Oregon OSHA Online Course 100Safety and Health Management Basics | | This material is for training purposes only. Its purpose is to inform Oregon employers of best practices in occupational safety and health and general Oregon OSHA compliance requirements. This material is not a substitute for any provision of the Oregon Safety Employment Act or any standards issued by Oregon OSHA. For more information on this online course and other OR-OSHA online training, visit the Online Course Catalog. |
MODULE SIX: INCIDENT/ACCIDENT ANALYSISGoing reactive!
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If your hazard identification and control program fails to eliminate workplace hazards, chances are pretty good an accident will happen. When it does, it's important to conduct an effective analysis of the accident process. Unfortunately, some employers perform accident investigations merely to place blame. When this occurs, the process becomes a very costly reactive procedure. |
The only way to receive any benefit from accident investigation is to make sure root causes are uncovered and permanently corrected. This module will help you understand the simple, but important steps in an effective accident investigation.
Although accident investigation is a valuable and necessary tool to help reduce accident losses, it is always considerably more expensive to rely on accident investigation than hazard investigation as a strategy to reduce losses and eliminate hazards in the workplace. In some cases it may cost hundreds of thousands of dollars more as a result of direct, indirect,
and unknown accident costs.
But, when the accident happens...it happens. And it's important to minimize accident costs to the company. This can be done if effective accident investigation procedures are used.
So, let's take a quick look at some basic concepts and then discuss the first steps to take in building an effective accident investigation program.
Accidents just happen...don't they?
Do they? Are they really unexpected or unplanned? If a company has 20 disabling injuries one year, and sets an objective to reduce the accident rate by 50% by the end of the next year, aren't they planning 10 accidents for that year? If they reach that goal, will they be happy about it...content? Is that really acceptable? (Just some food for thought)
What is an "accident"?
An accident is an unexpected (or unplanned, unwanted) workplace event that causes injury or illness to an employee. An accident will disrupt
the orderly flow of the work process. It involves the transfer of an excessive amount of energy due usually to the motion of people, objects, or substances.
Accident Causation Theories
Heinrich's Domino Theory In 1931 W.H. Heinrich developed the domino theory which argues that 98% of all accidents are caused by unsafe acts of people and actions and 2% by “acts of God”. He believed a five-step accident sequence occurred in which each factor would actuate the next step just like we see in a row of falling dominoes. The sequence of accident factors were:
1. ancestry and social environment
2. worker fault
3. unsafe act together with mechanical and physical hazard
4. accident
5. damage or injury. He believed that by removing a single domino in the row the sequence would be interrupted, thus preventing the accident. The key domino to be removed from the sequence, according to Heinrich was domino number 3. It's surprising how firmly
this theory took hold in the safety profession given that he provided no data for his theory.
Multiple Causation Theory
This theory argues that for any single accident there may be many contributing surface and root causes. This theory brings out the fact that rarely, if ever, is an accident the result of a single cause or act. Combinations of these give rise to accidents. According to this theory, the contributing factors may include:
A typical accident, according to this theory, is the result of many related and unrelated factors that somehow all come together at the same time. It is the unintentional harmful outcome of a number of otherwise stable interactive work processes that undergo changes. The process, itself, is a set of simultaneous, interacting, and cross-linked events. Oregon OSHA education supports and promotes this approach to accident analysis.
- Environmental factors. Hazardous conditions in the workplace such as improper guarding, defective equipment,
tools, equipment and machinery produced through inappropriate use and unsafe procedures.
- Behavioral factors. Factors such as improper attitude, lack of knowledge, lack of skills and inadequate physical and mental condition. These "states of being" also represent hazardous conditions in the workplace. It's important to understand there are underlying causes for these behavioral factors. Management can have great influence over these factors.
Pure Chance Theory
According to this theory, every of worker has an equal chance of being involved in an accident. Therefore, no single discernible pattern of events lead to an accident. All accidents correspond to "acts of God," and no interventions exist to prevent them. This theory contributes nothing at all towards developing preventive actions for avoiding accidents. (Personally, I think this approach to accident investigation is, itself, a major system weakness.)
Accident Proneness Theory
This
theory says that there exists within a workplace a subset of workers who are more liable to be involved in accidents. Contradictory research and professional consensus does not generally support this theory and, if accident proneness is supported by any empirical evidence at all, it probably accounts for only a very low proportion of accidents.
Energy Transfer Theory
This theory claims that a worker incurs injury from exposure to a harmful change of energy. For every change of energy there is a source, a path and a receiver. In OR-OSHA courses we refer to the harmful transfer of energy as the "Direct Cause of Injury." This theory is useful for evaluating work for energy hazards and engineering control methods.
Plan the work...work the plan!
When a serious accident occurs in the workplace, everyone will be too busy dealing with the emergency at hand to worry about putting together an investigation plan, so the best time to develop effective accident investigation
procedures is naturally before the accident occurs. The plan should include as a minimum procedures that determine and communicate:
- The purpose of the process (fix the system, not the blame!)
