Properly Conducted Accident Investigations
WHAT’S AT STAKE?
The term “accident” was often used when referring to an unplanned, unwanted event. To many, “accident” suggests an event that was random, and could not have been prevented. Since nearly all worksite fatalities, injuries, and illnesses are preventable, OSHA suggests using the term “incident” investigation.
Investigating a worksite incident- a fatality, injury, illness, or close call- provides employers and workers the opportunity to identify hazards in their operations and shortcomings in their safety and health programs. Most importantly, it enables employers and workers to identify and implement the corrective actions necessary to prevent future incidents.
WHAT’S THE DANGER?
ROOT CAUSES
In conducting an incident investigation, the team must look beyond the immediate causes of an incident. It is far too easy, and often misleading, to conclude that carelessness or failure to follow a procedure alone was the cause of an incident. To do so fails to discover the underlying or root causes of the incident, and therefore fails to identify the systemic changes and measures needed to prevent future incidents. When a shortcoming is identified, it is important to ask why it existed and why it was not previously addressed.
Incident investigations that focus on identifying and correcting root causes, not on finding fault or blame, also improve workplace morale and increase productivity, by demonstrating an employer’s commitment to a safe and healthful workplace.
SHARED RESPONSIBILITY
Incident investigations are often conducted by a supervisor, but to be most effective, these investigations should include managers and employees working together, since each bring different knowledge, understanding and perspectives to the investigation.
INVESTIGATION OBJECTIVES
Incidents may result from one of the following categories, or, from a combination of a few.
Task: A task-related root cause involves the actual work the employee was doing.
Example: A construction worker building a house jumps from one level to another instead of climbing down a ladder and sprains his ankle.
Material: A material-related accident is caused when equipment or materials are faulty or dangerous.
Example: A shelf collapses and heavy objects fall onto a worker, crushing her foot.
Environment: The physical work environment and changes to it could also cause an accident.
Example: A workspace is poorly lit, causing a worker to trip over an electrical cord she couldn’t see. As a result, she sprains her ankle.
Personnel: Sometimes an accident’s root cause comes from the employee’s education, experience, or physical or mental condition.
Example: An employee is tasked with lifting objects that are too heavy for them, resulting in a serious back strain.
Management: Management systems and styles may lead to workplace accidents.
Example: An employee’s manager does not inform him that employees must wear eye protection when entering a certain area. When the employee enters this area alone later, metal shavings fly into his eye, causing permanent blindness.
HOW TO PROTECT YOURSELF
STEPS TO CONDUCT EFFECTIVE INCIDENT INVESTIGATIONS
The point of the investigation should never be to assign blame, but rather to uncover the factors that led to accident so you can take corrective action to prevent it from happening again.
When a workplace incident occurs, gather a knowledgeable team to conduct the accident investigation. Your health and safety committee, as well as employees who have experience in the work the injured party was performing, should be part of the investigation. If possible, include the employee’s supervisor. Here are the steps:
1. Administer First Aid
Employee safety should be your number-one priority, so always start by administering first aid. You can address smaller injuries like scrapes or splinters in the workplace with a first aid kit. For more serious accidents, call 911 to get the employee the medical attention they need.
The only exception to this is if administering first aid would put you or the injured person in danger.
2. Secure the Scene
Next, secure the scene of the accident. Clear other employees from the area and rope it off. If possible, remove sources of immediate danger (e.g. put out a fire or turn off a machine). Try to keep the scene as intact as possible to ensure an accurate investigation. While providing medical care and removing imminent hazards may disturb the scene, minimize their effects when you can.
If the employee is killed or critically injured on the job, file a report with the Occupational Safety and Health Administration (OSHA), your union (if applicable), your workplace’s health and safety committee and the local police as soon as possible.
3. Collect Evidence
Perform this step as soon as you can after the incident. The less time that passes before you start the accident investigation, the easier it is to observe the scene’s conditions as they were at the time of the accident.
Collect physical evidence that may help you uncover the accident’s root cause. Record the scene visually using video or still photos. Study the conditions and environment. Finally, take copious notes so you don’t forget any details. Remember that fact-finding, not fault-finding, is your goal.
4. Conduct Interviews
In addition to collecting evidence, you should also identify witnesses. Interviewing witnesses provides insight into the accident that may not be apparent during your physical investigation. While you also need to interview the injured employee, they may feel too shaken up to provide accurate information right away.
5. Identify the Root Cause
The primary goal of every workplace accident investigation is to find the Root Cause. If you know what led to the accident, you can prevent it from happening again. Keep in mind that the accident may have multiple causes.
Root Causes must be:
- specific underlying causes
- reasonably identified (don’t take up too much time to identify)
- under management’s control
- able to have effective recommendations generated to prevent them from recurring
6. Prepare an Investigation Report
During the accident investigation you’ve collected evidence, interviewed involved parties and analyzed that information to find the incident’s root cause. Now you have to communicate it all to management.
If the thought of creating a final report fills you with dread, use case management software with one-click reporting capabilities.
7. Recommend and Implement a Corrective and Preventive Action (CAPA) Plan
Your final accident investigation report should include recommendations to prevent future incidents. Develop a Corrective and Preventive Action (CAPA) plan for management to implement that will mitigate risk. Your plan should consider the accident’s root cause and include concrete steps to take that will address it.
Corrective actions are immediate fixes to the accident’s causes. These could include replacing a faulty piece of equipment, giving the employee better training or changing their work tasks.
On the other hand, preventive actions avert similar accidents in the future. Examples might be reviewing and changing your health and safety procedures, scheduling more regular equipment inspections or making PPE mandatory.
8. Follow Up
Even the strongest CAPA plan won’t prevent workplace accidents if it isn’t enforced. Follow up with the recommendations after a few weeks, then a few months to ensure they’re being implemented. If the changes don’t seem to be making a difference, consider revising the CAPA plan and its timeline to maximize results.
FINAL WORD
Your business has just experienced an incident resulting in an unintentional injury to a worker. Reacting quickly to the incident with a prescribed procedure and actions can demonstrate your company’s commitment to safety and ensure the proper information is collected to fulfill an incident investigation’s ultimate purpose – to prevent future incidents.