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OSHA does not require employers to perform accident investigations, except in relation to Process Safety Management of Highly Hazardous Chemicals. OSHA does, however, expect employers to protect workers from recognized hazards. Investigating accidents to identify and mitigate the root causes is essential to preventing similar accidents from happening in the future.
All accidents, incidents, and near misses should be investigated. The focus of the investigation should be to identify the root cause. While there are many reasons for investigating accidents, the main reason is to keep similar accidents from happening again. Effective and thorough accident investigations show employees that their employer is concerned for their safety and well-being.
Except in relation to Process Safety Management (PSM), the Occupational Safety and Health Administration (OSHA) does not require employers to perform accident investigations. However, some states do require them, so be sure to understand any state laws and regulations. In addition, many insurance companies require accident investigations as a condition of coverage.
When an investigation is performed properly, the results can provide important information to help prevent future accidents. Breaking the chain of accident repetition is one of the most important reasons for accident investigations.
Showing concern for employees is another important aspect. Thorough investigations show employees that their employer is committed to providing a healthy and safe working environment. In contrast, poor accident investigations that only address what happened (or blame employees) may give employees the impression that the company doesn’t care about them.
Unfortunately, many employers and employees feel that the main reason for accident investigation is to find fault. Worse, supervisors may openly reprimand those involved in an accident in front of their peers. Employees may be suspended from work, reassigned to a different work area, or required to attend refresher training. Some employees may even be fired for being involved in an accident. Such consequences discourage interest and participation in the accident investigation. Participation can be encouraged, however, if employees understand the importance of accident investigations and the reasons for conducting an investigation.
Investigation objectives
To promote the need for accident investigations, it is a good idea to have some main objectives in mind. While there are more than four objectives, at least these four should always be considered:
Identifying root causes
Identifying root causes is the central purpose behind accident investigations. The goal should be to identify failures at a deep level in order to prevent not only a recurrence of the accident, but all potential accidents stemming from the same root cause.
Exposing errors in processes
Exposing errors in processes is an important part of the investigation because one or more errors may have played a part in the accident. The following list provides some examples of possible errors in processes:
Correcting unsafe acts and conditions
While investigating an accident, some unsafe conditions likely will be discovered. In addition to conditions that may have caused the accident, other conditions that may have contributed to the accident in some way might also be discovered.
The Occupational Safety and Health Administration (OSHA) requires employers to report any fatality, amputation, hospitalization, or loss of eye to the agency within prescribed time frames. Depending on the specifics of the case, OSHA will either perform an on-site inspection or conduct a Rapid Response Investigation (RRI).
During an RRI, OSHA asks employers to conduct a root cause analysis of the injury and report their findings to OSHA, along with steps taken or to be taken to correct the hazard and keep it from happening again.
If an employer conducts a thorough root cause analysis and implements findings, it is unlikely OSHA will then conduct an on-site inspection. However, if the employer does not respond adequately, an on-site inspection will likely be conducted.
Incident investigation is required under the Occupational Safety and Health Administration (OSHA) Process Safety Management (PSM) Standard at 1910.119. Employers covered by the standard must investigate each incident that resulted in, or could reasonably have resulted in, a catastrophic release of highly hazardous chemical in the workplace. The regulation requires employers to start an incident investigation as promptly as possible, but no later than 48 hours after the incident.
Employers must:
Form an incident investigation team
The incident investigation team must be made up of at least one person who understands the process involved in the incident. This person may be a contract employee if he or she is the person with the appropriate knowledge and experience to thoroughly investigate and analyze the incident.
Write a report
OSHA requires PSM-covered facilities to prepare a report at the conclusion of the investigation with the following information:
Review the report with all employees whose job tasks are relevant to the incident findings, including contract employees where applicable.
Establish a system to address the hazards
After the investigation, the employer must implement a system to promptly address and resolve the incident report findings and recommendations. Resolutions and corrective actions must be documented.
Retain reports and other documentation for five years.
Effective accident investigation starts before an accident by establishing a well-planned investigation procedure and a written plan. Preplanning is especially important because the quantity and quality of information begins to diminish immediately following the accident.
