Accident Investigation

CHAPTER2 - ..•

An Accident Happens What D o You Do? How Long D o You Do It?

These two questions are major issues of accident investigation that must be addressed and answered. Answering the first is simple: p1,;ovide emergency response, protect the employees involved from further harm, and try to determine what happened so that measures can be taken to prevent its happening again. Answering the second question is more difficult. Some companies commit a specific amount of time to an accident investigation-a day, two weeks, or a month, for example-depending on the severity of the accident. In a perfect world, there is no time limit-an accident investigator investigates an accident until he or she is reasonably certain of what happened and why. This book answers the first question-it tells you what to do-and it provides ways to decrease the amount of time it takes to do it.

Accident investigations are a dreadful part of a safety professional's job. Accident outcomes may include injuries, fatalities, and property or equipment damage. It is sometimes difficult to "get over" the outcome of an accident, especially if there is a fatality or an employee is hospitalized because of it. However, accident investigations are a necessary and critical part of the

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occupational safety process. A thorough acciden~ investigation can be of ~eat benefit to your organization, not only by preventmg ~e same type of accident from happening again, but also by finding syste~c problems that ~ould cause more severe accidents in the future. The main purpose of an accident investigation is to find the causes (what happened) and _fix the problems to prevent the accident from recurring. "Accidents do not )USt happen, but are caused" (Marshall 2000, 29).

Goals of Accident Investigation

Determine the Accident Sequence without Placing Blame An accident investigation determines the accident sequence and finds the causal factors of an accident. Its purpose is not to find fault or assign blame.

How do you keep from finding fault when an individual disregards a major safety policy? The answer is to be fair and consistent with your policy. If there is no accountability for violating a safety policy or disregarding the safety program, then the safety program will eventually fail. The main issue is to find out why the individual violated the safety policy. The accident investigator must determine why the safety program allowed the individual to disregard the rule and why supervisors did not enforce the rule. While these types of situations are rare, it is imperative for companies to correct problems with their safety programs to keep accidents from happening (Sorrell 1998).

Recommend Corrective Actions

Accident investigations determine corrective actions so that future accidents are prevented and the overall safety program is improved.

Update the Overall Safety Program By identifying hazards from th k 1 1 h

e wor er level up to the management systerns eve , t e safety progr b

. am can e updated and improved. An accident is afl opporturuty to find and fix problems wi·th th £

e sa ety program.

Chapter 2: An Accident Happens

Accident Reporting

Thorough Reporting Is Necessary Accidents cannot be investigated if they are not properly reported. All accidents, including fatalities, injuries, and property damage, as well as potential accidents (near misses), should be reported. Formal company policy and employee training must spell out how to properly and consistently report accidents, near misses, and property damage (Vincoli 1994). Individuals must have no fear of repercussions for informing the company or the safety department of an accident or near miss. If people fear punishment or repercussion (accusation of fault or blame) for accidents, they are less likely to report them (Speir 1998). It is crucial to a company's safety program and to the prevention of future accidents that all accidents and near misses be reported so that all of the problems in the safety program can be found.

Incentive Programs Must Reward Reporting Incentive programs have been developed to reward safe behaviors. Unfortunately, many of them do not actually reward safe behavior but instead inhibit the reporting of accidents and near misses because employees fear losing their incentives. Such incentives do not improve safety programs. Reporting accidents and near misses, finding causal factors, and determining corrective actions, however, will improve them. Reporting accidents and near misses should be rewarded, and incentive programs should be designed to reward the reporting of all accidents and near misses.

Documentation versus Investigation When accidents occur, it is not just meant to document the occurrence. The purpose of an accident investigation is to ask questions, interview, analyze, probe, and discover what happened. It is not just to take witness statements and document what happened. Many companies' accident investigation forms and record-keeping forms are just a documentation tool. The purpose is to use these forms and tools to investigate and determine the causal factors and prevent these instances from occurring.

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Why Do We Need Accident Investigations?

To Avoid Spending Money on Accidents in the Future

Accidents are a major expense for companies. According to the 2011 edition of I,gury Facts, in 2009 the total cost of unintentional injuries at work Was $168.9 billion dollars (National Safety Council 2011). This monetary figure does not reflect the cost of human pain and suffering as a result of accidents. In 2009, 3,582 fatal occupational injuries occurred and 5.1 million injuries were reported (National Safety Council 2011).

Bird and Germain compare the costs of an accident to an iceberg-like an iceberg, most of the costs of an accident are not obvious and are not seen. For every dollar of medical and insurance costs an injury or illness incurs, the uninsured costs are $5 to $50 and miscellaneous costs are $1 to $3. The uninsured costs include damage to equipment, tools, and products; production delays; and legal expenses. The miscellaneous costs include accident investigation expenses, hiring replacement workers, and loss of business (Bird and Germain 1985).

As expensive as an accident may be, the resulting investigation can ultimately save money by helping to prevent future accidents and update safety programs. Future savings will be found in identifying systemic problems in the safety program and correcting them. Near misses are excellent opportunities to prevent costly accidents and identify and deal with systemic problems in the safety program.

Accident costs come directly from a company's bottom line. While saving money is a great motivator for improving safety procedures, a bigger motivator is avoiding the pain and suffering accidents produce. The field of occupational safety is very dynamic, with theories and concepts that change over cirn_e. However, most people would agree that "the ultimate goal of all efforts 1~

. safety engineering should be to reduce accidents and harmful exposures (.Marshall 2000, 6).

