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THE OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION (OSHA) defines an accident as an unplanned event that results in personal injury or property damage. Accident investigations are a cornerstone in the foundation of effective safety and health programs. The information gathered during investigations assist management in meeting legal reporting requirements and filing insurance claims. Effective accident analysis will identify why the incident happened and recommend actions that will prevent future accidents. Finally, comprehensive investigations are a proven deterrent to the filing of fraudulent claims.
It would appear that contractors should attempt to investigate and analyze all accidents in the workplace. Thorough investigations protect workers and reduce operating costs. However, contractors must consider the expense of properly performing an accident analysis for every incident. More importantly, they must consider the impact investigations and reports have on litigation. Cases involving third parties and serious or willful misconduct require special handling. The very documents that you generate to create a safer workplace can be used against you in court. It is recommended that you have an attorney review all accident policies as well as the forms and procedures to be used. You should also seek legal advice on the filing and maintenance of all accident-related records and reports.
Two basic tools used in investigating accidents are the incident report and accident analysis. The incident report is the initial report—usually filed by supervisors to inform management—that an accident has occurred. An employer should file one for every workplace accident. Designed to collect objective information, the report will succinctly identify who, what, where and when and provide brief answers to the questions contained in the OSHA Form 301 (Injury and Illness Incident Report). It may also include basic facts required by your insurance provider.
Management must carefully develop the incident report form. It should have a policy that clearly identifies when such a report is required, who is required to complete it and how quickly they must be filed. Most effective policies require immediate notification if an accident involves death, hospitalization, medical treatment or a third party. OSHA requires notification be made to them within eight hours if a fatality or catastrophe occurs. Written reports should be completed within 24 hours. This may be required by certain government entities or insurance companies. Incident reports are likely to be subpoenaed during litigation and should be treated as such.
Many organizations also track and analyze near-miss accidents—undesired events that, under slightly different circumstances, could have resulted in personal harm, property damage or undesired loss of resources. Near-miss accident reports should be considered confidential and identified as such in your policy. These reports should be recorded on a different form and filed in separate locations.
Training must be provided to those workers required to submit the reports. The training should address all policies and procedures you expect them to follow. Some accidents require the area to be secured and evidence preserved. The scene should not be disturbed unless a hazard exists. Policies, procedures and training must also address the preservation of evidence.
Keep in mind that supervisors are usually the first representatives of management at the scene of an accident. Their decisions and actions can cost or save you thousands of dollars. Also remember, in most cases, local news crews arrive at the scene of accidents before emergency services. All managers, supervisors and workers should receive training and be advised on giving statements and unsolicited comments. Everyone should understand the level of cooperation they are required to provide OSHA, criminal investigators and private agencies. They should know what to say and what not to say. Compliance and confidentiality must be in balance. This does not happen by chance. You must develop policies and procedures and ensure that workers are effectively trained.
The objective of the accident analysis is to identify why and how the accident occurred. A detailed analysis of most accidents will reveal three cause levels. These include the direct, indirect and basic cause of the accident. The direct cause of an accident is usually the most obvious. Examples include the unplanned release of hazardous energy or exposure to a hazardous chemical.
Indirect causes are classified as unsafe acts and unsafe conditions. Unsafe acts, which account for the majority of accidents, occur when workers ignore safety rules, use unauthorized equipment or operate tools incorrectly. Unsafe conditions may include inclement weather, equipment failure and traps. Traps are defects in the design of the operation or workstation that increase the probability of an accident.
The basic cause of an accident refers to deficiencies in policies and procedures or failure in executing policies and procedures. The root cause may be traced to the fundamental attitude workers and management have toward safety. The central objective of the accident analysis is to determine the root cause and take corrective action.
The accident analysis begins by reviewing the initial incident report. The report provides enough information to identify the problem and scope of the analysis. The accident analysis team should quickly attempt to determine the initial sequence of events. This may require an inspection of the accident scene and equipment. Additional data—which may include pictures, statements, training histories and worker qualifications—is collected and confirmed.
Once the data has been collected and confirmed, the team determines what caused the accident. Some instruments used in this process are the job safety analysis, change analysis, barrier analysis and system failure analysis. An Internet search will provide procedures, flowcharts and forms.
The job safety analysis breaks down an operation into its component steps. The steps are listed in the order they are performed. Hazards are identified for each step and controls listed for each hazard. The job safety analysis will ensure that every hazard encountered in the operation is controlled and the worker is protected.
The change analysis is a tool that assists in determining the cause of the accident. It is a problem-solving process that compares what should have happened to what actually occurred. It looks at the distinctive differences in the two scenarios and helps you arrive at a list of likely causes.
The barrier analysis examines the barrier (or control) that should have prevented the accident to determine why it failed. Used to analyze the failure of engineering controls, administrative controls and protective equipment, it identifies if the barrier was missing, weak or ineffective and why.
The system failure analysis is designed to identify errors, mistakes or lapses in management control. These occur when written policies and procedures are not properly implemented. Examples include unenforced safety rules, incomplete inspections and ineffective training. Correcting system failures may have the most significant impact on the overall performance of your safety program.
You can identify the root cause(s) of the accident using these comprehensive analytical tools. A list of corrective actions can be developed and a report submitted to management. The report should also identify the strengths of your existing program. Once management has approved the final report, an agenda should be established, changes tracked and progress reported.
Management must develop a policy that identifies when to conduct an analysis as well as determine the procedures for conducting the accident analysis. At one time, accident analyses were routinely performed for cases involving a fatality, hospitalization or lost day.
Today, employers are cautioned against this policy. You should not do a routine accident analysis if you suspect litigation. Litigation will most likely result from situations involving extreme severity, willful misconduct and third parties. In these cases, you should seek immediate legal advice. Your attorney may recommend a private investigation service and instruct you how to proceed.
Management must determine who will conduct the analysis and complete the report. These tasks require time and skill. Policies, procedures and forms need to be developed and training provided for all accident analysis team members. Confidentiality is critical because of the sensitive nature and legal ramifications of the information. In many organizations, only trained managers are permitted to serve as analysis team members.
Identify all documentation resulting from the accident analysis as confidential in your policy. The documents should be filed in a separate location and kept away from incident reports and required OSHA reports.
This may help to establish your claim of confidentiality and make the documents more difficult to subpoena. Your policies and procedures may also limit the amount of time documents are kept on file. Some organizations destroy all analysis documents once an action list has been compiled or tasks completed. Your company must determine the criteria for managing an accident analysis. It is recommended that all decisions be based on sound legal advice. An attorney should review all policies, procedures and training outlines.
The benefits of conducting effective accident analysis far exceed the pitfalls. Analyzing accidents is a critical component of occupational safety and health programs. They provide an effective means of examining and improving your existing program. However, management must also take action to ensure they are legally protected. Use accident analysis to protect workers; don’t let it be a weapon used against you in court. EC
O'CONNOR is with Intec, a safety consulting, training and publishing firm that offers on-site assistance and produces manuals, training videos and software for contractors. Based in Waverly, Pa., he can be reached at 607.624.7159 or by e-mail at [email protected].