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.

Introduction

Workplace accidents occur each and every day all across the Country. Each Year the Bureau of Labor Statistics (www.bls.gov) publishes a statistical summary of injuries and illnesses (See summary below) that emphasizes this fact.

The failure of people, equipment, supplies, or surroundings to behave or react as expected causes most of the accidents. Accident investigations determine how and why these failures occur. By using the information gained through an investigation, a similar or perhaps more disastrous accident may be prevented. Conduct accident investigations with accident prevention in mind. Investigations are NOT to place blame.

BLS Summary: Workplace Injuries and Illnesses in 2000

A total of 5.7 million injuries and illnesses were reported in private industry workplaces during 2000, resulting in a rate of 6.1 cases per 100 equivalent full-time workers, according to the Bureau of Labor Statistics, U.S. Department of Labor. Employers reported about the same number of cases compared with 1999 and a 2 percent increase in the hours worked, reducing the case rate from 6.3 in 1999 to 6.1 in 2000. The rate for 2000 was the lowest since the Bureau began reporting this information in the early 1970s.

Of the 5.7 million total injuries and illnesses reported in 2000, about 2.8 million were lost workday cases, that is, they required recuperation away from work or restricted duties at work, or both. The remaining 2.9 million were cases without lost workdays. The incidence rate for lost workday cases was the same in 2000 as in 1999 (3.0 cases per 100 workers), while the rate for cases without lost workdays decreased from 3.3 cases per 100 workers to 3.2 cases per 100 workers.

This course introduces you to basic accident investigation procedures and describes accident analysis techniques. Throughout the course, you'll be taking what you've learned throughout the course to analyze a hypothetical accident!

What is an accident?

An accident is the final event in an unplanned process that results in injury or illness to an employee and possibly property damage.

An "event," occurs when one "actor" (one person/thing) performs an "action" (does something). In this definition, a person or thing will do something that results in a change of state (an injury). An accident may be the result of many factors (simultaneous, interconnected, cross-linked events) that have interacted in some dynamic way.

Why conduct an "investigation"?

The answer to this question is key to the success of the entire program. Does your organization conduct accident investigations for the same reason as Oregon OSHA? It shouldn't be. To determine the purpose of a process, it's important to look at the "output" of that process. The fatality investigation report is the output of the investigation process, so let's take a look at the sample given in OSHA Instruction CPL 2.113, Appendix C:

MEMORANDUM FOR: Regional Administrator
FROM: Area Director
SUBJECT: Results of Fatality Investigation

The following information supplements the OSHA-170, regarding investigation of the accident at _____ Company, Inc., which occurred on June 15, 1995.

Establishment Information: ____ Company, Inc., located at Grainfield Road, Grossfield, USA, has no previous inspection history. The company has a work force of 32 employees and operates on a seasonal basis, usually June to November.

Family Involvement: The next of kin information was obtained from the company and the CSHO telephoned to verify the information and advise the family that an investigation is in progress. The standard information letter was sent. There has been no further contact from the family.

Union Involvement: There is no union at this location.

Proposed Action: Issue citations for serious and other violations of machine guarding, open floor holes, hazard communication and recordkeeping with a penalty total of $5,475. A 5(a)(1) letter outlining the hazards to be corrected which were not clearly addressed by 29 CFR 1928 Safety and Health Standards for agriculture and for which other OSHA Standards are not applicable will also be mailed to the company.

The message in this document reflects the intent of OSHA to conduct accident investigation primarily to determine if violations in OSHA law caused the accident: The law mandates this approach. However, the law does not require your organization to carry out accident investigations for the same reason.

The employer's mandate: Analyze to fix the system...Don't investigate to fix the blame

Unfortunately, some employers believe that the investigation process ends once blame as been established. The problem, here, is that once the purpose of the analysis process has been achieved, analysis stops. When employers investigate to place blame, no further analysis is conducted to fix the underlying safety management system weaknesses that contributed to the accident.

According to OSHA's Safety & Health Program Management Guidelines, para (c)(2)(iv), the employer's primary purpose for investigating accidents is primarily, "so that their causes and means for preventing repetitions are identified."