The accident investigation team should be organized before an accident happens so team members can be trained in accident investigation procedures. Assembling an accident investigation kit is also critical.
Organizing an investigation team
Organize an accident investigation team before an accident occurs so team members can become familiar with the investigation procedures. Team members should know how to:
Although team membership will vary according to the type of accident, a typical team investigating an operating area accident might include:
Training the investigation team
Members of the accident investigation team should be trained to conduct an investigation. This includes interview techniques, writing reports, evaluating findings, estimating costs, and a host of other activities. Make the team aware of how the investigation reports will be used.
Developing a written plan
The preparation process includes developing a written plan. At a minimum, a written plan should contain the following types of information:
Assemble a kit
The planning process also requires assembling equipment needed to perform investigative duties. This equipment should be contained in an accident investigation kit. Examples of basic equipment include:
Conducting an effective accident investigation will involve the following steps:
People responding to an accident tend to be in a hurry because there may be injured workers who need help. Responders should use caution to arrive safely. If the first person to arrive is alone at the scene, the responder should:
In most cases, several employees will quickly arrive at the accident scene. A designated person should be in charge, preferably the accident investigator, and that person should delegate authority and set priorities. Some accident scene priorities may include:
While preserving the evidence at the accident scene is essential, it should never be more important than helping others in need or more important than protecting company property from further damage.
Controlling the accident scene is critical, not only to the success of an accident investigation, but also to the safety of those working at the scene. If the accident scene is disturbed, such as equipment moved or spills cleaned up, gathering facts about what happened will be more difficult. In addition, if bystanders are allowed to enter the accident area, they may interfere with the work of response personnel or disturb evidence needed for the investigation.
Securing the scene
Accident scenes are often disorganized; people may be hurt and equipment might be damaged. In addition, people involved in the accident or who witnessed the accident will likely be upset and may even be in shock. To help control the scene:
To secure the accident area, ensure that no one at the scene is in further danger from hazards such as falling debris, sharp objects, or rolling equipment. Continue to secure the area by surveying the accident scene for other hazards such as:
In order to prevent additional injuries, many of these hazards may need to be immediately corrected (such as the removal of fallen electrical wires), thereby disturbing the accident scene. If this is the case, try to get photos and sketches of the hazards and record some notes about how the hazards may have played a part in the accident.
These recommendations present a suggested direction; they are not mandatory. Because of the variety of accidents investigated and the diversity of operations, no attempt is made to provide a format for use in all situations. Rather, these guidelines represent an example of an effective investigation procedure that will help to:
Evidence is anything that helps to establish the facts of an accident investigation to help determine a root cause. Types of evidence can include:
Position of tools and equipment: The position of tools and equipment can provide information about how they were being used (or misused) prior to the accident. Because forklifts and other equipment often look the same, record the serial numbers or other identification numbers to help later identify the specific piece of equipment involved in the accident.
Air quality: If the quality of the air may have contributed to the accident in some way, test the air. Specific things to look for when evaluating air quality include exposure to:
If the air quality contributed to the accident, evaluate the engineering or administrative controls to see if the air quality can be improved, and ensure that proper personal protective equipment (PPE) is used. Determine if employees in the accident area were exposed above the permissible exposure limits (PELs).
Equipment operations logs: Equipment operations logs may provide information about the mechanical integrity of equipment, as well as where, when, and how the equipment has been used. Operations logs, charts, and records may also offer vital information about how the equipment was designed, constructed, installed, and maintained. These records also provide information about equipment malfunction history.
Work environment: Determine if any debris, trash, tools, or equipment contributed to the accident. Additional items to investigate could center around the following types of questions:
Floor or surface conditions: Floor or surface conditions often contribute to accidents. Some questions to ask regarding floor or surface conditions could include:
Other contributing factors: Some examples of other contributing factors to consider investigating include:
Photos document the facts surrounding an accident and provide the investigator with accurate information about the accident. In order to preserve the facts, instruct workers at the accident scene not to move equipment or other items involved in the accident until photos have been taken of the scene. If equipment must be moved to rescue injured workers, instruct the rescuers to move only what is absolutely necessary.
