Most safety regulatory agencies and management systems require a thorough investigation to take place following any safety incident. Be sure to check with your regulatory agency to ensure that you are meeting all requirements with regards to investigations, reporting and documentation. Typically the investigation must include the following components:
- A complete accident investigation report: this should list the details and all contributing factors that lead to the accident. This should also include statements from the injured party and any witnesses
- Evidence that validates statements: this could also include photographs of the area or equipment involved
- A documented Root Cause Analysis (RCA): this is a structured approach to finding the true root cause of an incident. This verifies that the corrective measures have the best chance at success by focusing on the actual root cause of the accident
- Identified control measure implemented: in order to prevent an accident from reoccurring, a control measure must be properly identified and implemented to avoid a repeat of the accident. You may also need to show that you are monitoring the control measure and prove that it is working
For this article I will use the term “accident.” You may differentiate accidents from incidents and near misses. For data collection and documentation, it is important to show if we are dealing with a near miss, an injury, property damage, etc.. No matter which one you are dealing with, your investigation will follow the same steps. In fact, I have always used the same template for an accident form and the same process for all of these. Each one requires a documented investigation and identified control measure.
As a safety professional, I have performed hundreds of accident investigations; more than I would have liked. I became very efficient at capturing all the information needed to identify the root cause and implement control measures. Following these steps, you will also become competent in accident investigation.
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Capture All Evidence and Information
Time to put on your CSI hat, and act like a crime scene investigator. You must capture all relevant evidence relating to the cause of the accident and determine an answer to the question: what really happened?
Once an accident occurs, it is important to investigate the scene immediately while the evidence is fresh. Another reason for this is to make sure that no one else gets hurt by the same exposed hazard. We want a control measure in place quickly. A short term fix may be needed, such as a barrier to block off the area until we know it is safe.
Accident Investigation Form
Having a good accident investigation form can make this whole process from start to finish much easier. A good form will do most of the heavy lifting for you. A good template will list all the information you need to capture, and require that you simply fill out the form with the requested information.
I created a template that we used for years, and have improved the template over time. If I took pictures as part of the investigation, I pasted these to the document, so they could be referenced as part of a complete report. The investigation form must capture all needed information including the control measure. I would always print a hard copy of the accident report for the injured party and witnesses to fill out. I then made an electronic copy to save and file. Electronic and hard copies were both saved and filed. This information must be saved as part of your health and safety management system and to make sure that you are compliant with safety regulatory agencies including OSHA. An auditor may ask to review these.
Data Collection and Review
You’ve done your investigation and filed the information. You have a new control measure in place with the hopes of preventing a repeat of the accident. Now you need to record the new data captured by the investigation. In a program such as MS Excel, you can create a simple spread sheet and list information to look for trends.
For the root cause analysis, I recommend tools such as the 5 Whys, Fish-bone diagrams and fault tree analysis maps (for more on FTA's, check out Fault Tree Analysis). These tools make root cause identification much easier. Once you have found what you believe to be the root cause, share it and see if others agree. Sometimes even the best of us miss something and are always thankful when someone notices what was not caught the first time.
Data to capture and review on your safety data spread sheet:
- Time of injury, day of the week and date - For instance we found January was a high month for injuries in our factory. We never found any trends involving time of day
- Injury type - Lacerations, muscle strains, contusions, etc.. You need to know what are the most common injuries and work to reduce them
- Place on Body Injured – Where do employees receive most of their injuries? (Hands, feet, back, head, etc.) After identifying this, the goal, again, is to reduce the occurrence of these injuries
Using Pareto charts and visual graphs will show trends and where to place your safety efforts. This goes a long way in showing that you are monitoring safety and taking a methodical, proactive approach to reducing injuries.
These visual graphs and charts should be placed on safety bulletin boards, in safety newsletters, etc.. These will help to drum up attention and support for reducing your most common injuries and help stop negative trends.
Be Nice While Conducting the Investigation
I always felt bad for the injured person. No one likes this type of attention on top of getting hurt, so try to have some sympathy. The injured worker will most likely be embarrassed. This is management’s opportunity to show that they care about the individual. Express sympathy and ask for their help to make sure a good control measure is created.
I find that most often the injured party really just wants to get back to work and put the injury behind them. They are almost always willing to help make sure no one else gets hurt that same way.
The Only Up-Side
The only up-side to an accident is to perform a thorough study of it with hopes of preventing any more like it. This is why the accident investigation process is so important. It needs a structured, standard approach. This means having standard instructions in place and followed for all accident investigations. Your guide should outline from start to finish what to do for the accident investigation. Keep it simple and easy to follow.
Accident investigation structure example:
- Fill out accident report form including statement from injured worker and witnesses
- Visit accident site: address any exposed hazards. This might require a short term fix
- Collect evidence from accident site (include taking pictures)
- Review all evidence and perform root cause analysis
- Complete the report including the root cause and new control measure and file as needed
- Record accident data on spread sheet to look for trends (Over the years, this data will be helpful and should show safety progress)
- Schedule 30, 60, 90 day reviews on control measure to make sure it is effective. You’ll find this takes little time
It does not matter how big your business is. When an employee is injured or a near miss occurs, we owe it to all workers to perform the best investigation we can. We must do everything in our power to make sure all apparent safety issues are addressed.
Improved safety is the only silver lining that can come out of someone’s pain from a work related injury. Let’s not pass up an opportunity to show we care and make a safer work environment. It won’t reverse the injury, but they will take some satisfaction in knowing that their injury may help prevent someone else from getting hurt.
This article is focused on the “How to” for accident investigation and reporting. It is important that you understand and meet set requirements by regulatory agencies like OSHA when it comes to recording and reporting health and safety. Be sure to check and make sure your meeting your governing agencies guidelines.