INVESTIGATE ACCIDENTS & INCIDENTS

 

ACCIDENT & INCIDENT INVESTIGATIONS

 

OBJECTIVE

 

The purpose of both accident and incident investigation is to determine what happened and what can be done to prevent a similar occurrence in future.

Certain classes of accidents are required to be investigated in terms of the Occupational Health and Safety legislation.

 

     In this article we will deal with the following key points:

    1) Documentation of accident scene

2)  Conducting interviews

3)  Analyzing facts and determining Surface and Root Causes

4)  Developing recommendations

5)  Writing the report

 

TIP!

The 5 W’s and the H is an easy way remembering to ask coworkers, witnesses or yourself these questions while conducting investigations, inspections or taking statements.

1)  WHAT

2)  WHERE

3)  WHY

4)  WHO

5)  WHEN & H-HOW

 

Investigation Benefits:

1) Its evidence and reflect concern for people

2) It increases production time

3) It identifies and quantifies losses occurred

4) It helps to determine facts of the situation

5) It helps to determine the extent of personal injury or diseases

6) It helps to determine the extent of damage

7) It reveals what happened and who and what was involved

The above model has two labels.

1) The bottom label is “Problem Solving Model”, while the top labelled is the “Loss Causation Model”.

2) This illustrates that the model can be used either as a problem-solving tool or a tool to explain why incidents are occurring at a site.

3) The problem-solving side of the model moves from the Loss section to the Inadequate Risk Assessment section.

4) This is what is expected from a good problem-solving model.

5) Moving from problem identification to problem causation to solution.

6) The top label namely, Loss Causation Model, explains the sequence why incidents occur.

7) It provides insights about actions needed to prevent them

 

Personal Factors could include factors such as:

a) Stress

b) Lack of knowledge

c) Skill

d) Inadequate motivation

e)  Physical or mental shortages

f) Poor attitude

 

 

Job Factors could include factors such as:

a)  Inadequate standards

b) Poor tools or equipment

c) Insufficient maintenance

d)  Poor purchasing standards

e) Lack of or poor supervision

 

 

Causes of Accidents:

There are five elements that give rise to the cause of undesired events of accidents:

1) People

2) Equipment

3) Processes

4) Materials

5) Environment

 

 

Why report incidents?

75% of all accidents are preceded by similar “near loss” incidents.

 

Why does the law require the supervisor to investigate accidents/incidents?

1.  They have personal interest to protect

2.  They know the best about people and conditions

3.  They know best to get information

4.  They will take action anyway

 

Research - Causes of accident/incidents

88% = Sub-standard Acts

10% = Sub-standard Conditions

2% = Acts of Providence

Research reveals that 98% of all industrial accidents/incidents can be prevented.

 

Why don’t people report?

1.  Fear of discipline

2.  Concern about the record

3.  Concern for reputation

4.  Fear of medical treatment

5.  Desire to prevent work interruption

6.  Avoidance of red tape

7.  Concern about attitude of others

8.  Poor understanding of importance

 

 

How to get people to report Incidents:

1.  React in a positive way – show belief by action.

2.  Simple reporting methods

3.  Positive behavior reinforcement

4.  Encourage at meetings, etc.

5.  Incident recall techniques

 

Encouraging reporting of injuries/accidents:

a) All accidents that caused a result in loss must be reported.

b)  Supervisors must react in a more positive way when injuries are reported to them.

c) Let the worker know the contribution of his/her information is voluble to the company and other employees.

d) Handle reporting properly and positively

e)  Present an atmosphere of cooperation and not of interrogation

f) Recognize individual contribution and performance

g) Emphasize the importance of the incident that was reported which could result in obviating a loss

h) When an injury or incident is reported, determine what to do immediately, and do it

i) Remember, there is always something that can be done.

