Accident Investigation

www.asse.org SEPTEMBER 2014 ProfessionalSafety 53

When I was an OSHA compli-ance officer, I performed sev- eral fatality investigations. One of my early investigations involved a fatality in a grain silo. The silo’s bottom part had an auger that transported corn. The corn had formed a crust over the auger and prevented the flow of corn. Two teenage cousins entered the silo to shovel the corn to another opening in the side of the silo. They had to walk on top of the 15-ft pile of corn to do so.

While they moved the grain to the side opening, they dislodged the crust above the bottom auger. As corn began to funnel through the bottom auger, the flow created a whirlpool effect and the boys could not escape. It was as if they were stuck in quicksand. They screamed for help but the response was too slow. One boy stood on a board on top of the corn holding his cousin’s hands as he was sucked into the grain funnel. He could not hold him and he watched as his cousin was pulled into the corn where he suffocated.

The incident happened in the early 1990s, and I remember the investiga- tion as if it were yesterday. I had to relive the incident in an interview with the surviving cousin. That was one of the hardest conversations I ever had because I could picture every word he described and I could feel the pain he felt for his loss. My memories of the investigation are vivid; but can you imagine how vivid the memory is for the cousin who lived?

Incident investigations are designed to answer the question “why” so that we can prevent future incidents. No one wants to investigate an incident because it is a reminder that injuries impact people. An investigation process is vital to the success of any SH&E program because it turns a reactive pro- cess into a proactive tool. Investigation processes driven by systematic urgency and discipline prevent future problems when they identify the real cause of the problem—and management takes ac- tion to solve the problem(s). We learn from mistakes to avoid future inter- views similar to the one I had with the survivor.

What characteristics do great investi- gation programs have? Great programs maximize the benefit of four critical stages in an investigation process.

Stage 1: Reporting Organizations cannot correct what

they do not know. Effective incident investigation programs encourage per- sonnel to report all incidents, including first-aid injuries, recordable injuries and near hits. When a workforce embraces the importance of reporting, it has an opportunity to correct small problems before they escalate to larger issues. Had the grain silo investigated near hits earlier, would the outcome have been different? Successful organizations create a transparent work environ- ment where employees want to share the potential risk they observe so that the company can make adjustments to prevent future injuries.

Incident reporting also has differ- ent dimensions. There is the initial report from the injured employee to the supervisor, then there are the notifications from the supervisor to the appropriate leaders in the organization. Both elements are important. Supervi- sors cannot correct a problem they do not know about, and management cannot demonstrate its commitment to sustainable improvement without knowledge of the issues. Communi- cation from the injured employee to leadership creates awareness and focus on injury prevention.

Critical Considerations Employers should implement several

critical practices with respect to inci- dent reporting:

- ing all incidents (e.g., first aid, record- ables and near hits).

reporting. Workers should feel free to share what they experience.

quickly workers should report inci- dents.

will be notified in the organization for all situations. Include time frames for how quickly people should hear about incidents.

each step of the process.

Stage 2: Investigation Effective investigation involves more

than filling out a report or checking boxes on a form. A paper exercise does not facilitate long-term improvement.

that surround an incident. Multiple prepackaged investigation tools are available that can help identify root causes. However, the brand on the tool does not make the process successful. The most successful investigation tool is the one that gains the full support of the company’s leaders. All layers of an organization must understand the process and provide their collective au- thority to make it successful. Manage- ment support is more important than the investigation tool itself.

Become an expert on the collection of information and analyze the impact of each detail. For example, evaluate steps

focus on the immediate circumstances that surround the event. Look up- stream and determine what steps (and

a road map from the start of the injured worker’s day (or before) to the moment of the incident. The goal is to create a storyboard that explains, step-by-step, how and why conditions and behaviors

- tions exist for a reason. Investigators should peel back the layers of every step to determine what led to the event.

A good investigator collects detailed data in stages and organizes notes so that s/he can write a coherent report with ease. The key is to ask questions about each step to populate the event

sense to the employee and document everything related to the step.

Incident Investigations Four Critical Stages

By David G. Lynn

When a workforce embraces the importance of

reporting, it has an opportunity to correct small problems before

they escalate to larger issues.

Best Practices

54 ProfessionalSafety SEPTEMBER 2014 www.asse.org

Critical Considerations An effective investigation explores

several critical points when analyzing each step of an event; describe ex- amples of:

employee;

step;

impacted each step;

each step;

step; -

ed each step. Utilize the value of multiple perspec-

tives to answer the appropriate ques- tions. The employees, direct supervisor, manager and senior manager should always participate in the investigation process; other subject-matter experts or employee representatives should participate as well. If the supervisor and manager fail to participate, they minimize their accountability for the incident and their lack of visibility contributes to a negative safety culture. Active participation from leadership establishes the importance of the incident.

Stage 3: Corrective Action Make sustainable corrective action

your goal. The investigation phase will paint a storyboard that led to the incident. Each step in the storyboard represents an opportunity to change the outcome. Corrective actions should address elements of the storyboard that failed or contributed to the incident. Sustainable corrective actions change the appropriate details throughout the sequence of events.

How do you put corrective actions in place? The event analysis will usually reveal a series of unwise choices or contributory causes that led to the final poor decision that caused the incident. The contributory causes can also in- clude latent organizational weaknesses. Corrective measures should address the source of these weaknesses.

Critical Considerations When applying corrective action, con- sider the following critical points:

the storyboard with sustainable correc- tive actions.

measures address any similar circum- stances.

on the log. -

rections.

progress.

term improvement.

Stage 4: Communication The communication phase is easy

to overlook. Once the investigation is over and the problem is solved, the natural reaction is to move on to the next challenge. Great programs maxi- mize the knowledge gained from the incident experience and communicate the lessons learned. Incidents should not happen in a vacuum, and leaders should tell others about the event to help ensure that a similar incident does not occur. The communication goal is to learn from the incident experience and prevent future incidents by com- municating what happened.

Make Lessons Learned Memorable Following are several ways to make

lessons learned memorable: -

pen to them.

share a personal example of how it ap- plies to the audience.

- quences. Share examples of related in- juries and the impact it has on families.

people to think about the incident throughout the day.

and feel the impact of the incident.

Conclusion The same incident should not hap-

build an incident investigation process around the four pillars: report, investi- gate, correct and communicate. When organizations invest in a full circle pro- cess that focuses on the small things, they can turn a reactive process into a proactive tool.

grain silo were the first to experience such a situation? Was that the first time corn had crusted over an auger? Was it the first time they had to use alterna- tive methods to remove grain? Was it reasonable to think that the corn would dislodge at some point? What would have happened if the company had investigated previous near hits—if it had recognized the potential for future incidents through past investigations? Most certainly the situation could have been different if the company had.

Minor incidents that occur every day have the potential to become future tragedies. Investigate the small things with relentless consistency so that you do not have to conduct hard interviews like I did with OSHA.

When organizations invest in a full circle process that focuses on the small things, they can turn a

reactive process into a proactive tool.

David G. Lynn, CSP, is a vice president of Signature Services, a division of Life & Safety Consul- tants. He is a professional speaker, author and improvement strategist with 20 years’ experience. Lynn’s books include Principle to Practice and Strategic Safety Plan. To learn more, visit www .lifeandsafety.com or www.david-lynn.com.

Best Practices

© IS

T O

C K

P H

O T

O .C

O M

/S T

U A

R T

M IL

E S

9 9

Copyright of Professional Safety is the property of American Society of Safety Engineers and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.