A-5 Accident Investigation

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ACCIDENT INVESTIGATION

Accident investigation is required activity by Washington State

Administrative code. It is also required by the Citys safety committeesfor review of the results of the investigations and follow-up

recommendations. This chapter provides some insight to the

philosophy and process of investigating accidents and incidents. The

Accident Worksheet is found in Appendix FA-3 and is also referred to in

Chapter A-3, Safety Committees.

The key to preventing a

reoccurrence

It is the position of the City of Spokane that all

accidents can be prevented, not just

theoretically, but realistically. A key 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 knowing that we

can make a difference if we can find the true causes of the accident.

This means dropping any assumptions that

there is nothing that can be done - it is an

accident.

Now that you have dropped this assumption,

realize that we should investigate all accidents

CITY OF SPOKANE RISK MANAGEMENT & SAFETY MANUAL A5.1

Chapter A-5: Accident Investigation

Created: September 2000


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Primary

Cause Secondary

Cause

Contributin

g

Causes

formally, and the near miss accidents in an informal investigation.

Heinrichs Accident triangle shows us this.

A study of accidents was done. What it revealed on the average is:

that out of 330 times in an identical situation, there would be 300 near

miss accidents, or opportunities to see an accident coming. 29 times

there would be a minor accident, and 1 out of the 330 would result in a

serious accident. For example: I could stumble on a crack in the

sidewalk 300 times, I might fall and sustain a scrape or bruise 29

times, and one time I could perhaps fall with a baby in my arms and

the child would be severely injured. Since this is a statistical model,

we dont know which time will be the serious injury. It could be the

first stumble, the last, or anywhere in the middle of the 330. This is

why we investigate all accidents and near miss opportunities.

Accidents Have Multiple Causes

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 exact same accident from

happening again. Many times eliminating one of

the causes also eliminates future accidents that might have occurred

with other elements as well. The key is to investigate until the true





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causes of the accident are discovered. Fortunately there is a

technique for doing this type of accident investigation. It is called the

Why Method of Accident Investigation.

The Why Method of Accident Investigation

This method starts out very simply by stating the name of the injured

party, the injury, and the element that caused the injury. These are

the apparent facts that we have to begin with. Then we start with the

Cause of Injury and ask the question why? Why was the person injured

by: whatever it was. Then repeat by asking why to the answer of that

question until there is a series of questions and answers. From that

list, select the Primary Cause that is most likely. Now you can take the

original question or any question in the primary cause list and ask once

again, why? There should be a different answer and we start

descending down the secondary cause list repetitively asking the

question, why?

Note that there

are two styles of

asking the

question. One in

a descending

order with each




Why ?

Accident

Why ?

Why ?

Why ?

Why ?

Injury Cause of

Injury


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answer resulting in another question - why? And the second style is to

keep asking the same question way over and over getting different

answers each time.

The Typical Results of an Investigation

The typical results of an

investigation reveal that 85% of

the causes are actions,

something that someone did.

15% of the causes of accidents

are physical conditions that

exist in the workplace. In the majority of controlled environments this

will hold true. The fortunate result of this is that most accidents can be

remediated through either training or an engineering control. We are

only looking for one or the other.

It is important that we stay objective with employees. Just because

85% of accidents are caused by something someone did, it does not

mean that they wanted to be involved in an accident. No one wants to

be injured. Accident investigation should not be punitive, but should

be presented as a caring function of management making the work

environment safer.




15% Condition

85% Personal Action


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Investigative Tools and Skills

The supervisor or manager filling out the injury report should also be

the one to do the accident investigation. Presumably they are close to

the worker and know the job best. If the supervisor starts the

investigation immediately, they will be closest to the fresh facts.

Furthermore 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 skills include interviewing both the injured individual and

any witnesses. It is important that we be sincere and caring during the

accident investigation. Remember and convey that our goal is to

prevent future injuries, not punish employees. The classic

investigative questions of who, what, why, when, where, and how

must be answered. Hidden and often human action type details must

be uncovered. These are not in the physical evidence realm, and





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therefore are more difficult to uncover. The supervisor filling out the

accident report should be able to spot an unsafe act or unsafe

condition quickly and then be able to communicate a clear picture to

secondary audiences. It helps to ask open-ended questions that

require more then a yes or no answer. Use of the awkward minute,

allows 60 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 OK to clarify information, but

wait until they have finished speaking. Our job in the investigative

stage is to take detailed notes and complete the paper work

immediately.

If the investigation does not yield apparent causes, we might want to

question things like policies, procedures and training. This includes

looking at who was near by, or who should have been near by. Were

there any unsafe acts, unsafe conditions, equipment or chemicals?

What personal factors might have come into play? Has there been any

change in productivity demands? The deeper we question the more

likely we are to come to realistic causes of the accident. Then we are

most likely to be solving root causes instead of symptoms.

Often an Accident Investigation Tool Box can be helpful. You might

want to include things like a camera to take accident photos with; or, a





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micro cassette recorder to record statements with; or, flashlight to

explore dark or dimly lit accident scenes. You 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 hazardous

debris to handle or blood borne pathogens. Having a roll of barrier

tape might also be a consideration if we need to keep employees out

of an accident site, or if we need to block off the area during the

investigation and until we get it cleaned up and back to a point of

productivity.

EFFECTING CHANGE

(Our Tool Box for Correcting Unsafe Actions or

Conditions)

There are six techniques that are widely accepted by safety

professionals for effective accident prevention. These are:

The Domino Theory

Industrial Hygiene Techniques

The Energy Release Theory

The Technique of Operations Review

System Safety Schematics

Antecedents, Behaviors & Consequences





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Different methods are more applicable to certain situations, so we will

cover all six.

