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Category: Miscellaneous
Volume: 30
Issue: 4
Article No.: 4957

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SAFETY SOLUTIONS: Accident Prevention & Investigation
What would you do if someone came to you and said, “We just had an accident?” Are you prepared to conduct an effective accident investigation? Most companies do not look for all the root causes of the accident, but concentrate on the injured employee as the cause of the accident occurring. This is not realistic.

Accidents are signs of a management system that is not working. I am not blaming management but I am blaming the management system. For example, why did the unsafe condition exist? Why didn’t someone notice it? And the list goes on. If I asked you if your company had a safety manual, most would answer, “Yes” but if I asked you if everyone knew what was in the manual, the answer would probably be. “No.” I can’t tell you how many times, when I am teaching at a client’s location or the OSHA Training Institutes and I ask the safety professional to tell me what is in their manual, in many cases they cannot tell me themselves. How can an employee follow the company safety manual if the safety director is unable to relate what is even covered in the manual? Accidents are usually thought of as a negative aspect of production and they are. They’re something you want to avoid, prevent and eliminate. But accidents have a positive aspect as well. They show us the gaps in our safety programs, procedures and practices. And they help us understand what we need to do to correct the situation to improve safety performance.

The whole point of accident investigations is not to lay blame or discredit existing safety efforts. It’s solely to find out what happened, so that similar incidents can be prevented in the future. With that focus in mind, accident investigations can be carried out efficiently and produce positive results for your entire facility.

William Heinrich the (Grandfather of Industrial Safety) built a safety triangle, commonly known as the safety pyramid or accident pyramid, It was originated in 1931 and detailed in his book, Industrial Accident Prevention: A Scientific Approach. Widely accepted for over 70 years, the safety triangle serves to illustrate Heinrich’s theory of accident causation: unsafe acts lead to minor injuries and, over time, to major injury. The accident pyramid proposes that for every 300 unsafe acts or near misses, 29 minor injuries or first aid cases and one major injury or lost time case will result. Have you had any first aid or lost time cases this year? If your answer was yes, then based on Heinrich, you had 300 chances to correct the problem before someone was injured.

Since unsafe acts are difficult to record accurately and Heinrich’s theory seems logical, the safety pyramid remained unchallenged for decades. Effective accident investigation requires a number of important steps:

  • Investigate all accidents. This includes near misses and accidents that did not result in injury. According to the National Safety Council, 75 percent of all workplace accidents were preceded by a near-miss incident.

  • Study the accident scene. The accident scene should be secured immediately after the accident to prevent anyone from moving or touching any material evidence. As you examine the scene, look for clues that will help you pinpoint the cause of the accident. Take photographs to preserve evidence and help you reconstruct the accident later, after the area has been cleaned up and normal operations have resumed.

  • Examine the events. Consider the who, what, when, where, how and why of the incident. Look at not only the specific events involved in the accident, but also at what was going on around it. Who was there? What were they doing? Which materials and equipment were involved in the accident? What about the surrounding work area? What hazards might have existed there at the time? Could any of these things have contributed to the accident?

  • Talk to witnesses. As soon after the accident as possible, talk to everyone who might have seen anything. You must move quickly here. Memories fade and get mixed up after even a few hours. And don’t forget the most important witness of all—the victim. If possible, speak to the victim as soon after the accident as possible to get their perspective on what happened. Be sure to encourage cooperation by reassuring employees that your goal is to find out what happened so that future accidents can be prevented, not to lay blame.

  • Determine the underlying causes. Was this accident caused by an unsafe act or unsafe condition? Are the circumstances involved in this accident limited to a particular work area or department, or does it have plant-wide safety implications? Look for patterns. And don’t forget to dig deep. Often the most obvious reasons for the accidents aren’t the only causes. For example, with accidents that appear to be caused by unsafe conditions, there are usually contributing causes that may not be easy to spot initially, such as lack of training or use of worn or inadequate personal protective equipment.

  • Write the incident report. The report should include all the facts of the incident (who, what, where, when, how and why). Then go on to explain your findings and draw your conclusions in clear and direct language. Be sure to include recommendations for corrective action. While your investigation of the scene and interviewing of witnesses should proceed with all possible haste, the writing of your report should be a thoughtful exercise, one on which you should take the necessary time to draw meaningful conclusions. When the report is completed it should be circulated to the appropriate managers and filed according to established policy.

  • Act on your findings. Remember that the real significance of the accident investigation is to prevent similar incidents in the future. Be sure to act on your findings. For example, provide additional training, correct unsafe conditions, revise procedures that may be causing safety problems or rewrite safety rules. Circulate your incident report to managers in other departments who may face similar safety problems. Do whatever is required to help ensure that this accident won’t happen again.
If you have questions, please feel free to contact me. I would like to thank BLR for allowing me to use some of their materials.

For more information, click on the author biography at the top of the page.

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