Chapter 8

1. Chapter 8 Accident Investigation and Reporting

2. Major Topics • Types of accident investigations • When to investigate • What to investigate • Who should investigate • Conducting the investigation • Interviewing the witness • Reporting accidents • Ten accident investigation mistakes to avoid

3. Rationale for investigating accidents • The primary reason for investigating accidents is not to identify a scapegoat, but to determine the cause of the accident. • This information benefits the ongoing effort of reducing the likelihood of accidents, and preventing similar accidents from happening in the future.

4. When should an investigation be reported? Why? • According to OSHA document 2056 employers of 11 or more employees must maintain records of occupational injuries and illnesses as they occur. • If an accident results in the death of an employee or hospitalization of 5 or more employees, a report must be submitted to the nearest OSHA office within 48 hours. This rule applies regardless of the size of the company. • The saddest part of non reporting of accidents is that they are not investigated to determine and eliminate the cause.

5. Accident report and accident analysis report • An accident report is completed when the accident in question represents only a minor incident. It answers the following questions: who, what, where, and when. However it does not answer the why question. Supervisors often complete accident reports. OSHA form 301 can be used for accident reports. • An accident analysis report is completed when the accident in question is serious. It answers all the questions: who, what, where, when, and why. Accident analysis must identify the actual root cause or the company will expend resources treating only the symptom or even worse solving the wrong problem. Serious accidents are always accompanied by the potential for litigation. If there might be legal action, it is important to have a professional conduct the investigation even if it means bringing in an outside consultant.

6. Most common causes of accidents • Personal beliefs and feelings: Individual did not believe the accident would happen to him or her; individual had personal problems that clouded his or her judgment, etc. • Decision to work unsafely: Some people, for a variety of reasons, feel it is in their best interest or to their benefit to work unsafely. • Mismatch or overload: Individual is in poor physical condition; individual is fatigued, etc. • System failure: Lack of rules, regulations, procedures; failure to correct known hazards; insufficient training for employees, etc. • Traps: Defective equipment; failure to provide, maintain, replace proper personal protective equipment, etc. • Unsafe conditions: unsafe conditions created by the elements; unsafe conditions created by a fellow employee, etc. • Unsafe acts: individual chooses to ignore the rules; individual uses drugs or alcohol, etc.

7. Accident investigation guide • The investigation should be guided by the following words: who, what, when, where, why, and how. Causes of the accidents should be the primary focus. • SME recommends the following questions: • What type of work was the injured person doing? • Exactly what was the injured person doing or trying to do at the time of the accident? • Was the injured person proficient in the task being performed at the time of the accident? Had the worker received proper training? • Was the injured person authorized to use the equipment or perform the process involved in the accident? • Were there other workers present at the time of the accident? If so, who are they, and what were they doing? • Was the task in question being performed according to properly approved procedures? • Was the proper equipment being used, including PPE? • Was the injured employee new to the job? • Was the process, equipment, or system involved new? • Was the injured person being supervised at the time of the accident? • Are there any established safety rules or procedures that were clearly not being followed? • Where did the accident take place? • What was the condition of the accident site at the time of the accident? • Had a similar accident occurred before? If so, were corrective measures recommended? Were they implemented? • Are there obvious solutions that would have prevented the accident? • The answers to these questions should be recorded. You may find it helpful to dictate your findings into a micro-cassette recorder. This approach allows you to focus more time and energy on investigating and less time on taking notes.

8. Safety personnel role in accident investigation • If the accident is very minor, the injured employee’s supervisor may conduct the investigation, but the safety and health professional should at least study the accident report and be consulted regarding recommendations for corrective action. • If the accident is so serious that it has widespread negative implications in the community and beyond, responsibility for the investigation may be given to a high level manager or corporate executive. In such cases the safety and health professional should assist in conducting the investigation. • If a company prefers the team approach, the safety and health professional should be a member of the team and in most cases should chair it. • Regardless of the approach preferred by a given company, the safety and health professional should play a leadership role in collecting and analyzing the facts and developing recommendations.

