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 7: WRITING THE REPORT

Introduction

Now that you have accurately assessed and analyzed the facts related to the accident, you must report your findings to those who have authority, accountability, and can take action (We call this the "A Person"). In this module, we'll cover the procedure for effectively reporting the facts.

Perception is reality...

Never forget that your primary objective, as an accident investigator, is to uncover the causal factors that contributed to the accident. It's not your job to place blame. Your challenge is to be as objective and accurate as possible.

Your findings, and how you present them, will shape perceptions and subsequent corrective actions. If your report arrives at conclusions such as..."Bob should have used common sense," or "Bobbie forgot to use PPE," how effective will it be? Of course, it won't be effective at all. If your report concludes with statements such as this, it will be virtually impossible to take corrective actions that permanently eliminate the causes. It's likely that similar accidents will repeatedly occur. Bottom line: If the accident investigation doesn't fix the system, it's most likely been a waste of time and effort.

So the challenge is to report your findings in a well-thought-out manner so that management will more likely adopt recommendations for improving its safety processes, thus solving problems long-term.

The Accident Report Form

The primary reason accident investigations fail to help eliminate similar accidents, is that report forms are poorly designed. In many cases the form design actually makes it possible to identify and correct only surface causes: root causes are often ignored. Let's take a look at one format that is designed to give emphasis to root causes. You can also take a look at sample below. This is a report format similar to that used by OR-OSHA accident investigators in conducting workplace accident investigations:

Section I. Background

This section contains background information that answers questions about who the victim is, and the time, date, location of the accident, as well as other necessary details. Most forms do quite well detailing background information.

Section II. Description of the accident

This section presents a descriptive narrative of the events leading up to, including and immediately after the accident. It's important that the narrative paint a vivid "word picture" so that someone unfamiliar with the accident can clearly see what happened. The format you choose is important. You may want to eliminate or keep event numbers. See the example below.

Section II: Description of the Accident

Event -3. Employee #1 returned to work at 12:30 PM after lunch to continue laying irrigation pipes.

Event -2. At approximately 12:45 PM employee #1 began dumping accumulated sand from an irrigation mainline pipe.

Event -1. Employee #1 oriented the pipe vertically and it contacted a high voltage power line directly over the work area.

Event 0. Employee #2 heard a ‘zap’ and turned to see the mainline pipe falling and employee #1 falling into an irrigation ditch.

Event +1. 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.

Event +2. Employee #2 than ran back to find employee #1 had fallen back into the ditch.

Event +3. Employee #2 jumped back into the ditch and held employee #1 out of the water until help arrived.

Event +4. Two other ranch employees arrived and assisted employee #2 in getting employee #1 out of the ditch.

Event +5. Approximately one minute later, paramedics arrived and began to administer CPR on employee #1. They also used a heart defibrillation machine in an attempt to stabilize employee #1’s heart beat.

Event +6. At approximately 1:10 PM an ambulance arrived and transported employee #1 to the hospital where he was pronounced dead at 1:30 PM.

Section III. Findings

The findings section describes the hazardous conditions, unsafe behaviors and system weaknesses your investigation has uncovered. Each description of surface and root cause will also include justification for the finding. The justification will explain how you came to your conclusion.

Some report forms used today "force" the investigator to list only surface causes for accidents. Consequently, the investigator believes the job is done without ferreting out the root causes. Other forms offer very little space to write findings. The form does not "report" the root causes uncovered associated with each surface cause. It is not the object of this section to find fault or place blame. Just state the facts: The hazardous conditions, unsafe procedures, inadequate or missing policies, training, accountability, etc. Be sure to write complete descriptive sentences. Not short cryptic phrases.

Sample primary surface cause finding statements

The findings describe the hazardous conditions and unsafe behaviors that directly caused injury. They exist or occur immediately prior to the injury event.

Hazardous condition: The bolts for the machine guard on the chipper were missing and the grating cut open.
Unsafe behaviors: The injured employee fed limbs into the unguarded chipper, exposing himself to the hazardous condition.

Sample secondary surface cause finding statements

These findings describe those conditions and behaviors produced by individuals at some point prior to the injury event. These conditions, activities, practices and behaviors can exist at any time, in any place, and be produced by any person in the organization.

Hazardous condition: Tools to repair the machine guard were broken and unusable.
Unsafe behaviors: An employee (could not be determined who) failed to replace bolts on the guard. An employee defeated the guard by cutting through the guard grating producing a large hole. The injured employee had not been trained in chipper operation or machine guarding principles.

Sample safety program implementation root cause finding statements

These findings describe management failures to implement programs, processes, plans, procedures within the safety management system. These failures result in secondary surface causes; those conditions and behaviors common to work groups or the entire organization.

Inadequate process: Employees are not being properly trained in safe work procedures around high voltage lines. None of the employees exposed to high voltage have been trained. Supervisors are unfamiliar with rules and have not received training in this subject.
Inappropriate behaviors: Supervisors are generally allowing unsafe work practices associated with high voltage lines.

