t e most in1portant and difficult causal actors to cause Th . . fu th culture of the company · e systemic cause is the cause that in ses e . f and if r more accidents. l a not found and corrected will lead to man)

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structured causal factors analysis is n ot performed, then syste _ facro rs wi ll no t be fou nd. If causes are always based O rnic causil_ .d . . . Id b . . n superficial then the acc1 enr m ves uga uo n cou e m1 ss 1.ng a ma· fl _ ca\lscs Jor aw 10 th • manageme nt system. For example, it was initially presumed e safety was having all types of h a nd injuries because of em 1

th at a tornpan}'

p oyees beh . wearing the wro ng personal protective equipment. An a "d _ avtor in determined that the real iss ue was tha t the workers w cci en~ investigation

. . ere tramt d to wrong perso nal p rotecuve equ1pment . The accidents would h . u~e the until the training was changed. 1 f the investigatio n had not 1 ;ve _conllnuc-d, factors then th e sys temic cause would not have been di

00 ed lrlto causal

scovered.

Spreading the Information

The lme~ne t has its ~roble m s , b~t it also ~as a wealth of information on it Co rn~arues c.a n u se It to. get the. tnformauon out much faster, especiallpt off-s ite locauons. E- m a1_l, webs tt ~s, sh arepoints, and even newsletters can b e a ~ool to s~read the m fo rmauo n about accidents and lessons leamro._ Th~ mformauon can al so be u sed for trending accidents, using many vanables to h elp spread the accident information. Graphs and charts an be d eveloped to m ake it eas ie r for the information to be understood by all employees. For OSHA record able accidents, the information is required to be posted, but other acc ident information and trending resul ts can be posted around the compa n y so e mployees are aware of the number of accidents, near misses, and prope rty damage that occurs within the company. Other information o n cau ses and corrective actions can also be posted or communicated.

Using Accident Theories and Analytical Techniques to Prevent Accidents

\Xlb y should you wait until the re is a n accident at your workplace before you perform safety m e asures? \Vh y sh ould yo u wait until there is an accidcnl to use th e accide nt theo rie s? Acc ident theo rie s have been used for accident

Ch([pttr f 5: /J ammgfrom /lmdm ts

inn~srigation and caus~l analysis for many years. lt is time t ~ start u sin~ these H.•chniques in a proacovc approach. One can use these acc1dem theones and ::in:ilytical techniques as proactive safety techniques to identify, analyze, a nd pre\'ent hazard s from b ecoming accident s.

As discus sed in previous chapters, the one question sa fety e ngi nee rs ha,·e po ndere d for decade s is, " How do we prevent accidents?" By fir st taking a look at how accidents occur. Accidents d o no r ju st happen- th ey are caused, and the key is to find the causes and control them b efore there is an accid ent.

Analytical Approach to Accidents The analytical approach to investigating accident s is u sed to find out \vhat happened and how tO prevent future accidems. This is :t very intuith·e and iterative process to u se techniques that develop scenario s and d e te rmines wha t happe ned. The purpose is to use techniques and methodologie s that help to determine th e accident sequence and then prevent that sequence b y corrective actions o r controls. The purpose of the anal ytical approach is to use the techniques and methodo logies to analyze th e knowledge :ind fact s to develop results or recommendations and corrective actio n s to preve nt accident s. A n analytical approach w ill establish consiste ncy and validity to the proactive process.

Systems Safety Approach The key to a systems safe ty o r task safety approac h is to analytically a nd methodically ide ntify, analyze, and control h azards before an accident occurs. The concept of conducting analyses is to b reak down the sys tem Yersu s the job or task. Analyze the systems such as the piece of equipme nt and look fo r hazards. Then break down the tas ks: \'(!hat th e process is fo r obtai ning raw malcrial, loading it into the m achine, and so on. O btai n all of the hazards for this task also. The n ext step is to discover the ha zards versus failures . Man y of the systems safety techniques find failures ; h owever, to prevent accidents you mu st look for hazards .

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Proactive Safery Techniques Using Accid e nt The o ries

k O all acciden ts is to uncover a nd analyze the accident The ey t , . . sequ ence d •ne the causal factors , and fi nd corr cc UY e acuon s that \vill , etermt . . prevent furure accidents. After th e h azar~s arc tdenu? ed and analyzed, causal factors are de\·eloped. Using the se a.ccident theon es . the cau sal factor s or wha t would have prevented th e acct.dent are u sed to devel~p the proper controls or corrective actions. The theones sh~uld be u sed to ~alidate and find systemic problems :a :ill levels. Management issu es, worker iss ues, engineering issues (design), as well as po licy is~ues n~ed to b e analyzed. All levels need to be looked at to provide corrective acaons and accountability to prevent future accidents. Telling a worker to work safer ,vill o nly prevent that worker from haYing a future acciden L If the control is a policy issu e or a design issue, then the corrective action needs to be addressed a t that level to fix future accidents. Pro1ctin sa fety is a chance to look at the failures in the sa fety program and Ii....: them. (It is not the time to p lace blame or look at h uman error. lbis is the rime to look at what caused the human e rror.)

The next step to prevent accid ents is to implement the corrective actions. All correctiw actions need to b e tracked and a strict timetable established. If corrective actions arc assigned to a d epartment or someone is accountable fo r the corrective action, th e n usually they will be fixed in a more timd)' manner. All corrective action s or recomme ndations must be communicated clearly and objectively. The las t ste p is to conduct a follow-up and m:ike sure the corrective actio ns are in place o r wo rking correctly to prevent accidents.