Take photos of anything that will help reconstruct the entire accident scene. This will usually require a series of photos that first focus on the general area, then progress to specific detailed items. When taking a series of photos, consider the following guidelines:
Record notes that explain the purpose of each picture and the reasons for taking the picture. These notes will help when creating an accident investigation report. Although photos capture relevant information, they can capture irrelevant information as well. As investigative team members study the photos, it is easy to become distracted with all the details and lose focus on what is truly important.
Other disadvantages to photos include: they may be distorted, and they do not show actual distances. For this reason, sketches of the accident scene should be used in parallel with photos.
Sketching the scene
Sketches are drawings made at an accident scene that provide detailed information about the accident. Sketches are helpful because they can be used later in the final accident investigation analysis and report.
A sketch often provides information that a photo will not. While photos play an important role, the images contain everything the camera sees, including things irrelevant to the investigation. In contrast, sketches contain only pertinent information that helps determine the accident cause.
Sketches should always include information such as an arrow pointing north, angles, distances, locations of people and equipment, and structural or geographical data. Include notes about the sketches that will aid in their use and understanding later. Sketches should only contain information that is directly related to the accident scene.
Accident investigation notes are a record of the facts surrounding an accident that contain information about what people have witnessed. Writing good notes helps develop the final accident investigation report.
Investigation notes should focus on the who, what, when, where, how, and why facts of the accident. Some example questions to ask during an investigation that could be used in the investigation report include:
Who:
What:
When:
Where:
How:
Why:
Conducting a detailed interview is probably not necessary for every accident. However, a consistent approach will enhance any ongoing analysis of accident types and trends.
When interviewing the victim(s) and observers, the goal is to get the facts, not to assign blame or point out how expensive or damaging the situation may be.
To conduct productive interviews, consider the following points:
Before conducting an interview, an interviewer should verify compliance with all company policies and/or union contracts. Also, privacy is essential when interviewing. Conduct interviews in a nearby office or vehicle.
List of interviewing do’s
Successful interviewers stress these techniques:
List of interviewing don’ts
When conducting the interview:
Identifying a root cause is ultimately what the accident investigation is all about. The investigation will likely discover several causes, not just one. Determining root causes involves:
It’s important to understand the difference between a symptom or surface cause, and a root cause.
A symptom is a contributing factor, while a root cause is the actual cause of the accident. For example, if a hammer falls from a scaffold and strikes a worker, the symptom is the falling hammer. The root cause might be a missing toeboard on the scaffold, where the hammer was accidentally pushed off the edge. Telling a worker to be more careful is unlikely to prevent other items from falling in the future.
While it is important to evaluate surface actions and conditions, doing so often leads to an emphasis on the individuals, which then tends to focus blame.
After identifying the root cause or causes, use that information to develop the corrective and preventive actions that will help prevent future accidents.
Reviewing the evidence
Examining the evidence collected along with the notes, photos, and sketches should help identify a root cause. If clarification is needed, consulting further with the accident witnesses and victims may be an option. Understand that some witnesses and victims may be able to provide a detailed account of the accident, while others may not be able to recall much information. Simply try to get them to remember as much information as they can.
Finally, understand that some witnesses or victims may not wish to discuss the accident if they were traumatized by the event. Be sure to ask witnesses or victims if they are able to further discuss the accident.
Examining reasons for employee actions
When looking for root causes, determine why an employee acted a particular way prior to the accident, and look at the specific conditions of the task performed just prior to the accident. Some questions to consider include the following:
Remember, the goal should be to identify the failures at a deep level in order to prevent not only a recurrence of the accident, but all potential accidents stemming from the same root cause.
Source: Occupational Safety and Health Administration (OSHA) incident investigation guide, 2015
A thorough approach to identifying root causes involves questioning employees and supervisors about actions and conditions surrounding the accident. The following questions provide ideas to help an interviewer drill down to the root causes:
One option for uncovering a root cause is to repeatedly ask “why” questions until the process uncovers a deeper reason for a failure.