 

Dos and Don’ts of accident investigation

Do not:

1)  Concentrate on finding guilt/fault or someone to blame, i.e., don’t point fingers

2) Use it as a fault-finding exercise

3) Use words such as carelessness, negligence, stupidity or ignorance

4) Investigate from a negative point of view

5) Jump to conclusions 

 

Do:

1) Establish the facts

2) Approach the investigation positively

3) Use a well-designed investigation form or loss causation model

4) Determine immediate and basic causes

5) Identify which control factor failed

6) Follow through on the investigation, rectify the situation and implement remedial measures

Accident investigation is fact-finding not fault-finding.

 

Investigator:

a) The supervisor, foreman and manager directly in charge of the area in which the accident occurred must be the prime investigator

b) Top management must also get involved somewhere in the process

c) The investigator may be assisted by the health and safety representatives or the safety committee for that area, shop stewards and any other relevant or expert person

d) The severity of the accident or injuries should not determine who should conduct the investigation

 

The investigation forum:

a) This is a key tool for any investigation and should be well designed for the purpose.

b) It must prompt the investigator to get all the facts and provide a true description of the accident as well as facilitate the selection of effective remedies/prevention/action plan

 

 

Investigation report should include the following:

1)  Names of all people involved

2) Department/area/location where accident occurred

3) Part of body injured

4) Type of injury experienced or property damage

5) Estimated loss

6) Type of accident

7)  Comprehensive description of what happened

8) Identification of any unsafe act or condition

9) Basic causes/root causes: Personal or job factors that contributed to immediate causes1

0) Evaluation of probability of a similar incident occurring

 

Immediate actions:

1) Supervisor must take charge of the scene

2) Ensure necessary medical and other emergency measures are initiated

3) Photograph scene of accident

4) Draw sketch of scene with key features marked clearly and numbered

5) Note and record environmental conditions e.g., Lighting, noise level and weather conditions

6) Report accident to the necessary authorities

7) Identify witnesses and take statements

 

Gathering facts:

Conduct accident investigations as soon as possible before facts become forgotten or distorted.

Accident investigation will establish:

a) Who was involved

b) What equipment was involved

c) What environmental conditions were involved

d) What systems failed

NB!!! Facts may be gathered by taking photographs, videos, measurements, examining items, reviewing standards, procedures, past experience and taking statements.

 

Determining the cause:

a) Don’t jump to conclusions

b) Use process of deduction and systematic identification of immediate and basic causes

Ask the question “why” repeatedly, to find out unsafe acts/conditions, which were identified by:

a) Physical inspection/examination of accident site, interviewing and taking statements from witnesses and consulting experts, categorizing and concluding

b) Once basic causes are established and categorized into personal and job factors, the root causes can be established, and remedial measures applied to address the matter

Taking preventive action

After the above process has been completed, urgent preventive or remedial measures must be instituted to prevent recurrence.

These should include:

1)  Engineering review

2)  Environmental review

3) Training and retraining

4) Motivational and publicity campaigns

5) Review of safety rules and standards

6) Enforcement of safety rules and standards

7) Enhanced supervision and disciplinary control

8) Follow-up of remedial measures/action Inspections

 

A well-managed inspection programme should meet the following goals:

1) Identify potential problems

2) Identify equipment defects

3) Identify improper employee actions and behavior

4) Identify effects of change in process and materials

5) Identify inadequacies in remedial actions

6) Provide management with self-appraisal information

7) Demonstrate management commitment to health and safety

 

Reporting findings: Why?

a) The report is the means by which we communicate information and avoid time-wasting duplication

b) In most cases, this report is critical and produced on an observation and recommendation basis

c) Recommendations are prioritized according to the degree of risk, current legal requirements and the cost of eliminating or reducing the risk

d) The purpose of H&S report is to present management with a phased programme of H&S improvement covering, say, a three-year period

 

Priority 1:

Recommendations apply:

1) To situations where there is serious risk and direct contravention of law

2) Where minor improvements can be made without capital expenditure

3) This phase can also include supply of PPE

4) Priority 1 recommendations can be implemented within three months of presenting the report

 

 

Priority 2:

1) These recommendations are normally implemented within six months of the report

