What is an accidents & why to investigate?
The term ‘Accident’ can be defined as an unplanned event that interrupts the completion of an activity, and that may (or may not) include injury or property damage.
The term ‘Incident’ refers to an unexpected event that did not cause injury or damage but had the potential. “Near miss” or “dangerous occurrence” are also terms for an event that could have caused harm but did not.
When accidents are investigated, the emphasis should be concentrated on finding the root cause of the accident rather so you can prevent it from happening again. When the root cause is determined, it is usually found that many events were predictable and could have been prevented if the right actions were taken. The purpose is to find facts that can lead to actions, not to find fault. Always look for deeper causes. Do not simply record the steps of the event.
Reasons to investigate a workplace accident include:
- Most importantly, to determine cause(s) and prevent similar accidents in the future
- Fulfill any legal requirements
- Determine the cost of an accident
- Determine compliance with applicable safety regulations
- Process workers’ compensation claims
Incidents that involve no injury or property damage should still be investigated to determine the hazards that should be corrected. The same principles apply to a quick inquiry of a minor incident and to the more formal investigation of a serious event.
Who should do the accident investigation?
An investigation should be conducted by someone experienced in accident causation and investigative techniques; as well as be fully knowledgeable of the work processes, procedures, persons, and industrial environment of a particular situation. For complex accidents or workplaces an experienced and independent investigator may be require. In most cases, the supervisor should help investigate the event. Other members of the team can include:
- employees with knowledge of the work
- safety officer
- health and safety committee
- union representative, if applicable
- employees with experience in investigations
- “outside” expert
- representative from local government
Why look for the root cause?
An investigator who believes that accidents are caused by unsafe conditions will likely try to uncover conditions as causes. On the other hand, one who believes they are caused by unsafe acts will attempt to find the human errors that are causes. In fact, it is often a combination of numerous factors which led to a preventable accident or incident. Therefore, it is necessary to examine some underlying factors in a chain of events that ends in an accident.
The important point is that even in the most seemingly straightforward accidents, seldom, if ever, is there only a single cause. For example, an “investigation” which concludes that an accident was due to worker carelessness, and goes no further, fails to seek answers to several important questions such as:
- Was the worker distracted? If yes, why was the worker distracted?
- Was a safe work procedure being followed? If not, why not?
- Were safety devices in order? If not, why not?
- Was the worker trained? If not, why not?
An inquiry that answers these and related questions will probably reveal conditions that are more open to correction than attempts to prevent “carelessness”.
What are the steps in investigating an accident?
The accident investigation process involves the following steps:
- Report the accident occurrence to a designated person within the organization
- Provide first aid and medical care to injured person(s) and prevent further injuries or damage
- Investigate the accident
- Identify the causes
- Report the findings
- Develop a plan for corrective action
- Implement the plan
- Evaluate the effectiveness of the corrective action
- Make changes for continuous improvement
As little time as possible should be lost between the moment of an accident or near miss and the beginning of the investigation. In this way, one is most likely to be able to observe the conditions as they were at the time, prevent disturbance of evidence, and identify witnesses.
Accident Causation Models
Many models of accident causation have been proposed, ranging from Heinrich’s domino theory to the sophisticated Management Oversight and Risk Tree (MORT). The simple model shown in Figure 1 attempts to illustrate that the causes of any accident can be grouped into five categories – task, material, environment, personnel, and management. When this model is used, possible causes in each category should be investigated.
Task- Here the actual work procedure being used at the time of the accident is explored.
Material- To seek out possible causes resulting from the equipment and materials used.
Environment- The physical environment, and especially sudden changes to that environment, are factors that need to be identified. The situation at the time of the accident is what is important, not what the “usual” conditions were.
Personnel- The physical and mental condition of those individuals directly involved in the event must be explored. The purpose for investigating the accident is not to establish blame against someone but the inquiry will not be complete unless personal characteristics are considered. Some factors will remain essentially constant while others may vary from day to day.
Management- Management holds the legal responsibility for the safety of the workplace and therefore the role of supervisors and higher management and the role or presence of management systems must always be considered in an accident investigation. Failures of management systems are often found to be direct or indirect factors in accidents.
This model of accident investigations provides a guide for uncovering all possible causes and reduces the likelihood of looking at facts in isolation. There is considerable overlap between categories; this reflects the situation in real life.