What Happens When Something Happens? Part 4
What should I know when making the analysis and conclusions?
At this stage of the investigation most of the facts about what happened and how it happened should be known. This has taken considerable effort to accomplish but it represents only the first half of the objective. Now comes the key question–why did it happen? To prevent recurrences of similar accidents, the investigators must find all possible answers to this question.
You have kept an open mind to all possibilities and looked for all pertinent facts. There may still be gaps in your understanding of the sequence of events that resulted in the accident. You may need to reinterview some witnesses to fill these gaps in your knowledge.
When your analysis is complete, write down a step-by-step account of what happened (your conclusions) working back from the moment of the accident, listing all possible causes at each step. This is not extra work: it is a draft for part of the final report. Each conclusion should be checked to see if:
- it is supported by evidence
- the evidence is direct (physical or documentary) or based on eyewitness accounts, or
- the evidence is based on assumption.
This list serves as a final check on discrepancies that should be explained or eliminated.
Why should recommendations be made?
The most important final step is to come up with a set of well-considered recommendations designed to prevent recurrences of similar accidents. Once you are knowledgeable about the work processes involved and the overall situation in your organization, it should not be too difficult to come up with realistic recommendations. Recommendations should:
- be specific
- be constructive
- get at root causes
- identify contributing factors
Resist the temptation to make only general recommendations to save time and effort.
For example, you have determined that a blind corner contributed to an accident. Rather than just recommending “eliminate blind corners” it would be better to suggest:
- install mirrors at the northwest corner of building X (specific to this accident)
- install mirrors at blind corners where required throughout the worksite (general)
Never make recommendations about disciplining a person or persons who may have been at fault. This would not only be counter to the real purpose of the investigation, but it would jeopardize the chances for a free flow of information in future accident investigations.
In the unlikely event that you have not been able to determine the causes of an accident with any certainty, you probably still have uncovered safety weaknesses in the operation. It is appropriate that recommendations be made to correct these deficiencies.
The Written Report
If your organization has a standard form that must be used, you will have little choice in the form that your written report is to be presented. Nevertheless, you should be aware of, and try to overcome, shortcomings such as:
- If a limited space is provided for an answer, the tendency will be to answer in that space despite recommendations to “use back of form if necessary.”
- If a checklist of causes is included, possible causes not listed may be overlooked.
- Headings such as “unsafe condition” will usually elicit a single response even when more than one unsafe condition exists.
- Differentiating between “primary cause” and “contributing factors” can be misleading. All accident causes are important and warrant consideration for possible corrective action.
Your previously prepared draft of the sequence of events can now be used to describe what happened. Remember that readers of your report do not have the intimate knowledge of the accident that you have so include all pertinent detail. Photographs and diagrams may save many words of description. Identify clearly where evidence is based on certain facts, eyewitness accounts, or your assumptions.
If doubt exists about any particular part, say so. The reasons for your conclusions should be stated and followed by your recommendations. Weed out extra material that is not required for a full understanding of the accident and its causes such as photographs that are not relevant and parts of the investigation that led you nowhere. The measure of a good accident report is quality, not quantity.
Always communicate your findings with workers, supervisors and management. Present your information ‘in context’ so everyone understands how the accident occurred and the actions in place to prevent it from happening again.
What should be done if the investigation reveals human error
A difficulty that has bothered many investigators is the idea that one does not want to lay blame. However, when a thorough worksite accident investigation reveals that some person or persons among management, supervisor, and the workers were apparently at fault, then this fact should be pointed out. The intention here is to remedy the situation, not to discipline an individual.
Failing to point out human failings that contributed to an accident will not only downgrade the quality of the investigation, it will also allow future accidents to happen from similar causes because they have not been addressed.
However never make recommendations about disciplining anyone who may be at fault. Any disciplinary steps should be done within the normal personnel procedures, not through the accident report.
How should follow-up be handled?
Management is responsible for acting on the recommendations in the accident investigation report. The health and safety committee, if you have one, can, and should, monitor the progress of these actions.
Follow-up actions include:
- Respond to the recommendations in the report by explaining what can and cannot be done (and why or why not).
- Develop a timetable for corrective actions.
- Monitor that the scheduled actions have been completed.
- Check the condition of injured worker(s).
- Inform and train other workers at risk.
- Re-orient worker(s) on their return to work.