The Five Whys is one root cause analysis methodology. It is used to explore the cause/effect relationships underlying a particular problem. Ultimately, the goal of applying the Five Whys method is to determine a root cause of a defect or problem.
The following example of a car not starting demonstrates the basic process:
Note that the questioning could be taken to a sixth, seventh, or even greater level since the “five” in Five Whys is not set in stone. However, five iterations is generally sufficient to identify a root cause. The real key is to encourage the troubleshooter to avoid assumptions and logic traps and instead to trace the chain of causality in direct increments from the effect through any layers of abstraction to a root cause that still has some connection to the original problem.
After determining the root cause of an accident, corrective and preventive actions must be implemented that will eliminate, or at least reduce, the chances of another accident occurring.
Developing an effective set of corrective and preventive actions starts with an evaluation of the identified root cause(s). Usually, recommendations for corrective actions follow in a rather straightforward manner.
Evaluate each root cause to determine how it can be prevented in the future. With the help of other supervisors, managers, and employees, discuss ways to remove the root cause from the system. Ensure that root causes (not merely symptoms or surface causes) are evaluated and discussed.
To aid in a discussion of root causes, refer to the list of why or why-not questions that probably led to the root cause. Develop a list of potential employee actions that may have contributed to the accident. By thoroughly evaluating this information, an investigator will be one step closer to reducing or eliminating root causes of accidents.
Depending on the situation and the type of root cause, there may be several potential options for reducing or eliminating root causes. Some examples may include:
Often, a thorough accident investigation will result in recommendations for improving a process or reducing hazards. Use the investigation as an opportunity to look for ways to improve the efficiency of a process, the working habits of employees, and the overall safety of the working area.
Some example recommendations may include: increasing lighting in a work area, improving machine guarding, establishing new procedures for housekeeping, or improving communication between management and employees.
Communicating the findings
Because upper management is ultimately responsible for the health and safety of the workforce, the findings of the accident investigation must be reported to them. In order to effectively communicate the investigation findings, provide the following information in the final report:
Through proper documentation of the accident investigation findings, and by reviewing the results of the investigation with appropriate personnel, recurrence of accidents may be prevented.
When an investigation is performed properly, the results can provide important information to help prevent future accidents. Breaking the chain of accident repetition is one of the most important reasons for accident investigations.
Showing concern for employees is another important aspect. Thorough investigations show employees that their employer is committed to providing a healthy and safe working environment. In contrast, poor accident investigations that only address what happened (or blame employees) may give employees the impression that the company doesn’t care about them.
Unfortunately, many employers and employees feel that the main reason for accident investigation is to find fault. Worse, supervisors may openly reprimand those involved in an accident in front of their peers. Employees may be suspended from work, reassigned to a different work area, or required to attend refresher training. Some employees may even be fired for being involved in an accident. Such consequences discourage interest and participation in the accident investigation. Participation can be encouraged, however, if employees understand the importance of accident investigations and the reasons for conducting an investigation.
Investigation objectives
To promote the need for accident investigations, it is a good idea to have some main objectives in mind. While there are more than four objectives, at least these four should always be considered:
Identifying root causes
Identifying root causes is the central purpose behind accident investigations. The goal should be to identify failures at a deep level in order to prevent not only a recurrence of the accident, but all potential accidents stemming from the same root cause.
Exposing errors in processes
Exposing errors in processes is an important part of the investigation because one or more errors may have played a part in the accident. The following list provides some examples of possible errors in processes:
Correcting unsafe acts and conditions
While investigating an accident, some unsafe conditions likely will be discovered. In addition to conditions that may have caused the accident, other conditions that may have contributed to the accident in some way might also be discovered.
The Occupational Safety and Health Administration (OSHA) requires employers to report any fatality, amputation, hospitalization, or loss of eye to the agency within prescribed time frames. Depending on the specifics of the case, OSHA will either perform an on-site inspection or conduct a Rapid Response Investigation (RRI).
During an RRI, OSHA asks employers to conduct a root cause analysis of the injury and report their findings to OSHA, along with steps taken or to be taken to correct the hazard and keep it from happening again.