9. Steps for conducting an accident investigation • Five steps: • Isolate the accident scene: This is done to keep curious onlookers from removing, disturbing, or unknowingly destroying vital evidence. Nothing but the injured worker should be removed from the scene. • Record all the evidence: As quickly as possible because certain types of evidence may be perishable; accident scene may be disturbed knowingly or unknowingly, pressure may mount to get a critical piece of machinery back into operation. If in doubt, record it. • Photograph or videotape the scene: Both still and video cameras must be on hand, loaded, and ready to use should an accident occur. Place a ruler or coin next to the object when making a close-up photograph to get the object’s size or proper perspective. • Identify witnesses: Primary witness, secondary witness and tertiary witness list. • Interview witnesses: Primary witness first. May be necessary to re-interview witness.

10. Importance of recording all evidence immediately • It is important to make a record of all pertinent evidence as quickly as possible. There are 3 reasons for this: • 1. Certain types of evidence may be perishable. • 2. The longer an accident scene must be isolated, the more likely it is that evidence will be disturbed, knowingly or unknowingly. • 3. If the isolated scene contains a critical piece of equipment, pressure will quickly mount to get it back in operation. • Evidence can be recorded in a variety of ways including written notes, sketches, photography, videotape, dictated observations, and diagrams. In deciding what to record, a good rule of thumb is, if in doubt record it.

11. Proper perspective of close-up photographs • A problem with photographs is that, by themselves, they do not always reveal objects in their proper perspective. • The National Safety Council recommends that when photographing objects involved in an accident be sure to identify and measure them to show the proper perspective. Place a ruler or coin next to the object when making a close-up photograph. This technique will help to demonstrate the object’s size or perspective.

12. Three categories of witnesses to an accident • In identifying witnesses, it is important to compile a witness list. • Names on the list should be recorded in three categories: • 1. Primary witness. • 2. Secondary witness. • 3. Tertiary witness. • When compiling the witness list, ask employees to provide names of all three types of witnesses.

13. When and where of interviewing witnesses • To ensure that the information is objective, accurate, and untainted by the personal opinion and feelings of the witness, and able to be corroborated. • When to interview: Immediately after the list has been compiled. The witnesses recollection will be best right after the accident. Immediacy also avoids the possibility of comparing notes and as a result changing their story. Individuals should be interviewed individually and separately, preferably before they have talked to each other. • Where to interview: The best place to interview is at the accident scene. Ensure that distractions are removed, interruptions are guarded against, and witness is not accompanied by other witnesses. If it is not possible to interview at the accident scene, select a location that is not intimidating to the witness.

14. How to interview • The information being sought is who, when, where, why, and how. • The key to getting at the facts is to put the witness at ease and listen. • Listen to what is said, how it is said, and what is not said. • Ask questions, but phrase them in an open ended format – “What did you see?” • Do not lead the witness with your questions, and interrupt only if absolutely necessary. • Remain non judgmental and objective. • Ask witness to simulate rather than actually perform the steps that led to the accident if possible. Record if possible and it is not intrusive. • At the end of the interview summarize what you have heard and ask have the witness verify your summary.

15. Purpose of an accident report • An accident investigation should culminate in a comprehensive accident report. • The purpose of the report is to record the findings of the accident investigation, the cause of the accident, and recommendation for corrective actions. • According to OSHA document 2056 employers of 11 or more employees must maintain records of occupational injuries and illnesses as they occur. • If an accident results in the death of an employee or hospitalization of 5 or more employees, a report must be submitted to the nearest OSHA office within 48 hours. This rule applies regardless of the size of the company. • The saddest part of non reporting of accidents is that they are not investigated to determine and eliminate the cause. • More in the text book.

16. Summary • Accidents are investigated to identify causes, so that they can be corrected, not to assign blame. • Accidents should be investigated as soon as possible so that evidence and memories of witnesses are still fresh. • An accident investigation should ask the questions who, what, when, where, and how. • A safety and health professional should play an active role in the accident investigation. • Steps in an accident investigation: isolate the accident scene, record all evidence, photograph or video tape the accident scene, identify witnesses, and interview witnesses. • Interviews should take place at the accident site whenever possible. • Ask open ended questions. • Accident report forms must meet the specifications of OSHA.

17. Home work • Answer questions 2, 6, 7, 8, 11, and 12 on page 179-180. • 2. When should an investigation be reported? Why? • 6. What role should the safety and health professional play in the conduct of an accident investigation? • 7. List and explain the steps for conducting an accident investigation. • 8. Why is it important to record all pertinent evidence relating to an accident immediately after an accident has occurred? • 11. Briefly explain the when and where of interviewing witnesses. • 12. Briefly explain the how of interviewing witnesses.