ACCIDENT INVESTIGATION

Accident investigation is required activity by Washington State Administrative code. It is also required by the Citys safety committees for review of the results of the investigations and follow-up recommendations. his chapter provides some insight to the he philosophy and process of investigating accidents and incidents. Chapter A-$% Safety Committees.

Accident Wor!sheet is found in Appendi" #A-$ and is also referred to in

he !ey to preventing a reoccurrence

It is the position of the City of Spo!ane that all accidents can be prevented% not &ust theoretically% but realistically. A !ey step in this prevention program is accident investigation and then the corrective actions that follow.

Accident Investigation
It is critical that accident investigation be entered into !nowing that we can ma!e a difference if we can find the true causes of the accident. his means dropping any assumptions that there is nothing that can be done - 'it is an accident.( )ow that you have dropped this assumption% reali*e that we should investigate all
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accidents formally% and the near miss accidents in an informal investigation. +einrichs Accident triangle shows us this. A study of accidents was done. What it revealed on the average is, that out of $$- times in an identical situation% there would be $-- near miss accidents% or opportunities to see an accident coming. ./ times there would be a minor accident% and 0 out of the $$- would result in a serious accident. #or e"ample, I could stumble on a crac! in the sidewal! $-- times% I might fall and sustain a scrape or bruise ./ times% and one time I could perhaps fall with a baby in my arms and the child would be severely in&ured. Since this is a statistical model% we dont !now which time will be the serious in&ury. It could be the first stumble% the last% or anywhere in the middle of the $$-. why we investigate all accidents and near miss opportunities. his is

Accidents +ave 1ultiple

All accidents have multiple causes that intersect in time and space. If we can deduce the causes and eliminate anyone of them% we can prevent a repeat of the e"act same accident from happening again. 1any times eliminating one of

Causes

Primary Ca se

Secondary Ca se

Contrib ting Ca ses

the causes also eliminates future accidents that might have occurred with other elements as well. he !ey is to investigate until the true
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causes of the accident are discovered. #ortunately there is a technique for doing this type of accident investigation. It is called the Why 1ethod of Accident Investigation.

he Why 1ethod of Accident Investigation

his method starts out very simply by stating the name of the in&ured party% the in&ury% and the element that caused the in&ury. the apparent facts that we have to begin with. hese are

hen we start with the

Cause of In&ury and as! the question why2 Why was the person in&ured by, whatever it was. hen repeat by as!ing why to the answer of that

question until there is a series of questions and answers. #rom that list% select the 3rimary Cause that is most li!ely. )ow you can ta!e the original question or any question in the primary cause list and as! once again% why2 here should be a different answer and we start

descending down the secondary cause list repetitively as!ing the question% why2

Accident Accident

In# ry

Cause of In u!"

)ote that there are two styles of as!ing the

!hy " !hy "

question. 4ne in a descending order with each

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!hy "
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!hy "

!hy "

answer resulting in another question - why2 And the second style is to !eep as!ing the same question way over and over getting different answers each time.

he ypical 5esults of an Investigation

15$ Condition
he typical results of an investigation reveal that 678 of the causes are 'actions(% something that someone did. 078 of the causes of accidents

%5$ Persona& Action

are 'physical conditions( that

e"ist in the wor!place. In the ma&ority of controlled environments this will hold true. he fortunate result of this is that most accidents can be

remediated through either training or an engineering control. We are only loo!ing for one or the other.

It is important that we stay ob&ective with employees. 9ust because 678 of accidents are caused by something someone did% it does not mean that they wanted to be involved in an accident. )o one wants to be in&ured. Accident investigation should not be punitive% but should be presented as a caring function of management : ma!ing the wor! environment safer.

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Investigative ools and S!ills

he supervisor or manager filling out the in&ury report should also be the one to do the accident investigation. 3resumably they are close to the wor!er and !now the &ob best. If the supervisor starts the investigation immediately% they will be closest to the fresh facts. #urthermore they should have the ability to come to a logical conclusion and effect positive change. We must reiterate that the accident investigation must begin immediately and that the person doing the accident investigation should go to the scene of the accident. Important details come from the accident scene. We want to get there before causal factors are removed and we want the opportunity to interview witnesses. Waiting is not acceptable and the accident investigation is due with the accident report% which should be completed before the end of that shift.