If an employer conducts a thorough root cause analysis and implements findings, it is unlikely OSHA will then conduct an on-site inspection. However, if the employer does not respond adequately, an on-site inspection will likely be conducted.
Incident investigation is required under the Occupational Safety and Health Administration (OSHA) Process Safety Management (PSM) Standard at 1910.119. Employers covered by the standard must investigate each incident that resulted in, or could reasonably have resulted in, a catastrophic release of highly hazardous chemical in the workplace. The regulation requires employers to start an incident investigation as promptly as possible, but no later than 48 hours after the incident.
Employers must:
Form an incident investigation team
The incident investigation team must be made up of at least one person who understands the process involved in the incident. This person may be a contract employee if he or she is the person with the appropriate knowledge and experience to thoroughly investigate and analyze the incident.
Write a report
OSHA requires PSM-covered facilities to prepare a report at the conclusion of the investigation with the following information:
Review the report with all employees whose job tasks are relevant to the incident findings, including contract employees where applicable.
Establish a system to address the hazards
After the investigation, the employer must implement a system to promptly address and resolve the incident report findings and recommendations. Resolutions and corrective actions must be documented.
Retain reports and other documentation for five years.
Effective accident investigation starts before an accident by establishing a well-planned investigation procedure and a written plan. Preplanning is especially important because the quantity and quality of information begins to diminish immediately following the accident.
The accident investigation team should be organized before an accident happens so team members can be trained in accident investigation procedures. Assembling an accident investigation kit is also critical.
Organizing an investigation team
Organize an accident investigation team before an accident occurs so team members can become familiar with the investigation procedures. Team members should know how to:
Although team membership will vary according to the type of accident, a typical team investigating an operating area accident might include:
Training the investigation team
Members of the accident investigation team should be trained to conduct an investigation. This includes interview techniques, writing reports, evaluating findings, estimating costs, and a host of other activities. Make the team aware of how the investigation reports will be used.
Developing a written plan
The preparation process includes developing a written plan. At a minimum, a written plan should contain the following types of information:
Assemble a kit
The planning process also requires assembling equipment needed to perform investigative duties. This equipment should be contained in an accident investigation kit. Examples of basic equipment include:
Conducting an effective accident investigation will involve the following steps:
People responding to an accident tend to be in a hurry because there may be injured workers who need help. Responders should use caution to arrive safely. If the first person to arrive is alone at the scene, the responder should:
In most cases, several employees will quickly arrive at the accident scene. A designated person should be in charge, preferably the accident investigator, and that person should delegate authority and set priorities. Some accident scene priorities may include:
While preserving the evidence at the accident scene is essential, it should never be more important than helping others in need or more important than protecting company property from further damage.
Controlling the accident scene is critical, not only to the success of an accident investigation, but also to the safety of those working at the scene. If the accident scene is disturbed, such as equipment moved or spills cleaned up, gathering facts about what happened will be more difficult. In addition, if bystanders are allowed to enter the accident area, they may interfere with the work of response personnel or disturb evidence needed for the investigation.
Securing the scene
Accident scenes are often disorganized; people may be hurt and equipment might be damaged. In addition, people involved in the accident or who witnessed the accident will likely be upset and may even be in shock. To help control the scene:
To secure the accident area, ensure that no one at the scene is in further danger from hazards such as falling debris, sharp objects, or rolling equipment. Continue to secure the area by surveying the accident scene for other hazards such as:
In order to prevent additional injuries, many of these hazards may need to be immediately corrected (such as the removal of fallen electrical wires), thereby disturbing the accident scene. If this is the case, try to get photos and sketches of the hazards and record some notes about how the hazards may have played a part in the accident.
These recommendations present a suggested direction; they are not mandatory. Because of the variety of accidents investigated and the diversity of operations, no attempt is made to provide a format for use in all situations. Rather, these guidelines represent an example of an effective investigation procedure that will help to:
Evidence is anything that helps to establish the facts of an accident investigation to help determine a root cause. Types of evidence can include:
Position of tools and equipment: The position of tools and equipment can provide information about how they were being used (or misused) prior to the accident. Because forklifts and other equipment often look the same, record the serial numbers or other identification numbers to help later identify the specific piece of equipment involved in the accident.