- Who should be notified of accident
- Who is authorized to notify outside agencies (fire, police, etc.)
- Who is assigned to conduct investigations
- Training required for accident investigators
- Who receives and acts on investigation reports
- Timetables for conducting hazard correction
Securing the accident scene
For a serious accident, the first action the accident team needs to take is to secure the accident scene so material evidence is not moved or removed. Material evidence has a tendency to walk off after an accident. If the accident is quite serious, OR-OSHA may inspect and require that all material evidence be marked and remain at the scene of the accident. The easiest
way to do this is to place yellow warning tape around the area. If tape is not available, warning signs or guards may be required.
Gathering information
The next step in the procedure is to gather useful information about what directly and indirectly contributed to the accident. Interviewing eye witnesses to the accident is probably one of the most important techniques in gathering information, but there are many other tools and techniques too. - Of course you want to get initial statements through interviews with eye witnesses. They can give you much information about the circumstances surrounding the accident. You should tell those who you initially interview that you may conduct follow-up interviews if more questions surface.
- Interview other interested persons such as supervisors, co-workers, etc.
- You should also interview records.... what? That's right, take a look at records associated with the accident, including:
- Training
records
- Disciplinary records
- Medical records (as allowed)
- Maintenance records
- EMT reports
- Police reports (rare)
- Coroner's report (fatalities)
- OSHA 300 Log (past similar injuries)
- Safety Committee records
- Take photographs of the scene.
- Videotape the scene.
- Make sketches of the scene.
- Make observations about the scene. Include measurements.
Remember you are gathering information to use in developing a sequence of steps that led up to the accident. You are ultimately trying to determine surface and root causes for the accident. It is not your job, as an accident investigator, to place blame. Just gather the facts.
What happened next?
Now you've gathered lots of information about the accident, and it's piled high on your desk. What do you do with it? It's important that you read through the information initially to develop an accurate sequence of events that led up to and
included the accident. See what an accident investigation sequence of events might look like below.
Sample accident investigation event sequence
The following is a sequence of events of an accident that actually occurred a few years ago.
1. Employee #1 returned to work at 12:30 PM after lunch to continue laying irrigation pipes.
2. At approximately 12:45 PM employee #1 began dumping accumulated sand and laying the irrigation mainline pipe.
3. Employee #1 oriented the pipe vertically and it contacted a high voltage power line directly over the work area.
4. Employee #2 heard a "zap" and turned to see the mainline pipe falling and employee #1 falling into the irrigation ditch.
5. Employee #2 ran to employee #1 and pulled him from the irrigation ditch, laid him on his back and ran about 600 ft. to his truck and placed a call for help on his mobile phone.
6. About four minutes
later, paramedics arrived and began to administer CPR on employee #1. They also used a heart defibrillator in an attempt to stabilize employee #1.
7. At about 1:10 p.m., an ambulance arrived and transported employee #1 to the hospital where he was pronounced dead at 1:30 p.m. |
OR-OSHA Course 102, Accident Investigation, goes into more detail on this subject.
What caused the accident?
The next step is to determine the surface and root causes for the accident. This step may be rather involved because you are first analyzing events to discover surface cause(s) for the accident, and then, by asking "why" each surface cause existed, attempting to identify their related root causes. Remember, surface causes are usually pretty obvious and not too difficult to uncover. However, you may find it takes a great deal more time to accurately determine the root causes (weaknesses in the management system) that contributed to the thinking, behaviors, and conditions associated
with the accident.
More on surface causes
The surfaces causes of accidents are those hazardous conditions and specific unsafe or inappropriate behaviors that have directly caused or contributed in some way to the accident.
Hazardous conditions may exist in any of the following categories: - Materials
- Machinery
- Equipment
- Tools
- Chemicals
| - Environment
- Workstations
- Facilities
- People
- Workload
| It's important to know most hazardous conditions in the workplace are the result of a number of unsafe or inappropriate behaviors that may occur anytime/many times, anywhere by any person(s) in the organization.
Some example of unsafe employee/manager behaviors include:
- Failing to comply with rules
- Using unsafe methods
- Taking
shortcuts
- Horseplay
- Failing to report injuries
- Failing to report hazards
| - Allowing unsafe behaviors
- Failing to train
- Failing to supervise
- Failing to correct
- Scheduling too much work
- Ignoring worker stress
|
More examples of direct and contributing surface causes:
1. Unguarded machinery exposing moving parts to employee.
2. Uneducated employee, first day on the job.
3. The employee removed a guard exposing himself to dangerous moving parts.
4. The employee did not perform required lockout/tagout procedures prior to servicing/maintenance.
5. The employee wore gloves while working around moving machinery parts.
6. The employer did not provide adequate safety orientation prior to the start of the employee's work tasks.
7. The employer did not provide adequate safety training related to removing machine guards -- lockout/tagout.
8. The employer
did not provide adequate safety training about the prohibition of use of gloves while working near moving machinery parts.
