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Establishing the Objectives for Investigating an Incident/Accident
In conducting a workplace accident investigation, knowing the objective or purpose of related undertakings, serves as the primary guideline on what should be performed.
Distinguishing an event as either an incident or an accident is considered irrelevant: Any unexpected occurrence that impedes a workplace activity requires an investigation into its root cause. The objectives for doing so include:
- The prevention of similar episodes from occurring in the future.
- The determination of the cost and extent of the damages sustained.
- The assessment of the degree of compliance with the safety regulations being implemented.
- The review of the adequacy of the mitigation plus prevention measures in place and being enforced.
- The fulfillment of the requirements mandated by the Occupational Health and Safety Administration (OHSA) and other state regulatory agencies covering areas not governed by federal OHSA regulations.
- Compliance with the required documentation for processing workers’ compensation and insurance claims.
In considering all these objectives, it is essential that the members of the team tasked to investigate a workplace accident have adequate experience in data gathering and identifying the underlying causes of the accident.
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Qualifications of the Investigating Team
Haphazard investigations often stem from a lack of knowledge of the work processes involved. There is also a lack of understanding of the human behaviors, the materials used, the company policies in place, the corporation’s core values and mission, as well as the environment in which the untoward event took place.
Best practices recommend that both management and the labor sector should be well represented, in order to avoid issues of whitewash or cover-ups. The contention to this argument is that any attempt can be thwarted if both parties are provided with factual information, but not to the extent of hampering the process of investigation.
The following individuals are often suggested as candidates to be considered as members of an investigating committee or team:
- An officer of the company with superior knowledge of the work and its processes plus adequate experience in conducting investigative proceedings.
- Employees with excellent records in performing the tasks related to the incident, including those employees that perform audit and compliance reviews.
- Independent professionals or those who are considered experts in investigating similar adverse occurrences.
- A representative from OHSA or any federal/state regulatory agency, not only as counsel but also to provide credence to the quality of the inquiries and research activities being conducted.
- A union representative if the occasion calls for it.
Distinguishing whether the episode is an incident or accident adds bearing to the selection process. Inasmuch as an accident is regarded as an unlikely occurrence that resulted not only in the hampering of workplace activities, its consequences may or may not have resulted in fatality, injury, destruction of property or all three of those.
Moreover, it is important that the careful selection of the investigating team members has been pre-determined as part of the company’s risk management strategies for the purpose of expediting the investigation processes.
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Guidelines for Investigating Accidents that Occur in the Workplace
In carrying out inquiries about adverse workplace events, there are five critical concerns to address in order to attain the objectives of an in-depth investigation. These are:
- Reportorial requirements
- Data gathering and assembly
- Data analysis, i.e. root cause analysis
- Identification of risks and their control measures
- Written report and the recommendations for plans of action to implement and follow up.
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1. Reportorial Requirements
The investigating team should check that the reportorial requirements of OSHA and other state regulatory agencies have been satisfied.
OSHA Reporting and Record Keeping Requirements
As a rule, this federal agency requires that workplace incidents resulting in the fatality of at least one worker or in the hospitalization of at least three employees shall be reported to OSHA within eight hours from the time that the unfortunate episode took place.
OSHA further imposes the maintenance of its Form 300, which is the “Log of Work-Related Injuries and Illnesses" for minor workplace incidents. This log is one of the references being used by the investigating team in reviewing the safety and health measures being implemented in a particular workplace.
Understand that the log does not necessarily meet the report required for claiming workers’ compensation and other insurance claims.
In addition to Forms 300 and 300A, OHSA further requires that an injury and illness incident report using Form 301 or its equivalent be filled out by the employer within seven days of receiving information about the workplace incident. Said incident reports along with the log for workplace injuries and illnesses shall be kept on file for five years. The five-year period shall commence on the following year after the incident took place.
State and Industry Reporting Requirements
Different states and industries have separate reportorial requirements governing their areas of coverage. Accordingly, the State of California has the most number of regulations over workplace accident investigations, for aspects not covered by OSHA.
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2. Data Gathering and Assembly
Data gathering should be performed systematically and always with the investigation objectives in view. The methods involved are mainly by way of interviews, photographs or sketches and data maps, models, charts, scales and other processes. Below are some important points to consider when gathering essential relevant data:
1. During the interview process, questions should broach three significant factors: human, physical and system.
2. Interviews should not interfere with the work of the rescue or medical teams. It is important to place priority on the treatment and prevention of further injuries over investigations.