OSHA goes on to say this about the investigation process:

"Although a first look may suggest that "employee error" is a major factor, it is rarely sufficient to stop there. Even when an employee has disobeyed a required work practice, it is critical to ask, "Why?" A thorough analysis will generally reveal a number of deeper factors, which permitted or even encouraged an employee's action. Such factors may include a supervisor's allowing or pressuring the employee to take short cuts in the interest of production, inadequate equipment, or a work practice which is difficult for the employee to carry out safely. An effective analysis will identify actions to address each of the causal factors in an accident or "near miss" incident."

Bottom line. The output of the employer's accident investigation process should not end with merely identifying violations of employer safety rules. The final report should focus on identifying safety management system weaknesses. Following this policy will help make sure the accident analysis process is a "profit center" activity for the company. It will result in long-term returns that are substantially greater than the investment put into the process.

The most effective employer accident investigations address liability only after an honest evaluation by a qualified person concludes that all relevant elements of the safety management system are effectively designed and implemented.

A quick reprimand almost guarantees adequate evaluation was not conducted.

Are accidents always unplanned?

We like to think that accidents are unexpected or unplanned events, but sometimes, that's not necessarily so. Some accidents result from hazardous conditions and unsafe behaviors that have been ignored or tolerated for weeks, months, or even years. In such cases, it's not a question of "if" the accident is going to happen: It's only a matter of "when." But unfortunately, the decision is made to take the risk.

A competent person can examine workplace conditions, behaviors and underlying systems to predict closely what kind of accidents will occur in the workplace. Technically, we can't say an accident is always unplanned. Like any system, a safety management system is designed perfectly to produce what it produces. Consequently, written safety plans may be (unintentionally) designed such that they create circumstances that cause accidents.

In companies that decide to take the risk, it's likely their attitude about accidents is that, "accidents just happen; there's nothing we can do about them." Of course, that's an unacceptable notion in any effective safety culture. Employers with a healthful attitude about accidents consider them to be "inexcusable," and demand that hazards be corrected before they cause an accident.

Accidents and incidents

Accidents are part of a broad group of events that adversely affect the completion of a task. These events are incidents. For simplicity, the procedures discussed in this course apply most appropriately to accidents, but they also applicable to all incidents in general.

Characteristics of effective incident/accident analysis program

The program will be guided by written plan that identifies specific procedures and responsibilities. It's important to make sure procedures are clearly stated and easy to follow in a step-by-step fashion.
The plan clearly assigns responsibility for conducting accident investigations. It's up to the employer to determine who conducts accident investigations. Usually a supervisor, management/labor team, or safety committee member conducts the investigation. Whoever conducts the investigation, needs to understand his or her role as an accident investigator. Usually, two heads work better than one, especially when gathering and analyzing material facts about the accident. We recommend a team approach.
All accident investigators will be formally trained on accident investigation techniques and procedures. Investigators may attend accident investigation training presented by OR-OSHA, private educational institutions, or in-house training conducted by a qualified person.
Accident investigation must be perceived as separate from any potential disciplinary procedures resulting from the accident. The purpose of the accident investigation is to get at the facts, not find fault. The accident investigator must be able to state with all sincerity, that he or she is conducting the investigation only for the purpose of determining cause, not blame.
The accident investigation report will be in writing and will make sure that the surface causes and root causes of accidents are addressed. Most accident reports are ineffective precisely because they neglect to uncover the underlying reasons or factors that contribute to the accident. Only by digging deep, can you eliminate the hazardous conditions and work practices that, on the surface, caused the accident.
The accident investigation report will make recommendations to correct hazardous conditions and work practices, and those underlying system weaknesses that "caused" them into existence. In many instances, the surface causes for the accidents are corrected on the spot, and will be reported as such. But the investigator must make recommendations for long-term corrections in the safety and health system to make sure those surface causes do not reappear.
Follow-up procedures to make sure short and long-term corrective actions are completed.
There will be an annual review of accident reports. A couple of safety committee members evaluate accident reports for consistency and quality. They must make sure root causes being addressed and corrected. To do this, information about the types of accidents, locations, trends, etc., should be gathered.

With all this in mind, let's move on to Module One to begin discussing the six-step process for conducting an effective accident investigation.

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