by Jeanette Showalter
How many times have you addressed the same kind of accident or injury only to revisit it again? What if you didn’t have to keep fixing the same problem? How much time could you save?
Every organization wants to achieve a zero accident workplace, and there are companies that have proven it can be done. Reducing injuries will drop you worker’s compensation costs, keep employee moral high, and demonstrate the dollar value of your safety program to leadership.
Employee injuries are unacceptable, and yes, there are steps you can take to reduce the frequency and severity of accidents. One of the most critical ones is to thoroughly investigate every accident so you can identify the factors that led to it and put measures in place to prevent a future occurrence.
Since all accidents are preventable, corrective action is the key. If the investigation merely records the event, it has been a waste of time, effort, resources and paperwork. Nothing has changed and you’re left with another accident waiting to happen. With each event the risk becomes greater. The longer you ignore it, the worse it gets.
What Defines an Accident
An accident is the result of an unplanned process that causes injury or illness to an employee. In some cases, an incident might cause property damage instead, or in addition to injuries.
The key phrase here is “unplanned process.” No one comes to work to be hurt, and no system is ever designed to overlook safety. But gaps do occur. The four most commonly reported causes of injury are: lack of training; faulty equipment/process; inadequate oversight; and failure to enforce. Any one of these will cause OSHA to determine that your program to protect employees is ineffective.
• Lack of Training: Experienced or not, employees must be taught how to perform their tasks, so their responsibilities are specific and understood. And everyone performs the task the same way, so that deviations become highly visible.
• Supervisors must know how to perform the tasks they oversee so they are capable of ensuring they are being followed.
• Faulty Equipment/Process: Employee training must include use of equipment, PPE, inspection, and immediate reporting of defective machinery or programs. Reporting to the supervisor must be a positive experience resulting in correction of the cause.
• Inadequate Oversight: People will perform to the extent that they are measured. Supervisors must recognize excellence and level consequences for risky behaviors. How the job is done is not for the employees to decide.
When an incident does not cause harm or damage, it is referred to as a “near miss.” While it is critical to investigate accidents and injuries, “near misses” are a free warning that identifies risk before anyone is injured.
The purpose of your work systems is to accomplish the task efficiently and safely. Per OSHA, if an employee is injured, the company’s safety system has failed its responsibility to protect the employee from harm. For example:
• If the employee did not know how to perform the task; training was ineffective.
• If the employee ignored safety protocols; supervision was inadequate.
• If the equipment failed; maintenance was insufficient.
Why Investigate Accidents?
OSHA guidelines state that the primary purpose of investigating an accident is to ensure that its causes, and methods for preventing its re-occurrence, are identified and then addressed. Workplace accidents should also be investigated to:
• Fulfill legal requirements
• Determine the costs incurred (to demonstrate the value of success)
• Verify compliance with applicable and mandatory safety regulations
• Process worker compensation claims
10 Steps to Follow During an Accident Investigation
1) Take Immediate Action – Whenever an accident occurs, take immediate action to secure the area and interview those involved. The accident investigation team should include members with experience in accident causation and investigation techniques; knowledge of the work process, procedures, and personnel involved; and always include the employees who actually perform the task. It is helpful to provide team members with checklists so that critical information is not missed. Investigation team members must have decision-making authority to direct, authorize, and implement change. Members may include: immediate department supervisors, managers, and leads; employees with knowledge of the work, chemicals, or equipment; safety officers; safety committee members; and union representatives, if applicable.
2) Record the Accident – The person directly involved in the accident, or that person’s immediate supervisor, should fill out an accident report. Serious accidents (or incidents) should be reported immediately to the relevant manager in accordance with your emergency protocols.
3) Report to the Authorities – Severe accidents must be reported to Fed/OSHA (800-321-6742) as follows: A fatality within 8 hours; an in-patient-hospital admission, amputation, or loss of an eye within 24 hours.
4) Take Care of All Victims – Ensure that any and all accident victims are taken care of. Administer first aid, call first responders as needed, or transport victims for emergency medical care, and secure the area until it is safe for use.
5) Gather Information – Evidence and witness memories change with time. Observe and record as much initial information as soon as possible. Your goal is to understand what happened, as well as how and why. Accidents are embarrassing. Participants tend to rush to closure. Emphasizing cause, not blame, and reviewing the sequence of events thoroughly will encourage the dialog necessary. Cause of an injury cannot be assigned to the injured employee. We are not looking to blame, we are looking to prevent.
Possible causes to include and rule out include: hazardous conditions; unsupervised behaviors; inadequate or missing safety programs; defective equipment; inadequate PPE; lack of plans, policies, processes, instructions, and procedures and actions that were not taken which contributed to the accident have been included and/or ruled out.
Include multiple departments if indicated, and refrain from premature judgment until systemic weaknesses are corrected.
6) Review the Facts – Once you’ve developed the sequence of events, it is crucial to ask why the events took place as they did, and not as expected. For example, if defective equipment was a causal factor, your questions might be:
• Why was defective equipment unmarked and available for use?
• Is there a procedure for equipment inspection?
• Was the employee trained to pre-inspect equipment?
• Was there sufficient time to do so?
• Was the pre-inspection policy enforced?
• Was preventive maintenance of equipment current?
• Was sufficient equipment available so that defective equipment need not be used?
• Was the employee empowered to identify and remove defective equipment from service?
• Had the supervisor been notified?
7) Implement Solutions – Recommend improvements to prevent future incidents. Hazard control strategies must be specific, observable and measurable to demonstrate that the controls or corrections made have been effective at eliminating the causes of the accident.
Write a thorough report. The manner in which you present your findings will shape perceptions and subsequent corrective actions. The accident report form should include:
• Background
• Description of the accident
• Findings
• Recommendations
• Summary (list participants)
• Corrections and follow-up actions
• Attachments (photos, sketches, interview notes, and so on)
8) Calculate the Costs – The cost (or potential cost) of an incident may be calculated as part of the investigation and included in the final report. This may include both direct costs and indirect costs.
Direct (insured) costs: worker’s compensation payments, medical expenses, legal services.
Indirect (uninsured) costs: lost work time, hiring/retraining, property damage, OSHA fines.
9) Conduct a Root Cause Analysis – A root cause analysis is a methodical process to evaluate and estimate the risks associated with a particular hazard. The purpose of conducting a root cause analysis is to identify the underlying problems within the system of work that failed to prevent the injury. If the incident was a direct result of employee actions, what system could have prevented those actions? What process failed? (training, supervision, enforcement, maintenance…) It becomes easy to see that assigning blame does not fix programs that failed to protect.
10) Record the Details – Keep records and documentation of all accident notification, reporting, investigation, and corrective actions. Keep these records for at least three years or for the period required by legislation in your jurisdiction.
Wrap Up
The primary objective of accident investigation is to uncover and eliminate the factors that contributed to the accident, to protect your employees. Using the opportunity to improve the protective system(s) prevents recurrences and improves your program.
Jeanette Showalter is a Health and Safety Advisor with 38 years of experience in safety management. She can be reached by calling (619) 462-4469 or email [email protected].