The Domino Theory

H.W. Heinrich, a leading Industrial Safety Engineer, developed the

Domino theory. He believed that all accidents could be modeled with a

chain of five factors. They were:

o Ancestry and social environment

o The fault of a person

o An unsafe act and/or physical hazard

o An accident

o The resulting injury

If the chain could be broken before the accident, injuries could be

eliminated. He believed that the easiest place to break the chain was

by eliminating an unsafe act or physical hazard. This 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. This also simplifies corrective activity that can be

categorized in two groups, education and training, or change of a

physical hazard.





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Industrial Hygiene Methods

These are eleven basic methods developed by hygienists and

engineers over the years for controlling work processes. It is the plan

that we use to make processes safer. They are:

1. Substitute a less harmful material

2. Alter process to reduce worker contact

3. Isolate or enclose a process

4. Use wet methods to reduce particulates

5. Ventilate to disperse contaminates

6. Dilution ventilation

7. Maintain good housekeeping

8. Monitor & control exposure

9. Personal Protective Equipment (PPE)

10. Implement baseline & detection programs

11. Educate and train employees

The Energy-Release Theory

The Energy-Release Theory is credited to Dr. William Haddon Jr. of the

Insurance Institute for Highway Safety and was developed in the

1970s. There are ten basic principals that are used widely wherever

energy-release is seen. They are:

1. Prevent the marshaling of energy

2. Reduce the amount of energy

3. Prevent the release of built-up energy

4. Modify the rate or distribution of release

5. Separate energy in space or time

6. Create a physical barrier





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7. Modify the contact surface to absorb

8. Strengthen the contact surface

9. Detection, evaluation & counter measures

10. Take long-term action

It is important to remember that this is applicable wherever energy is

released, including gravity. Think of hardhat situations!

The Technique of Operations Review

The Technique of Operations Review is a specific look at management

practices that is attributed to D.A. Weaver. He 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. This technique is very critical of management, but it

often yields truth that cannot be found in the other techniques - if we

can objectively evaluate ourselves.

Inadequate Coaching

Failure to coach w/ new process

Lack of instruction to situation

Failure to see a need for trainingInadequate instruction / explanation

Failure to listen to the employee

Failure To Take Responsibility

Duties responsibility or tasks are not clear

Conflicting goals / responsibilities exist

Time / task pressures

Accountability issues

Inadequate job descriptions

Unclear Authority

By passing or conflicting direction

Incorrect decision or authority

Evasion of decisions





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Unclear direction

Subordinate fails to exercise decisions

Inadequate Supervision

Low moral, tension, insecurity

Poor conduct examples

Failure to see problems & exert influence

Lack of credibility

Lack of leadership skills

Workplace Disorder

Insufficient or hazardous layout

Failure to inspect and understand hazards

Insufficiently maintainedCluttered or over crowded

Willing to live with disorder

Inadequate Planning/Organization

Not preplanning work

Work space problems

New or unusual tasks

Size of workforce

Lack of job / worker match

Poor coordination between stakeholders

Personal Deficiencies

Poor health or physical ability

Limited intelligence or knowledge

Substance abuse

Dysfunctional personality traitsPoor habits

Unsuitable assignments

\

Poor Organizational Structure/Planning





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Failure to set policy

Unclear goals - follow-through

Lack of accountability

Overburdened functional areas

Lack of human resources development

Failure to encourage and support decisions

System Safety

System Safety is based on the thought that we can take complex

systems and break them down into smaller interrelated systems with

relationships. With the chunks of the system in smaller pieces and the

relationships diagramed, we can more effectively deal with problems.

System safety is usually used in very complex or important situations

that deserve detailed evaluation. An example of this is how they found

the o-ring that caused the explosion in the space shuttle Challenger.

System safety takes on many different forms and can be quite

elaborate, but they all share four basic points.

They identify potential hazards

Incorporate safety into designEvaluate 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, Behaviors & Consequences

The ABCs 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. The concept itself is quite simple.When unsafe behavior is exhibited, we look at the antecedents or

behavior triggers to reveal the motivations for that behavior. Once the

antecedents are established, then the

consequences for the behavior can be adjusted to

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. Every time you touch it, the burner is

hot. The feedback is immediate and consistent.

Extrinsic consequences are much more inconsistent. For example we

may not see an employee without their hardhat on nine out of ten

times. Even though we may be consistent in calling them on it on the

tenth, the feedback is inconsistent and not naturally occurring as in the

intrinsic consequences. Extrinsic consequences can also be positive or

negative. Positive extrinsic consequences are rewards or recognition

when people do things right. They are synonymous with building a

competent and loyal work force. On the other hand, negative extrinsic

consequences are punitive and punishing in nature. It is suggested

that if we are using negative extrinsic consequences on more than an

occasional basis that the management technique is flawed and we

should return to the Technique of Operations Review to examine our

own strengths and weaknesses. It is key to remember that extrinsic

consequences take constant effort to maintain and regular focus on

safety as a value must be embraced. This techniques main strengths





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lie in the discovery of the basis of behavior and the modification

opportunities that are revealed.

EmpowermentEssential to the theory of Accident Investigation is empowerment. The

very reason we do accident investigation and take all the time to

discover the primary causes is so that we can take action to effect safe

change. That goal can only be accomplished if you realize that you

make a difference every time a safety cause is championed. Some

changes will not come about immediately. Many changes require

significant effort. However, each step towards a safer work

environment pays multiple dividends. You can create a safer

environment that will cause less physical pain to others. You may save

a life. You can prevent significant financial losses through workers

compensation, lost productivity and material loss. You will help us to

comply with the safety regulations and laws that are there to protect

our employees. Your efforts make a difference.




Documents

A-5 Accident Investigation