They include:

a) Items which do not require large scale-expenditure, but which are essential for improving working conditions and safety standards

b) E.g. improvements to lighting conditions in the working area, installation of specific exhaust ventilation to processes, or improvements to access to parts of the plant

 

Priority 3:

Recommendations in this category are those for which long-term planning is needed, together with capital expenditure approval.

a) a) E.g., provision of new amenities

b) Replacement of worn or obsolete plant and equipment

c) Provision of improved chemical storage facilities

d) Improved fire protection measures

 

Accident records

Safety staff are faced with two tasks:

1) Maintaining records required by law and management

2) Maintaining records useful to effective safety programme

a) Records of accidents, incidents, inspections, job observation are essential to maintain efficient and successful safety programmes

b) Records supply information necessary to transform haphazard, costly, ineffective safety work into planned safety programme that controls conditions and acts that contribute to accidents.

c) Good record keeping is a foundation of a scientific approach to occupational health and safety

 

Uses of records:

1) They provide safety staff with means for an objective evaluation of their accident problems and with a measurement of the overall progress and effective of their safety programme

2) They identify high accident rate units, plant or departments and problem areas so that extra effort can be made where the need arises

3) They provide data for an analysis of accidents and illnesses, pointing to specific causes or circumstances, which can then be rectified

4) They create interest in safety among supervisors by furnishing them with information about their departments’ accident experience

5) They provide supervisors and safety committees with hard facts about their safety problems so that their efforts can be concentrated

6) They measure the effectiveness of individual countermeasures and determine whether specific programmes are doing the job they were designed to do.

7) They assist management in performance evaluation

 

 

Record-keeping systems

An accident report should accomplish three things:

a) Establish all causes contributing to the accident

b) Reveal questions the investigator should ask to determine all environmental and human causes

c) Provide a means of accumulating accident data

 

Accident reports and injury records:

The primary purpose of accident report is to:

1) Obtain information and not to fix blame

2) Information begins at the first aid pos

3)  Copies are sent to the worker’s supervisor, safety department and management

4) First-aid attendant to know enough about accident investigation, analysis and record-keeping

5) Supervisor makes detailed investigation report about each accident, even when minor or no-injury occurrences take place

Section 24 of the OHS Act and Section 39 of the COID Act 130 of 1993 specify which accidents should be reported to the DMRE.

 

1) No-injury or loss incidents that have the potential for catastrophic loss …….

2) Should also receive attention as would serious injury and loss accidents

3) Minor injuries should not be regarded lightly.

4) Complications may arise, leading to serious results

        Completion of accident investigation report:

5) Supervisors should complete accident investigation report as soon as possible after the accident

6) They should send copies of reports to the Safety Department and other designated persons

7) Information concerning activities and conditions that preceded the accident is important to prevent future occurrences

8) Items such as total time lost and monetary cost of the accident can be filled in later

9) This should not prevent other items from being recorded immediately after the accident

10) Another useful document is the employee illness and injury record

11) After cases is closed, the first-aid report and supervisor’s report are normally filed by agency of injury type of accident

12) Another form must be used to record the injury experience of individual employees

13) This approach is useful in large enterprises where supervisors have many people working for them

14) They may not remember the total number of injuries suffered by individual employees, especially if injuries are minor

15) From employee record, supervisors learn about accident causes from its study

16) If certain employees or job classifications experience frequent injuries, a study of employee working habits, physical and mental abilities, training, job assignments, working environment, instructions and supervision given them may reveal as much as a study of accident locations, agencies and other factors

17) An increase in the frequency of accidents by an employee's bears further investigation

18) When injury reports are complete, they should be filed in a convenient system that permits rapid access of information

 

These reports may be filed:

a) According to the agency of injury

b) Occupation of the injured person

c) Department or classification

 

Golden rule because accidents/incidents “must” be investigated:

A) "What is not reported, cannot be investigated.”

B) “What is not investigated, cannot be changed.

C) “What is not changed, cannot be improved.”