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SAFETY SOLUTIONS: Accident Prevention & Investigation
What would you do if someone came to you and
said, “We just had an accident?” Are you prepared
to conduct an effective accident investigation?
Most companies do not look for all the root causes
of the accident, but concentrate on the injured employee
as the cause of the accident occurring. This is not realistic.
Accidents are signs of a management system that is
not working. I am not blaming management but I am
blaming the management system. For example, why did
the unsafe condition exist? Why didn’t someone notice it?
And the list goes on. If I asked you if your company had a
safety manual, most would answer, “Yes” but if I asked you
if everyone knew what was in the manual, the answer
would probably be. “No.” I can’t tell you how many times,
when I am teaching at a client’s location or the OSHA
Training Institutes and I ask the safety professional to tell
me what is in their manual, in many cases they cannot tell
me themselves. How can an employee follow the company
safety manual if the safety director is unable to relate
what is even covered in the manual?
Accidents are usually thought of as a negative aspect of
production and they are. They’re something you want to
avoid, prevent and eliminate. But accidents have a positive
aspect as well. They show us the gaps in our safety
programs, procedures and practices. And they help us
understand what we need to do to correct the situation to
improve safety performance.
The whole point of accident investigations is not to lay
blame or discredit existing safety efforts. It’s solely to find
out what happened, so that similar incidents can be prevented
in the future. With that focus in mind, accident
investigations can be carried out efficiently and produce
positive results for your entire facility.
William Heinrich the (Grandfather of Industrial Safety)
built a safety triangle, commonly known as the safety
pyramid or accident pyramid, It was originated in 1931
and detailed in his book, Industrial Accident Prevention: A
Scientific Approach. Widely accepted for over 70 years,
the safety triangle serves to illustrate Heinrich’s theory of
accident causation: unsafe acts lead to minor injuries and,
over time, to major injury. The accident pyramid proposes
that for every 300 unsafe acts or near misses, 29 minor
injuries or first aid cases and one major injury or lost time
case will result. Have you had any first aid or lost time
cases this year? If your answer was yes, then based on
Heinrich, you had 300 chances to correct the problem
before someone was injured.
Since unsafe acts are difficult to record accurately and
Heinrich’s theory seems logical, the safety pyramid
remained unchallenged for decades.
Effective accident investigation requires a number of
important steps:
- Investigate all accidents. This includes near misses and
accidents that did not result in injury. According to the
National Safety Council, 75 percent of all workplace accidents
were preceded by a near-miss incident.
- Study the accident scene. The accident scene should be
secured immediately after the accident to prevent anyone
from moving or touching any material evidence. As you
examine the scene, look for clues that will help you pinpoint
the cause of the accident. Take photographs to preserve evidence
and help you reconstruct the accident later, after the
area has been cleaned up and normal operations have
resumed.
-
Examine the events. Consider the who, what, when,
where, how and why of the incident. Look at not only the
specific events involved in the accident, but also at what
was going on around it. Who was there? What were they
doing? Which materials and equipment were involved in
the accident? What about the surrounding work area?
What hazards might have existed there at the time? Could
any of these things have contributed to the accident?
- Talk to witnesses. As soon after the accident as possible,
talk to everyone who might have seen anything. You must
move quickly here. Memories fade and get mixed up after
even a few hours. And don’t forget the most important witness
of all—the victim. If possible, speak to the victim as
soon after the accident as possible to get their perspective
on what happened. Be sure to encourage cooperation by
reassuring employees that your goal is to find out what
happened so that future accidents can be prevented, not
to lay blame.
- Determine the underlying causes. Was this accident
caused by an unsafe act or unsafe condition? Are the circumstances
involved in this accident limited to a particular
work area or department, or does it have plant-wide
safety implications? Look for patterns. And don’t forget to
dig deep. Often the most obvious reasons for the accidents
aren’t the only causes. For example, with accidents
that appear to be caused by unsafe conditions, there are
usually contributing causes that may not be easy to spot
initially, such as lack of training or use of worn or inadequate
personal protective equipment.
- Write the incident report. The report should include all
the facts of the incident (who, what, where, when, how and
why). Then go on to explain your findings and draw your
conclusions in clear and direct language. Be sure to
include recommendations for corrective action. While your
investigation of the scene and interviewing of witnesses
should proceed with all possible haste, the writing of your
report should be a thoughtful exercise, one on which you
should take the necessary time to draw meaningful conclusions.
When the report is completed it should be circulated
to the appropriate managers and filed according to
established policy.
- Act on your findings. Remember that the real significance
of the accident investigation is to prevent similar
incidents in the future. Be sure to act on your findings. For
example, provide additional training, correct unsafe conditions,
revise procedures that may be causing safety
problems or rewrite safety rules. Circulate your incident
report to managers in other departments who may face
similar safety problems. Do whatever is required to help
ensure that this accident won’t happen again.
If you have questions, please feel free to contact me. I
would like to thank BLR for allowing me to use some of
their materials.
For more information, click on the author biography at the top of the page.
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