Investigative s!ills include interviewing both the in&ured individual and any witnesses. It is important that we be sincere and caring during the accident investigation. 5emember and convey that our goal is to prevent future in&uries% not punish employees. he classic

investigative questions of 'who% what% why% when% where% and how( must be answered. +idden and often human action type details must be uncovered. hese are not in the physical evidence realm% and
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therefore are more difficult to uncover.

he supervisor filling out the

accident report should be able to spot an unsafe act or unsafe condition quic!ly and then be able to communicate a clear picture to secondary audiences. It helps to as! open-ended questions that require more then a yes or no answer. ;se of the 'aw!ward minute%( allows <- seconds of silence for the interviewee to formulate and respond to a question. It is important that we do not interrupt the interviewee once they have started. It is 4= to clarify information% but wait until they have finished spea!ing. 4ur &ob in the investigative stage is to ta!e detailed notes and complete the paper wor! immediately.

If the investigation does not yield apparent causes% we might want to question things li!e policies% procedures and training. his includes

loo!ing at who was near by% or who should have been near by. Were there any unsafe acts% unsafe conditions% equipment or chemicals2 What personal factors might have come into play2 +as there been any change in productivity demands2 he deeper we question the more hen we are

li!ely we are to come to realistic causes of the accident. most li!ely to be solving root causes instead of symptoms.

4ften an Accident Investigation ool >o" can be helpful. ?ou might want to include things li!e a camera to ta!e accident photos with@ or% a
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micro cassette recorder to record statements with@ or% flashlight to e"plore dar! or dimly lit accident scenes. ?ou definitely want to have the accident report and investigation forms and perhaps a clipboard to write on. We also recommend gloves in case there is ha*ardous debris to handle or blood borne pathogens. +aving a roll of barrier tape might also be a consideration if we need to !eep employees out of an accident site% or if we need to bloc! off the area during the investigation and until we get it cleaned up and bac! to a point of productivity.

EFFECTING CHANGE

A4ur ool >o" for Correcting ;nsafe Actions or ConditionsB

here are si" techniques that are widely accepted by safety professionals for effective accident prevention. he Comino heory hese are,

Industrial +ygiene echniques he Dnergy 5elease heory he echnique of 4perations 5eview

System Safety Schematics Antecedents% >ehaviors E Consequences

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Cifferent methods are more applicable to certain situations% so we will cover all si".

he Comino heory
+.W. +einrich% a leading Industrial Safety Dngineer% developed the Comino theory. +e believed that all accidents could be modeled with a chain of five factors. hey were,

o Ancestry and social environment o he fault of a person

o An unsafe act andFor physical ha*ard o An accident o he resulting in&ury

If the chain could be bro!en before the accident% in&uries could be eliminated. +e believed that the easiest place to brea! the chain was by eliminating an unsafe act or physical ha*ard. his theory is the

corner stone of our accident investigation program because it simplifies our search to the two basic elements of prevention : the unsafe act or physical condition that can be commonly found in all accidents. his also simplifies corrective activity that can be

categori*ed in two groups% education and training% or change of a physical ha*ard.

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Industrial +ygiene 1ethods

hese are eleven basic methods developed by hygienists and engineers over the years for controlling wor! processes. It is the plan that we use to ma!e processes safer. 0. .. $. G. 7. <. I. 6. /. 0-. 00. hey are,

Substitute a less harmful material Alter process to reduce wor!er contact Isolate or enclose a process ;se wet methods to reduce particulates Hentilate to disperse contaminates Cilution ventilation 1aintain good house!eeping 1onitor E control e"posure 3ersonal 3rotective Dquipment A33DB Implement baseline E detection programs Dducate and train employees

he Dnergy-5elease heory
he Dnergy-5elease heory is credited to Cr. William +addon 9r. of the Insurance Institute for +ighway Safety and was developed in the 0/I-s. here are ten basic principals that are used widely wherever hey are, energy-release is seen.

1'
.. $. G. 7. <.

3revent the marshaling of energy 5educe the amount of energy 3revent the release of built-up energy 1odify the rate or distribution of release Separate energy in space or time Create a physical barrier
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I. 6. /. 0-.

1odify the contact surface to absorb Strengthen the contact surface Cetection% evaluation E counter measures a!e long-term action hin! of hardhat situationsJ

It is important to remember that this is applicable wherever energy is released% including gravity.

he echnique of 4perations 5eview

he echnique of 4perations 5eview is a specific loo! at management practices that is attributed to C.A. Weaver. +e believed that all accidents are a result of the failure of management and that it was critical for management to be accountable in resolving issues that cause accidents. his technique is very critical of management% but it often yields truth that cannot be found in the other techniques - if we can ob&ectively evaluate ourselves. Inadequate Coaching