Complian ce/Regula lio n s

One o f the best ways to use the tl1eo ri es o f accidents is to use the standards/ regulations to find hazardou s situ a ti o n s . \X' hile sta ndards are the minimil compliance, it is a great starting point. W h e n performing a walkaround, look for potential accidem sequences or u se the OSHA categories of accidents as listed in Exhibit 15.2. Th es e are the ca tegories that would be marked for:in OS HA recordable, so if you alleviate th ese from occurring, then you stopped lhe domino or seque nce of evenrs of an accident.

Chapter 15: Lrami11gfro111 Amdmts

Exhibit 15.2

C OSHA CATEGORIES OF ACCDENTS Stru ck By Slru ck Ag:un st

Ca uglu Betwee n

Co nta ct \'1/ ith

Co nt ac t By Co ntact On

Job Sa fety Anal ysis

Ca ught In

Fall, Sa me Le \·cl

Fall 10 Below

Ovcrcxe ni o n

E..,o;:posurc

E\·eryone has probab ly perform ed the basic job sa fety anal ysis of listing th e steps t0 a job, documen ting the hazards, and developing controls. A jo b sa fety analysis is an excellent p roactive safety approach. \Vhen conducting a jo b safety analysis, look at the po te n tial dominos and sequence of event s for an accident. Look fo r negative paths and use the OSHA categories to structure yo ur hazard s. Also u se the unsafe acts/ unsafe conditions to detem1ine where lack -of-comrol situations can occur.

\X' hilc identifying the hazards is the h ardes t step o f the job 5afety analysis, the mos t impo rta nt step is developing solutions to preven t the accident. The hazard co ntro l precedence was developed to try to prevent the accident in the bes t possib le way to ensure that the co ntrol is fixed . l11e first step is to try to design out or get rid of the hazard; if tl1 at ca nno t be accom p li shed, then try to substitute for less hazardous tas ks or equipment. Th e next step is to try to use guard s and safety de vices to reduce the hazard. TI1e ne.xt step is to use administrative controls and pro cedures to co ntrol the hazard. The last step is to use personal p rotective equipme nt to guard the perso n from the hazard . This is extremely important in that vo u want to try to control the hazard at the highe st level. ·

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Bam ·er A.nalysis

T his is a simple an al y~is_ dia~ is ,·.ery good a t locating hazards and contro . _1 r\ barrier an alysis 1s fairly simple co perfonn- keep the h,, .. d lling u1en1. _ _ ''-"ar frornth target. Thi s type of barrier :rnalys1s con s1~ers potential hazards, the pocen . '

' • =e rs and assesses th e ad equacy of b:uners o r other safeguards th ttal •-b • • . . at shoUJd

pre,·cnr ~r nUtig:i te an acade_m (Spear 2002) . Ths a nalysis is extremely US(fuj because Jt prod~ces a graplucal chart. T h e ~utcome ca n graphically explain the :iccid ents failure~ and also find the barner~ that n:ed to be corrected or :idded ro prevent accidents. ~e approach to this technique is very siJ:n le is lisled in E\:hibit 15.3. T here IS a hazard and a target. The barriers try ~o k'MIIJ. the hazard from reaching the target. The first step is to identify the hazard CCp the rn.rge t. Th : ne~ t step is to ide nti~, or brainstorm all of t~e barriers to: a comprehensn·e list and docume nt It on a form, as shown m Exhibit IS.4.

Exhib it 15.3

THE STEPS NEEDED TO PERFORM A BARRIER ANALYSIQ

Perfo rming a Barrier Analys is

1. Identify the hazard and the target 2. Id entify (b rain storm) barriers and controls 3. Ev aluate the intended function of th e

barrier

Th e barri er analys is summ a ry chart can be an excellent graphical chw tha t di splays th e fail u res of barri e r s for the accident in an easy to read graphjcal fo rm at. Thi s cha rt can b e ge nerated easi ly from the workshtel and be very h e lp ful in d eve lo ping c o rrectiv e actions to p reve nt furo re acci dents. A n ex ampl e o f a barrier ana lys is summary chart is illu5uated in Exhi bit 15.5. This exa mp le di spla ys the hazard of an electrical shoe~ from m ainte n a nc e o f a ma c hine . \\/ hen thinking proactively, }'OU

I d . . I h k canelec<rtt cone u e tha t th e barn e r s to preve nt an e lectr1ca s oc ar . . d safety p rocedure , a loc ko u t tagout program, electrical safety uainmg, an personal protectfre e q uipme nt.

Exhibi t 15.4

Barrier

Exhibit 15.5

HAZARD

BARRIERS

TARGET

Chap ter 15: Uamll,gjrom A a idmts

Purpose o f B arrier

Electrical Shock

Electrical Safety Procedure

LOTO Program

Safety Training

PPE

Worker

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1 t is important to understand how and why accidents occur by looking at the many accident theories. Proactive safety techniques are extremely useful in identifying, analyzing, and controlling accidents. Simple techniques can be used to prevent these accidents. It is important to understand the aspect of and impact of proactive safety and the true reasons these tools and techniques are applied, which is to prevent accidents.

Summary

Accidents can be very simple or extremely complex; however, the important aspect of an accident investigation is to learn from them and not repeat them. Lessons learned from accidents need to be communicated to the company to prevent similar accidents. No accident should be repeated.

Other aspects of an accident investigation is to develop an accident review board that acts to check the accident report for quality, consistency, and ensure the facts, causal factors, and corrective actions are correct. The focus of the accident investigation is to prevent problems and improve the safety program.

REVIEW QUESTIONS 1. Why is it important to learn from accidents?

2. What is the purpose of an accident review board?

3. Who is on a review board?

4. What is the problem if systemic causes are not analyzed?

5. What are some ways to communicate lessons learned?

6. What are some ways to use accident theories and analytical techniques to prevent accidents?