Air quality: If the quality of the air may have contributed to the accident in some way, test the air. Specific things to look for when evaluating air quality include exposure to:
If the air quality contributed to the accident, evaluate the engineering or administrative controls to see if the air quality can be improved, and ensure that proper personal protective equipment (PPE) is used. Determine if employees in the accident area were exposed above the permissible exposure limits (PELs).
Equipment operations logs: Equipment operations logs may provide information about the mechanical integrity of equipment, as well as where, when, and how the equipment has been used. Operations logs, charts, and records may also offer vital information about how the equipment was designed, constructed, installed, and maintained. These records also provide information about equipment malfunction history.
Work environment: Determine if any debris, trash, tools, or equipment contributed to the accident. Additional items to investigate could center around the following types of questions:
Floor or surface conditions: Floor or surface conditions often contribute to accidents. Some questions to ask regarding floor or surface conditions could include:
Other contributing factors: Some examples of other contributing factors to consider investigating include:
Photos document the facts surrounding an accident and provide the investigator with accurate information about the accident. In order to preserve the facts, instruct workers at the accident scene not to move equipment or other items involved in the accident until photos have been taken of the scene. If equipment must be moved to rescue injured workers, instruct the rescuers to move only what is absolutely necessary.
Take photos of anything that will help reconstruct the entire accident scene. This will usually require a series of photos that first focus on the general area, then progress to specific detailed items. When taking a series of photos, consider the following guidelines:
Record notes that explain the purpose of each picture and the reasons for taking the picture. These notes will help when creating an accident investigation report. Although photos capture relevant information, they can capture irrelevant information as well. As investigative team members study the photos, it is easy to become distracted with all the details and lose focus on what is truly important.
Other disadvantages to photos include: they may be distorted, and they do not show actual distances. For this reason, sketches of the accident scene should be used in parallel with photos.
Sketching the scene
Sketches are drawings made at an accident scene that provide detailed information about the accident. Sketches are helpful because they can be used later in the final accident investigation analysis and report.
A sketch often provides information that a photo will not. While photos play an important role, the images contain everything the camera sees, including things irrelevant to the investigation. In contrast, sketches contain only pertinent information that helps determine the accident cause.
Sketches should always include information such as an arrow pointing north, angles, distances, locations of people and equipment, and structural or geographical data. Include notes about the sketches that will aid in their use and understanding later. Sketches should only contain information that is directly related to the accident scene.
Accident investigation notes are a record of the facts surrounding an accident that contain information about what people have witnessed. Writing good notes helps develop the final accident investigation report.
Investigation notes should focus on the who, what, when, where, how, and why facts of the accident. Some example questions to ask during an investigation that could be used in the investigation report include:
Who:
What:
When:
Where:
How:
Why:
Conducting a detailed interview is probably not necessary for every accident. However, a consistent approach will enhance any ongoing analysis of accident types and trends.
When interviewing the victim(s) and observers, the goal is to get the facts, not to assign blame or point out how expensive or damaging the situation may be.
To conduct productive interviews, consider the following points:
Before conducting an interview, an interviewer should verify compliance with all company policies and/or union contracts. Also, privacy is essential when interviewing. Conduct interviews in a nearby office or vehicle.
List of interviewing do’s
Successful interviewers stress these techniques:
List of interviewing don’ts
When conducting the interview:
Evidence is anything that helps to establish the facts of an accident investigation to help determine a root cause. Types of evidence can include:
Position of tools and equipment: The position of tools and equipment can provide information about how they were being used (or misused) prior to the accident. Because forklifts and other equipment often look the same, record the serial numbers or other identification numbers to help later identify the specific piece of equipment involved in the accident.
Air quality: If the quality of the air may have contributed to the accident in some way, test the air. Specific things to look for when evaluating air quality include exposure to:
If the air quality contributed to the accident, evaluate the engineering or administrative controls to see if the air quality can be improved, and ensure that proper personal protective equipment (PPE) is used. Determine if employees in the accident area were exposed above the permissible exposure limits (PELs).