3. Take decisive steps to preserve evidence. If the investigation of the accident requires the participation of local police authorities or the coroner, the site and all evidence therein should not be moved unless with prior approval from the authorities.
4. Take photographs or videotapes of the site and of the evidence in their undisturbed states. Create sketches of the general area for purposes of recording measurements, and make notes of the time of occurrence. Also, note the weather conditions. It is likewise important that all data gathered are assembled in chronological sequence.
Please continue on page 2, with pointers for identifying risks and identification of risk-control measures--and more.
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Have yourself in the right mindset when performing a workplace accident investigation: Be constantly aware that the objective is to get to the root cause of the incident in order to come up with adequate preventive measures against recurrences. Moreover, making recommendations must be specific. Facts should properly present a clear picture of what was uncovered that warrants those recommendations. Find more guidelines on how to achieve the goals of a fact-finding mission and its analysis in this article by Ciel S. Cantoria.
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5. Witnesses who are not badly injured should be interviewed separately with little time lost after the incident. It should be clear to the witnesses that the objective of the interview is to establish the cause in order to formulate preventive measures and not to find fault.
6. Ask questions that will prompt the witness to answer explicitly, but don't deliver the questions in an intimidating manner. Avoid questions that tend to lead and be answerable by a yes or no, which could lack clarity whether the information gathered is based on the interviewer’s own perception or an actual eyewitness account of the incident.
7. Assess the credibility of the witness as a reliable source of information--i.e., his or her tendency to exaggerate, poor recall, or lack of confidence about the information being provided.
8. Get hold of technical data sheets, minutes about health and safety issues, OSHA inspection reports, company policies and manuals of safe work procedures, records of disciplinary actions, maintenance feedback reports and requests, OSHA Form 300, 300A and 301. Study related information or similar occurrences, including the changes that were implemented after the previous incidents
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3. Data Analysis
Analysis to determine the root cause of the incident should be performed if sufficient data have been gathered. There are different root cause analysis methods available to use, and selecting the method to employ depends on the degree of data analysis required.
The degree, however, should not be based on what is apparent on the surface. Nor should it be based on determining the extent of human errors. The extent of the analysis to be performed should be based on the conditions and elements present:
- Workload, with considerations for its regularity or any extraordinary quality and quantity
- Working conditions and their proneness to failures or accidents, to weather or climate changes, or to their volatility to economic and social conditions
- Environment, which could be physical, natural or emotional
- Materials, whether hazardous or non-hazardous
- Machinery, tools and equipment used
- People and their expertise, competencies, training and manifestations of behaviors
Team members should all be knowledgeable of the root cause analysis method being used. That way, the tasks of analyzing the underlying causes can proceed with everyone having the right mindset to do their jobs as investigators require.
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4. Identification of Risks and Their Control Measures
Risk identification is necessary to determine the control measures that will prevent the recurrence of the workplace accident. Risks may arise from different aspects of health and safety issues. Most often, the common sources of risks in the workplace are weaknesses in a system's design or laxity in the implementation of systems control.
(a) Examples of weaknesses in systems design include:
- Lack of control measures at certain critical points to provide built-in checks and balances,
- Inadequate training or training programs for the handling of equipment or machinery
- Poorly devised plans and procedures in place, which also means insufficient testing and anticipation of potential risks
- Insufficiency of maintenance initiatives.
(b) Examples of weaknesses in systems implementation:
- Lack of internal examinations regarding systems compliance.
- Lack of training initiatives for safety by way of dry runs or drills.
- Inadequate supervision during work activities.
- Review and analysis lacking depth and consistency.
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5. Written Report and Recommendations
The culmination of a workplace investigation is the written report that contains the information about what, how, and why the adverse incident took place, as well as the recommendations formulated to prevent its recurrence.
- The information presented should be clear, precise, factual and properly outlined. Best practices also observe avoiding the mention of surface causes but instead provide a straightforward report of its root causes. That way, management and all other users of this report can easily grasp the significance of the recommendations.
- Moreover, recommendations should specifically state the plan of actions to be taken, i.e. “install two to three large-sized exhaust fans" instead of simply stating: “install a ventilating system".
- Identify the department or employees who will follow-up and assess the effects of the recommended plan of actions.
As a recap, the best way to investigate incidents is to have a ready plan of the steps to be undertaken. That way, the fact-finding process can be expedited in the most organized and efficient manner possible.
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Reference and Image Credit Section
- Occupational Health and Safety Section Department of Environmental Health-- "Guide to Accident/Incident Investigations".