()ai& re to coach *+ ne* process (,ac- o. instr ction to sit ation ()ai& re to see a need .or training (Inade/ ate instr ction + e0p&anation ()ai& re to &isten to the emp&oyee )ai& re 1o 1a-e 2esponsibi&ity (3 ties responsibi&ity or tas-s are not c&ear (Con.&icting goa&s + responsibi&ities e0ist (1ime + tas- press res (Acco ntabi&ity iss es (Inade/ ate #ob descriptions 4nc&ear A thority (5y passing or con.&icting direction (Incorrect decision or a thority (6vasion o. decisions
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(4nc&ear direction (S bordinate .ai&s to e0ercise decisions Inade/ ate S pervision (,o* mora&7 tension7 insec rity (Poor cond ct e0amp&es ()ai& re to see prob&ems 8 e0ert in.& ence (,ac- o. credibi&ity (,ac- o. &eadership s-i&&s !or-p&ace 3isorder (Ins ..icient or ha9ardo s &ayo t ()ai& re to inspect and nderstand ha9ards (Ins ..icient&y maintained (C& ttered or over cro*ded (!i&&ing to &ive *ith disorder Inade/ ate P&anning+:rgani9ation (;ot prep&anning *or(!or- space prob&ems (;e* or n s a& tas-s (Si9e o. *or-.orce (,ac- o. #ob + *or-er match (Poor coordination bet*een sta-eho&ders

3ersonal Ceficiencies

(Poor hea&th or physica& abi&ity (,imited inte&&igence or -no*&edge (S bstance ab se (3ys. nctiona& persona&ity traits (Poor habits (4ns itab&e assignments
< 3oor 4rgani*ational StructureF3lanning
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()ai& re to set po&icy (4nc&ear goa&s - .o&&o*-thro gh (,ac- o. acco ntabi&ity (:verb rdened . nctiona& areas (,ac- o. h man reso rces deve&opment ()ai& re to enco rage and s pport decisions

System Safety
System Safety is based on the thought that we can ta!e comple" systems and brea! them down into smaller interrelated systems with relationships. With the chun!s of the system in smaller pieces and the relationships diagramed% we can more effectively deal with problems. System safety is usually used in very comple" or important situations that deserve detailed evaluation. An e"ample of this is how they found the o-ring that caused the e"plosion in the space shuttle Challenger. System safety ta!es on many different forms and can be quite elaborate% but they all share four basic points. hey identify potential ha*ards Incorporate safety into design Dvaluate the designs early on And% monitor all safety aspects throughout the life of the system. Some of the common forms of System Safety are,

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Antecedents% >ehaviors E Consequences

he A>Cs of Safety is a very trendy program that is getting a lot of attention. Its value is quite strong in that it helps us to ferret out the reasons people behave unsafely. he concept itself is quite simple. When unsafe behavior is e"hibited% we loo! at the antecedents or behavior triggers to reveal the motivations for that behavior. 4nce the antecedents are consequences for the motivate a safer behavior. Consequences can be thought of in two ways. Intrinsic% the very natural% consistent and reoccurring consequences that is similar to burning yourself on a hot stove. Dvery time you touch it% the burner is hot. he feedbac! is immediate and consistent. D"trinsic consequences are much more inconsistent. #or e"ample we may not see an employee without their hardhat on nine out of ten times. Dven though we may be consistent in calling them on it on the tenth% the feedbac! is inconsistent and not naturally occurring as in the intrinsic consequences. D"trinsic consequences can also be positive or negative. 3ositive e"trinsic consequences are rewards or recognition when people do things right. hey are synonymous with building a competent and loyal wor! force. 4n the other hand% negative e"trinsic consequences are punitive and punishing in nature. It is suggested that if we are using negative e"trinsic consequences on more than an occasional basis that the management technique is flawed and we should return to the echnique of 4perations 5eview to e"amine our own strengths and wea!nesses. It is !ey to remember that e"trinsic consequences ta!e constant effort to maintain and regular focus on safety as a value must be embraced. his techniques main strengths established% then the behavior can be ad&usted to

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lie in the discovery of the basis of behavior and the modification opportunities that are revealed.

Dmpowerment
Dssential to the theory of Accident Investigation is empowerment. very reason we do accident investigation and ta!e all the time to discover the primary causes is so that we can ta!e action to effect safe change. hat goal can only be accomplished if you reali*e that you ma!e a difference every time a safety cause is championed. Some changes will not come about immediately. 1any changes require significant effort. +owever% each step towards a safer wor! environment pays multiple dividends. ?ou can create a safer environment that will cause less physical pain to others. ?ou may save a life. ?ou can prevent significant financial losses through wor!ers compensation% lost productivity and material loss. ?ou will help us to comply with the safety regulations and laws that are there to protect our employees. ?our efforts ma!e a difference. he

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