Sample safety program design root cause finding statements

These findings describe one or more inadequate safety management system policies, programs, and processes in any of the seven element areas: commitment, accountability, involvement, identification/control, incident/accident analysis, education/training, and evaluation. These "deep root causes" result in inadequate implementation of the safety management system.

Conditions: Safety training policy statement does not exist. Safety training plan does not include policies and practices for employees working around high voltage line systems. The safety training plan does not include supervisor or manager level training on this subject.

Section IV. Recommendations

If root causes are not addressed properly in Section III of the report, it is doubtful recommendations in this section will include improving system inadequacies. Effective recommendations will describe ways to eliminate or reduce both surface and root causes. They will also detail estimated investments involved with implementing corrective actions and system improvements. Let's take a closer look at effective recommendation writing.

Sample recommendations that correct primary surface causes

These recommendations describe how to correct those unique hazardous condition(s) and unsafe behaviors that directly resulted in injury. These recommendations will impact only the unique condition or behavior.

To correct a condition. Repair and/or replace the machine guard. Benefit: This hazardous condition is eliminated. Estimated investment: $200.00
To correct a behavior. Educate and train the injured employee on hazard reporting procedures. Benefit: The injured employee will understand and gain the skills necessary to prevent a similar accident. Estimated investment: $30.00

Sample recommendations that correct secondary surface causes

These recommendations describe how to correct those common hazardous conditions and unsafe or inappropriate behaviors that eventually "set up" or produced the unique conditions and behaviors of the injury event. Correcting secondary surface causes is accomplished by improving the implementation of the safety management system. These recommendations will have a general positive impact throughout the work group or organization.

Implement an effective education and training process covering machine guarding principles for all maintenance and affected employees Benefit: Affected employees will understand and be skilled in identifying and correcting machine guard hazards. Estimated investment: $500.00
Implement improved employee orientation that includes education and training on hazard reporting procedures. Benefit: New employees will understand and gain skills in appropriate hazard reporting procedures. Estimated investment: $100
Conduct supervisor/manager training on new policies. Management will better understand and gain skills in their responsibilities in response to hazard reports. Estimated investment: $200

Sample recommendations that correct implementation and design root causes

Solving implementation weaknesses is accomplished by improving system design. These recommendations address improvements to written safety management system and specific program policies and plans that correct inadequate implementation of processes and procedures. Recommendations may include improvements in more than one of the seven safety management system element areas discussed earlier. In most instances, safety committees and/or safety coordinators will be involved in this process. Draft policies, plans, procedures are developed and forwarded to upper management for approval.

Review and improve the safety training plan to ensure it includes machine guarding, lockout/tagout, and hazard reporting procedures. Benefit: Ensures the safety training plan addresses affected employee responsibilities regarding machine guarding, and other related safety programs. Estimated investment: $1500.00
Develop company safety policy and safe work plan addressing work near high voltage lines. Benefit: Ensures safe work policies and procedures regarding work around high voltage lines are detailed and properly implemented. Estimated investment: $1,000
Include supervisor/manager education and training in accountability principles and application. Benefit: Ensures management is effectively educated and trained in their accountabilities to the employer and employees, and how to administer corrective actions. Estimated investment: $500
Include supervisor/manager education and training in recognition principles and application. Benefit: Ensures management is effectively educated and trained in methods to motivate hazard reporting and discretionary behaviors such as suggesting and involvement. Estimated investment: $500

Section V. Summary

This section contains a brief review of the causes of the accident and recommendations for corrective actions. In your review, it's important to include language that contrasts the costs of the accident with the benefits derived from investing in corrective actions. Including bottom-line information will ensure that your recommendation will be understood and appreciated by management.

Section VI. Review and Follow-Up Actions

This section describes the actions taken to repair equipment/machinery, conduct training, revise policies, etc. It also describes the persons responsible for carrying out corrective actions and system improvements.

Section VII. Attachment

This section describes contains all of the photos, sketches, interview notes, etc. material to the investigation. Of course the more comprehensive the investigation, the more supporting documentation will be included here.

Last Words

There you have it...all there is to know about the accident analysis process, and how to report it. Well, not quire all there is to know...but you've worked hard on these seven modules and now have the basic understanding about effective accident investigation procedures. Only experience will transform knowledge into expertise. Good luck in that effort. One last task before you're through. It's time you take the module quiz.

Let's Review

31. What is the purpose of the accident report?

32. What, if anything, is incorrect or "wrong" about the following: "Finding -- Employee #1 demonstrated poor safety attitude by not properly wearing hearing protection.

33. In the finding above, what might be a root cause for the unsafe behavior?

34. Given your answer to the previous question, how might you rewrite the finding above?

35. Once the report is completed, who should receive it? Who receives it in your company?

Congratulations on completing this final module! If you haven't been working on the course assignments yet, now is the time to download the assignments page to draft your responses.

Once you've completed your draft responses, return to the course outline page, and click on the "Submit Your Coursework" link.

I hope the information within these eight modules as been helpful to you and I hope to see you participate in another course soon. When you're ready, submit your coursework, evaluation, and certificate information. As always, if you have any questions or comments, just drop me an email at email.

Have a great safe day!

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