9. The employer did not provide adequate supervision for during the employee's first day of work. He was "on his own" with no supervisory oversight during the first day of work.
More on root causes
The root causes or "system causes" for accidents are the underlying system weaknesses that have somehow contributed to the general presence of hazardous conditions and common occurrence of unsafe behaviors that represent surfaces causes of accidents. If we see trends in conditions or behaviors - more than one unique instance - we should suspect system design or implementation weaknesses exist. Equally important is to understand that unsafe behaviors are caused by errors in thinking. The real solution is to find out why errors in thinking exist. Answering that question will usually uncover root causes.
Root causes always pre-exist
surface causes. Indeed, inadequately designed system components have the potential to feed and nurture hazardous conditions and unsafe behaviors. If root causes are left unchecked, surface causes will flourish!
Root causes may be separated into two categories: - Design weaknesses. Missing or inadequately designed programs, policies, plans, processes and procedures will naturally affect conditions and behaviors generally throughout the workplace. Defects in system design represent hazardous system conditions.
- Performance weaknesses. Failure to initiate, carry out, or accomplish safety policies, programs, plans, processes, and procedures. Defects in performance represent ineffective system behavior.
Root Cause - System Design Weaknesses - Failure to develop: - Missing or inadequate safety policies/rules
- Training program not in place
- Poorly written plans
- Inadequate
process
- No procedures in place
| Root Cause - Implementation Weaknesses - Failure to carry out: - Safety policies/rules are not being enforced
- Safety training is not being conducted
- Adequate safety supervision is not conducted
- Incident/Accident analysis is inconsistent
- Lockout/tagout procedures are not reviewed annually
|
More examples of system design and implementation root causes: 1. Safety training program for supervisors and managers does not include orientation responsibilities. (Design weakness)
2. New employees are not receiving an overview of safety rules during initial orientation. (Implementation weakness)
3. New employee orientation plan does not include a review of safety rules regarding use of gloves. (Design weakness)
4. Lockout/tagout training plan does not include training for "other" or "affected" employees. (Design weakness)
5. The safety committee is
not evaluating the employer's accountability system. (Implementation weakness)
6. Some departments are not conducting safety inspections. (Implementation weakness)
Time to report...
Now that you have developed the sequence of events and determined surface and root causes, it's time to report your findings. Some employers also ask accident investigators to make recommendations for corrective action, so be prepared for that.
Most companies purchase accident investigation forms. That's fine, but some forms leave little room to write the type of detailed report that is necessary for a serious accident. If you use such a form, make sure you attach important information like the sequence of events, and findings which include both surface and root causes.
A better idea is to develop your own form that includes the following five sections:
Section One: Background Information. This is the who, what, where, why, etc. It
merely tells who conducted the inspection, when it was done, who the victim was, etc: Just a fill-in-the-blank section.
Section Two: Description of the Accident. This section includes the sequence of events you developed to determine cause. Just take the numbers off, and make a nice concise paragraph that describes the events leading up to, and including the accident.
Section Three: Findings. This section includes a description of the surface and root causes associated with the accident. List the surface causes first, and then it's associated root cause. Remember, your investigation is to determine cause, not blame. It's virtually impossible to blame any one individual for a workplace accident. Don't let anyone pressure you into placing blame.
Section Four: Recommendations. This section may be part of your report if requested by your employer. Recommendations should describe the engineering/management controls and/or interim measures
that relate directly to the surface and root causes for the accident.
It's crucial, after making recommendations to eliminate or reduce the surface causes, you use the same procedure to recommend actions to correct the root causes. If you fail to do this, it's a sure bet that similar accidents will continue to occur.
Section Five: Summary. In this final section, it's important to present a cost-benefit analysis. What are the estimated direct and indirect costs of the accident being investigated? These represent potential future costs if a similar accident were to occur. Compare this figure with the costs associated with taking corrective action? You may want to address return on investment also (Cost benefit analysis and ROI is covered in OR-OSHA courses 102).
Let's Review!26. What approach do we take to most effectively analyze an accident? a. First determine if system weaknesses exist.
b. First determine if personal
weaknesses exist.
c. First determine if the employee violated safety rules.
d. First determine if the employee ignored instructions 27. The first step in the six-step accident investigation process described in the text is to: a. Call 911
b. Document the accident scene
c. Get witness statements
d. Secure the accident scene 28. In an accident investigation, which of the following steps follows the development of the sequence of events? a. Analyze each event to determine surface and root causes
b. Analyze each event to determine fault
c. Analyze each event to determine actors and actions
d. Analyze each event to determine solutions 29. According to the text, the process of analysis stops after: a. liability has been determined
b. the purpose of the analysis is fulfilled
c. the causes have been identified
d. the sequence of steps is determined 30. A worker has slipped
on a wet floor in the processing plant. Which of the following is not a possible root cause for this accident? a. Safety committee no inspecting
b. Housekeeping policy not enforced
c. Leak in a pipe
d. Inadequate hazard reporting Answer the questions on the following review quiz. Here are the answers. |
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