Equipment operations logs: Equipment operations logs may provide information about the mechanical integrity of equipment, as well as where, when, and how the equipment has been used. Operations logs, charts, and records may also offer vital information about how the equipment was designed, constructed, installed, and maintained. These records also provide information about equipment malfunction history.
Work environment: Determine if any debris, trash, tools, or equipment contributed to the accident. Additional items to investigate could center around the following types of questions:
Floor or surface conditions: Floor or surface conditions often contribute to accidents. Some questions to ask regarding floor or surface conditions could include:
Other contributing factors: Some examples of other contributing factors to consider investigating include:
Photos document the facts surrounding an accident and provide the investigator with accurate information about the accident. In order to preserve the facts, instruct workers at the accident scene not to move equipment or other items involved in the accident until photos have been taken of the scene. If equipment must be moved to rescue injured workers, instruct the rescuers to move only what is absolutely necessary.
Take photos of anything that will help reconstruct the entire accident scene. This will usually require a series of photos that first focus on the general area, then progress to specific detailed items. When taking a series of photos, consider the following guidelines:
Record notes that explain the purpose of each picture and the reasons for taking the picture. These notes will help when creating an accident investigation report. Although photos capture relevant information, they can capture irrelevant information as well. As investigative team members study the photos, it is easy to become distracted with all the details and lose focus on what is truly important.
Other disadvantages to photos include: they may be distorted, and they do not show actual distances. For this reason, sketches of the accident scene should be used in parallel with photos.
Sketching the scene
Sketches are drawings made at an accident scene that provide detailed information about the accident. Sketches are helpful because they can be used later in the final accident investigation analysis and report.
A sketch often provides information that a photo will not. While photos play an important role, the images contain everything the camera sees, including things irrelevant to the investigation. In contrast, sketches contain only pertinent information that helps determine the accident cause.
Sketches should always include information such as an arrow pointing north, angles, distances, locations of people and equipment, and structural or geographical data. Include notes about the sketches that will aid in their use and understanding later. Sketches should only contain information that is directly related to the accident scene.
Accident investigation notes are a record of the facts surrounding an accident that contain information about what people have witnessed. Writing good notes helps develop the final accident investigation report.
Investigation notes should focus on the who, what, when, where, how, and why facts of the accident. Some example questions to ask during an investigation that could be used in the investigation report include:
Who:
What:
When:
Where:
How:
Why:
Conducting a detailed interview is probably not necessary for every accident. However, a consistent approach will enhance any ongoing analysis of accident types and trends.
When interviewing the victim(s) and observers, the goal is to get the facts, not to assign blame or point out how expensive or damaging the situation may be.
To conduct productive interviews, consider the following points:
Before conducting an interview, an interviewer should verify compliance with all company policies and/or union contracts. Also, privacy is essential when interviewing. Conduct interviews in a nearby office or vehicle.
List of interviewing do’s
Successful interviewers stress these techniques:
List of interviewing don’ts
When conducting the interview:
Identifying a root cause is ultimately what the accident investigation is all about. The investigation will likely discover several causes, not just one. Determining root causes involves:
It’s important to understand the difference between a symptom or surface cause, and a root cause.
A symptom is a contributing factor, while a root cause is the actual cause of the accident. For example, if a hammer falls from a scaffold and strikes a worker, the symptom is the falling hammer. The root cause might be a missing toeboard on the scaffold, where the hammer was accidentally pushed off the edge. Telling a worker to be more careful is unlikely to prevent other items from falling in the future.
While it is important to evaluate surface actions and conditions, doing so often leads to an emphasis on the individuals, which then tends to focus blame.
After identifying the root cause or causes, use that information to develop the corrective and preventive actions that will help prevent future accidents.
Reviewing the evidence
Examining the evidence collected along with the notes, photos, and sketches should help identify a root cause. If clarification is needed, consulting further with the accident witnesses and victims may be an option. Understand that some witnesses and victims may be able to provide a detailed account of the accident, while others may not be able to recall much information. Simply try to get them to remember as much information as they can.
