What Happens When Something Happens? Part 1
Accidents happen. Despite your best efforts, zero accident policies, and well trained employees, things sometimes go wrong. So what happens after an accident or near miss happens in your facility is a question you have to be ready to answer at a moment’s notice.
Accident Investigations should -never- be used as a tool to punish those who might be responsible. Properly conducted accident investigations analyze and eradicate the hazards that cause accidents. Investigations also educate and motivate to prevent future incidents.
The term “accident” can be defined as an unplanned event that interrupts the completion of an activity, and that may (or may not) include injury or property damage.
An “incident” usually refers to an unexpected event that did not cause injury or damage this time but had the potential. “Near miss” or “dangerous occurrence” are also terms for an event that could have caused harm but did not.
The term “incident” is used in some situations to cover both an “accident” and “incident”. It is argued that the word “accident” implies that the event was related to fate or chance. When the root cause is determined, it is usually found that many events were predictable and could have been prevented if the right actions were taken — making the event not one of fate or chance (thus, the word incident is used). For simplicity, we will use the term accident to mean all of the above events.
Incidents that involve no injury or property damage should still be investigated to determine the hazards that should be corrected. The same principles apply to a quick inquiry of a minor incident and to the more formal investigation of a serious event.
Investigations, Step By Step
When an accident occurs, you have to find all the causes quickly to prevent another similar incident. Here’s the general step-by-step accident investigation procedure recommended by OSHA:
- Secure the site and make sure it will be left undisturbed (unless, of course an immediate hazard must be dealt with.
- Define the scope of the investigation.
- Select the investigators, assigning specific tasks to each, preferably in writing.
- Present a preliminary briefing to the investigation team. It should include a description of the accident, normal operating procedures, relevant maps, the location of the accident site, a list of witnesses, and events that preceded the accident.
- Visit the accident site to get updated information.
- Inspect the site, preparing and labeling appropriate sketches and photographs.
- Interview each victim and witness.
- Determine what was not normal before the accident, where the abnormality occurred, when it was first noted, and how it occurred.
- Analyze the data obtained in step 8 and repeat any prior steps if necessary.
- Determine why the accident occurred, a likely sequence of events and probable causes, and possible alternative sequences.
- Check each sequence against the data from step 8.
- Determine the most likely sequence of events and the most probable causes.
- Conduct a post-investigation briefing.
- Prepare and distribute a summary report, including recommended actions to prevent a recurrence. According to OSHA, an investigation is not complete until all data are analyzed and a final report prepared.
Who should do the accident investigating?
Ideally, an investigation would be conducted by someone experienced in accident causation, experienced in investigative techniques, fully knowledgeable of the work processes, procedures, persons, and industrial relations environment of a particular situation.
Some jurisdictions provide guidance such as requiring that it must be conducted jointly, with both management and labour represented, or that the investigators must be knowledgeable about the work processes involved.
In most cases, the supervisor should help investigate the event. Other members of the team can include:
- Employees with knowledge of the work process
- Security officer/manager
- Safety officer/manager
- Health and safety committee members
- Union representative, if applicable
- Employees with experience in investigations
- “Outside” expert
- Representative from local government
The advantage of having the immediate supervisor on the team is that this person is likely to know most about the work and persons involved and the current conditions. Furthermore, the supervisor can usually take immediate remedial action. The counter argument is that there may be an attempt to gloss over or hide the supervisors shortcomings, if any, in the accident. This situation should not be a factor if the accident is investigated by a team of people, and if the worker representative(s) and the members review all accident investigation reports thoroughly.
Why look for the root cause?
An investigator who believes that accidents are caused by unsafe conditions will likely try to uncover conditions as causes. On the other hand, one who believes they are caused by unsafe acts will attempt to find the human errors that are causes. Therefore, it is necessary to examine some underlying factors in a chain of events that ends in an accident.
The important point is that even in the most seemingly straightforward accidents, seldom, if ever, is there only a single cause. For example, an investigation which concludes that an accident was due to worker carelessness, and goes no further, fails to seek answers to several important questions such as:
- Was the worker distracted? If yes, why was the worker distracted?
- Was a safe work procedure being followed? If not, why not?
- Were safety devices in order? If not, why not?
- Was the worker trained? If not, why not?
An inquiry that answers these and related questions will probably reveal conditions that are more open to correction than attempts to prevent “carelessness”.