To Prevent Future Accidents A 'd . . . d . 1·ured, n acc1 ent 1nvest1gat1on cannot do anything for the person alrea Y U1 . . the machine already damaged, or the product already destroyed. Its value is JJl

Chapter 2: An Accident Happens

preventing future accidents. Although investigations are performed reactively, they allow companies to be proactive in improving their safety programs.

To Comply with the Law and Detennine the Total Cost of an Accident

Accident investigations must also be performed to complete workers' compensation claims, to comply with legal requirements and Occupational Safety and Health Administration (OSHA) regulations, and to determine the total costs of accidents.

Decisions to Be Made Before an Investigation Begins

Determine the Level of Investigation Companies define levels of accidents and levels of accident investigations to help answer questions about how an investigation will be conducted- such as how much detail the investigation should uncover and how long the investigation should take. In general, the more serious an accident is, the more detailed the investigation will be and the longer it will take. The philosophy of this book is that whether an accident is minor or catastrophic, the investigation process still follows the same steps---develop the accident sequence, analyze it, determine causal factors, and recommend corrective actions. The levels of accidents and types of accident investigations are listed in Exhibit 2.1.

Decide Who Will Investigate Once the accident level and the depth of investigation are determined, your company must decide whether to use an individual or a team to do the investigation. Many people from throughout your organization may be able to perform adequate accident investigations. The key is to choose the person (or persons) who is in the best position to discover what really happened and determine how to prevent it from happening again. Foremen and supervisors are excellent choices if they are able to look beyond their departments to

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Exhibit 2.1 CATEGORIZATION OF ACCIOENTS

LEVELS OF ACCIDENTS TYPES OF ACCIDENT INVESTIGATIONS

1. Near miss Near misses can range from potentially minor to potentially catastrophic accidents. At the least, document the near miss on a form, determine its causes, and recommend corrective actions.

2. Minor injury or first-aid case

3. Major injury or recordable injury

4. Catastrophic injury (fatality, many injured, or major property damage)

Investigate, interview injured employee, determine causes, and recommend corrective actions. Document on a form.

Investigate, interview the injured employee and witnesses, use analytical techniques, determine causes, and recommend corrective actions. Write a short report.

Team investigation. Interview injured, eyewitnesses, and other employees; use analytical techniques; determine causes; and recommend corrective actions. Write a full report explaining the analytical techniques used.

· • c gernent, system1c causes-problems with the overall system of sa1ety mana d

· shoul They usually understand the workers' jobs and the roles supervisors play. Safety professionals can do investigations, but usually they do;; fully understand all of the workers' job functions, so they must spen~ .is 1 · · b d · fessionai earruog JO uttes and sequences. A more useful role for safety pro . aJs · ·din · . fession is prov1 g assistance to accident investigators, since safety pro (11

. d t syste are trame to uncover and analyze systemic causes and managernen causes.

The Team Approach . cioD

For large or comple "d th "d , ... vestlgi1 x acci ents, e team approach to acc1 ent ,,, . Jess seems loo-ical beca · . d th n with

. i:,· use more 10format1on must be analyze a ,vbO senous accidents Th al . . }eade! · e usu team approach is to appoint a team tbe oversee~ and manages the investigation. The number of individuals o:)•ect team will vary dep din -ny s1.1 en g on the accident's complexity. NortnaJ.L '

Chapter 2: An Accident Happens

matter experts will be used to lend expertise about the complex issues that will be uncovered in the accident investigation.

In order for a team investigation to work effectively, the team leader must assign each subject matter expert to work in his or her area of expertise. Having the subject matter experts work separately on the overall investigation rather than concentrating on their own areas is a waste of time. Each subject matter expert should have a separate area to focus on, such as a technical or engineering issue, training, management systems, supervision, emergency response, etc. The team leader coordinates all of the efforts and ensures that all of the subject matter experts are working toward a common goal- finding out what happened and how to prevent it.

Decide How Much Time Will Be Allotted to the Investigation Deciding how much time the investigators will be given to perform the investigation and document the findings is a difficult decision. Many companies allot a set amount of time based on the level of the accident and the type of investigation to be performed. Ideally, the company should allow enough time to find out what happened and determine how to prevent it from recurring. In most cases, a first-aid case or an OSHA-recordable case will take a few days, while a major injury, fatality, or other complex accident may take anywhere from a couple of days to a month. Investigations of catastrophes with multiple fatalities and involving complex systems (plant explosions, plane crashes, etc.) usually take from a month to several years. The time needed to perform investigations at any level depends on the amount of data collected, the number of interviews, the number of people helping with the investigation, the analytical methods used, the complexity of the systems involved, and the length of the final report or form.

Determine Whether Additional Resources Will Be Needed For the most part, this book discusses nonproprietary investigation techniques that do not require extra expenses. However, in many investigations, consultants (subject matter experts, medical doctors, lawyers) or special

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equipment (testing equipment, external testing, laboratory work, computer software) may be needed. Coordinating these resources will extend the tune needed to perform an investigation.

Summary

The basic requirement for a successful accident investigation program is a formal accident-reporting policy with proper and consistent reporting of all accidents and near misses from employees who do not fear repercussions. In the past, most accident investigations began with the question ''Who did it?" In a mod~m investigation, the accident investigator must concentrate on causal factors and corrective actions and not place blame. Accident investigations should be conducted by a qualified individual or team. The purpose of the investigation is to find the causal factors of the accident and determine the corrective actions to prevent recurrence of the accident as well as to find systemic causes and thus prevent other types of accidents in the future.

Accident investigations are a necessary part of the occupational safety process. Although proactive accident prevention and loss control strategies are the main purpose of a safety program, accidents will occur. The company and the accident investigator must learn from each accident and revise the safety program as needed.