Finally, understand that some witnesses or victims may not wish to discuss the accident if they were traumatized by the event. Be sure to ask witnesses or victims if they are able to further discuss the accident.
Examining reasons for employee actions
When looking for root causes, determine why an employee acted a particular way prior to the accident, and look at the specific conditions of the task performed just prior to the accident. Some questions to consider include the following:
Remember, the goal should be to identify the failures at a deep level in order to prevent not only a recurrence of the accident, but all potential accidents stemming from the same root cause.
Source: Occupational Safety and Health Administration (OSHA) incident investigation guide, 2015
A thorough approach to identifying root causes involves questioning employees and supervisors about actions and conditions surrounding the accident. The following questions provide ideas to help an interviewer drill down to the root causes:
One option for uncovering a root cause is to repeatedly ask “why” questions until the process uncovers a deeper reason for a failure.
The Five Whys is one root cause analysis methodology. It is used to explore the cause/effect relationships underlying a particular problem. Ultimately, the goal of applying the Five Whys method is to determine a root cause of a defect or problem.
The following example of a car not starting demonstrates the basic process:
Note that the questioning could be taken to a sixth, seventh, or even greater level since the “five” in Five Whys is not set in stone. However, five iterations is generally sufficient to identify a root cause. The real key is to encourage the troubleshooter to avoid assumptions and logic traps and instead to trace the chain of causality in direct increments from the effect through any layers of abstraction to a root cause that still has some connection to the original problem.
Source: Occupational Safety and Health Administration (OSHA) incident investigation guide, 2015
A thorough approach to identifying root causes involves questioning employees and supervisors about actions and conditions surrounding the accident. The following questions provide ideas to help an interviewer drill down to the root causes:
One option for uncovering a root cause is to repeatedly ask “why” questions until the process uncovers a deeper reason for a failure.
The Five Whys is one root cause analysis methodology. It is used to explore the cause/effect relationships underlying a particular problem. Ultimately, the goal of applying the Five Whys method is to determine a root cause of a defect or problem.
The following example of a car not starting demonstrates the basic process:
Note that the questioning could be taken to a sixth, seventh, or even greater level since the “five” in Five Whys is not set in stone. However, five iterations is generally sufficient to identify a root cause. The real key is to encourage the troubleshooter to avoid assumptions and logic traps and instead to trace the chain of causality in direct increments from the effect through any layers of abstraction to a root cause that still has some connection to the original problem.
After determining the root cause of an accident, corrective and preventive actions must be implemented that will eliminate, or at least reduce, the chances of another accident occurring.
Developing an effective set of corrective and preventive actions starts with an evaluation of the identified root cause(s). Usually, recommendations for corrective actions follow in a rather straightforward manner.
Evaluate each root cause to determine how it can be prevented in the future. With the help of other supervisors, managers, and employees, discuss ways to remove the root cause from the system. Ensure that root causes (not merely symptoms or surface causes) are evaluated and discussed.
To aid in a discussion of root causes, refer to the list of why or why-not questions that probably led to the root cause. Develop a list of potential employee actions that may have contributed to the accident. By thoroughly evaluating this information, an investigator will be one step closer to reducing or eliminating root causes of accidents.
Depending on the situation and the type of root cause, there may be several potential options for reducing or eliminating root causes. Some examples may include:
Often, a thorough accident investigation will result in recommendations for improving a process or reducing hazards. Use the investigation as an opportunity to look for ways to improve the efficiency of a process, the working habits of employees, and the overall safety of the working area.
Some example recommendations may include: increasing lighting in a work area, improving machine guarding, establishing new procedures for housekeeping, or improving communication between management and employees.
Communicating the findings
Because upper management is ultimately responsible for the health and safety of the workforce, the findings of the accident investigation must be reported to them. In order to effectively communicate the investigation findings, provide the following information in the final report:
Through proper documentation of the accident investigation findings, and by reviewing the results of the investigation with appropriate personnel, recurrence of accidents may be prevented.