Accident Investigation

OSH 4601, Accident Investigation 1

Course Learning Outcomes for Unit VIII Upon completion of this unit, students should be able to:

2. Describe the accident investigation process. 2.1 Identify the key elements of an accident investigation report.

6. Examine the relationship between accident investigation and hazard prevention.

Reading Assignment Chapter 14: Reporting and Follow-up Chapter 15: Learning from Accidents In order to access the resource below, you must first log into the myWaldorf Student Portal and access the Business Source Complete database within the Waldorf Online Library. Geller, E. S. (2014). Are you a safety bully? Professional Safety, 59(1), 39-44. Access the resource below, and read Reporting the Results (pp. 2-92 to 2.110): U.S. Department of Energy. (2012). Accident and operational safety analysis: Volume I: Accident analysis

techniques. Retrieved from http://energy.gov/sites/prod/files/2013/09/f2/DOE-HDBK-1208- 2012_VOL1_update_1.pdf

Access the resource below, and read Module 7: Writing the Report (pp. 30-34): Oregon Occupational Safety & Health Administration. (n.d.). Conducting an accident investigation. Retrieved

from http://www.orosha.org/educate/materials/Accident-Investigation-110/9-110print.pdf

Unit Lesson Accident investigations can take days, weeks, or months to complete, depending on the complexity of the accident and the organization’s approach to the accident investigation process. That means a comprehensive investigation takes resources to complete—resources that could be used for more productive pursuits. However, if organizations are diligent and implement the corrective actions identified through accident investigation, they will gain in the long run by not having to investigate the same accidents repeatedly. Corrective actions eliminate hazards, and eliminating hazards reduces the probability of accidents. However, cost avoidance is not always easy to sell. Safety practitioners need to keep the cost of accidents visible. Production delays, cleanup, investigation, and training are all significant hidden costs related to accidents, and they should all be tracked. We have said that accident investigation is a reactive process. When we implement corrective actions, the process becomes proactive. Information about accidents and corrective actions should be communicated to all levels of an organization. Organizational managers need to see the cost of accidents, and employees need to see that actions to protect them from injury have been taken.

UNIT VIII STUDY GUIDE

Reporting and Follow-Up

OSH 4601, Accident Investigation 2

UNIT x STUDY GUIDE

Title

Communicating accident information begins with the accident investigation report. What this report will look like may depend on the organization’s philosophy concerning accidents, the seriousness of the accident, or the resources available. The Occupational Safety & Health Administration (OSHA) requires most organizations to keep a log of injuries and illnesses (OSHA, 2001). The OSHA 300 log is a basic description of the who, what, and where of injuries and illnesses. Some organizations expand the OSHA log to include causal factors and corrective actions. Accident forms are reports that contain more room for detail about an accident, but they still follow a “fill-in-the-blank” format. Logs and forms have their place and are useful for establishing trends or tracking corrective actions, but they are not a substitute for the accident investigation process. A compete accident investigation report should contain all the facts obtained during the investigation, copies of interviews and statements, photographs, discussion of the analytical process used to develop the causal factors and corrective actions, and discussion of all causal factors and proposed corrective actions (Oakley, 2012). In other words, it documents the entire process. Realistically, most organizations do not have the resources to conduct an in-depth investigation for every near miss, minor injury and major injury. They choose to put more resources into the accidents with more serious consequences but require reporting using logs or forms for all accidents, regardless of the severity. Regardless of the format, accident investigation reports have little value if actions are not taken to implement the corrective actions. This is where the process becomes proactive and justifies the resources expended in the investigation. Accident causal factors represent hazards or workplace conditions that may cause illness or injury. They are no different than hazards identified through workplace compliance inspections, job hazard analysis, or risk assessment; therefore, they should become a part of whatever hazard tracking system is in use (presuming there is such a system. If not, the problems go much deeper than accidents). Each corrective action should be clearly assigned to a specific individual or group who is then held accountable for completion of the necessary tasks. Periodic follow-up is necessary to ensure established timelines are met and that the corrective actions are working as intended. Learning from accidents is important. Even if our corrective actions are implemented and are effective in preventing a recurrence, is there anything revealed by the investigation that can be applied to other parts of the organization, even if different processes are involved? Looking back one last time at our accident scenario involving Bob slipping in the water on the floor, we identified that supervisors in the valve department were not aware of their responsibility to submit maintenance requests. Does the same problem exist in other departments? Perhaps the overall preventative maintenance program is inadequate? Likewise, we identified a communication problem between supervisors and employees. Is this an indicator of a systemic problem? It takes practice to become an effective accident investigator. Large organizations may have a team dedicated to accident investigations. There are government agencies, such as the National Transportation Safety Board and the U.S. Chemical Safety Board, whose sole purpose is accident investigation. For most employers, the opportunities to conduct a thorough investigation are not frequent enough to provide the needed practice. On one hand, not having accidents to investigate is a good thing and may indicate the presence of an effective safety program (or a string of good luck). On the other hand, the lack of practice might result in a poor-quality investigation. If we understand the theories of accident causation, there is no reason we cannot apply those theories proactively to reveal potential accident causes. Accident prevention is much more than eliminating hazards from the workplace. It requires an examination of systems and the interactions among workers, equipment, and processes. It is not hard to brainstorm the types of accidents that might happen in a given workplace. Using an imagined accident or an accident that happened in another organization, you can work backwards and examine the conditions that might contribute to such an accident. Applying the various domino theories will help focus on unsafe actions and unsafe conditions or basic and immediate causes. We can use the Haddon matrix to help identify human, equipment, and environment factors. We can use change analysis to identify what alterations in a process or procedure might result in an accident, and we can use barrier analysis to determine if the barriers in place are sufficient and to decipher what might happen should they fail. Fault tree analysis can be used to examine complex processes for potential paths to an accident (Oakley, 2012). Accidents happen. They happen in organizations with no active safety programs, and they happen in organizations with large staffs of credentialed safety professionals. They are elusive because they involve complex interactions of human behavior, equipment, and the environments in which they operate. No one can accurately predict when or where an accident will happen, but we can, and should, learn at least something from every accident. The accident investigation process is the conduit for this learning. The more we learn,

OSH 4601, Accident Investigation 3

UNIT x STUDY GUIDE

Title

the more we can reduce the probability of another accident. We can also be proactive and apply accident theories to identify vulnerabilities in processes and procedures. No one is happy when an accident happens, but each accident should be viewed as a unique opportunity for improvement. Not taking advantage of these opportunities does a great disservice to those workers who were adversely affected. We owe them, their families, and their colleagues our best efforts.

References

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

Occupational Safety & Health Administration. (2001). 29 CFR 1904.7, general recording criteria. Retrieved

from https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=9638

Suggested Reading 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. The Royal Society for the Prevention of Accidents (RoSPA) believes that there are many opportunities for learning in the field of safety prevention. This article focuses on RoSPA’s key theme that understanding accidents is important in preventing them. This article also contains other interesting information about RoSPA and its investigation practices. Bibbings, R. (2010). Learning from accidents. RoSPA Occupational Safety & Health Journal, 40(7), 35-36. The article below explores the Chemical Safety and Hazard Investigation Board and how this organization is trying to prevent chemical accidents. Their five core goals are identified and discussed in the article, as well. Bergeson, L. L. (2006). The Chemical Safety and Hazard Investigation Board: Thinking strategically in

investigating (and preventing) chemical accidents. Environmental Quality Management, 16(2), 81-88.