Accident Investigation

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Course Learning Outcomes for Unit III

Upon completion of this unit, students should be able to:

3. Apply accident investigation techniques to realistic case study scenarios. 3.1 Explain the steps necessary for an effective accident investigation.

Reading Assignment

Chapter 4: Using the Analytical Approach to Investigate Accidents

Chapter 5: Investigative Techniques

In order to access the resources below, you must first log into the myWaldorf Student Portal and access the Business Source Complete database within the Waldorf Online Library. To reduce the amount of results you receive, it is recommended to search for the article by title and author.

Hughes, B. (2009). Incident investigation: Evidence preservation. Professional Safety, 54(10), 55-57.

Lynn, D. G. (2014). Incident investigations. Professional Safety, 59(9), 53-54.

Rinker, R. C. (2005). Organizing investigative interviews. Claims, 53(4), 26-28.

Unit Lesson

Investigation is a Process

Most safety practitioners have seen accident investigation reports that read like this one below:

 Description of accident: o Employee cut finger on unguarded saw blade

 Accident cause: o Employee removed saw guard

 Corrective action: o All employees retrained on the proper use of machine guarding

Certainly, the fact that the blade was unguarded resulted in the injury. However, there are many other questions that arise: Why did the employee remove the guard? Did the employee really remove it, or was a guard not available? Have other employees operated the saw without the guard? Have there been similar injuries? Will retraining make any difference—especially if there is no guard available? Are there administrative consequences for removing the guard?

It should be evident that our simple accident scenario is anything but simple, but many investigations never get past the most obvious causes. Training or retraining is often the only action taken to prevent a recurrence. Imagine what might be overlooked in a more complex accident scenario. Ensuring that accidents are thoroughly investigated, all possible causes are identified, and effective corrective actions are taken is the purpose of the accident investigation process.

Calling an accident investigation a process implies that it is a planned, systematic effort. Remember that

UNIT III STUDY GUIDE

Investigative Techniques

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Title accidents are statistically rare events, and it is critical for an organization to have a well-defined, documented investigation process. How an investigation will be conducted should not be decided on the way to the accident scene.

Defining the Process

Accident investigation is a linear process; each step should be completed before moving on to the next. A simple model of the process uses three steps, which are as follows (Oakley, 2012):

1. Gain knowledge. 2. Analyze the knowledge. 3. Develop corrective actions.

For our unguarded saw blade accident example, the unanswered questions would indicate that the “gain knowledge” step was not completed before the other two steps were accomplished. One might wonder if any analysis of the knowledge took place at all. A limitation of this model is that it stops at the development of corrective actions. Corrective actions must actually be implemented, and after implementation, the actions must be evaluated for effectiveness (Lynn, 2014). This may seem obvious, but it is surprising how often an investigation becomes a paper exercise with no actions taken. It is also important to communicate throughout the organization the results of the investigation and the actions taken. “Make workers imagine, think about, and feel the impact of the incident” (Lynn, 2014, p. 54).

Accidents by definition are unplanned and unanticipated, and to ensure the investigation process is responsive and dynamic, adequate preparation is needed (Oakley, 2012). A clear, written policy on accident reporting and investigation procedures should outline goals and responsibilities. A written emergency response plan identifies the first responders for on-scene medical care and outlines the initial securing of the accident scene. Employees responsible for accident investigation must be trained in the investigation procedures and provided with the necessary tools and equipment. All employees in the organization must be trained on the importance of accident investigation and the procedures for ensuring all accidents are reported. An unreported accident is a missed prevention opportunity.

Gaining Knowledge

It is not possible to answer the question of why something happened without a complete understanding of what happened. This understanding is gained through the gathering of evidence. Dividing the types of evidence into four categories is helpful; the “four Ps” are as follows (Oakley, 2012):

 Physical evidence includes the materials and objects at the scene of the accident. Where these materials are located on the scene and their condition are important facts.

 Paper evidence includes policies, procedures, logs, checklists, and any other

written information related to the accident. Of course, many of these documents may be in electronic form, but we still think of them as paper evidence for the sake of the “four P” concept.

 People evidence includes the statements and interviews of people that may have relevant knowledge, such as those who are directly involved, witnesses, and first responders. Supervisors and managers are also important sources of this type of evidence.

The accident investigation sequence (Oakley, 2012, p. 39)

UNIT x STUDY GUIDE

Title

 Photographic (picture) evidence includes photographs and videos taken of the accident scene, as well as photos or videos that may have been taken of the same scene or the surrounding area before an accident. In the era of digital photography, this type of evidence is often available from a wide variety of sources—not just a photographer dispatched to the scene.

Whenever possible, the accident investigator or the investigation team should be directly involved in gathering the evidence—especially for the people component. Perhaps you have played the party game where the players are arranged in a line, and the first person whispers a message to the second person. The second person repeats the message to the third, and this continues until the last person receives the message and announces it to the entire group. Often, what the last player announces is substantially changed from the original message. The more people in the line, the more likely that the message changes. The same phenomenon is likely to happen with information about an accident. Critical consideration of the source should be applied to any evidence provided by persons outside the investigation team.

What evidence would you want to gather for our unguarded saw blade accident? For physical evidence, you could examine the saw for other mechanical defects. If a guard was available, you would want to know how easily it attaches to the saw. You might be interested in the layout of the shop, the equipment, and the housekeeping in the area. For paper evidence, you would look for the operator’s manual, any policies or procedures published by the organization related to the saw operation, and training records. For people evidence, you would want to interview any witnesses as well as other shop employees and shop supervisors.

How much evidence is collected and how much time is devoted to gathering evidence can be guided by the impact of the accident (Hughes, 2009). Was a fatality involved? Were there multiple injuries? Has the same or similar type of accident happened in the past? Will there be a substantial cost to recover from the damages?

The Next Step

As noted earlier, accident investigation is a linear process, and following the sequence is important. Once the evidence is gathered, then we can proceed to the next step of analyzing the knowledge we have gained and begin to answer the important question of why the accident happened. In the next two units, we will learn about various ways the evidence can be analyzed to determine causal factors.

References

Hughes, B. (2009). Incident investigation: Evidence preservation. Professional Safety, 54(10), 55-57.

Lynn, D. G. (2014). Incident investigations. Professional Safety, 59(9), 53-54.

Oakley, J. S. (2012). Accident investigation techniques: Basic theories, analytical methods, and applications (2nd ed.). Des Plaines, IL: American Society of Safety Engineers.