Five words that strike fear into any business operator’s heart (besides “60 Minutes is waiting outside”) are certainly, “We’ve just had an accident.” Keeping employees safe is of primary concern to any employer, but in spite of our best efforts, undesirable events with negative results still happen.
When an accident occurs, a business should approach the investigation with the thought in mind of, “what can we learn for this event that will help us avoid a similar event in the future?” Our focus should be on preventability.
Businesses need to investigate not only accidents that occur, but also investigate those events where no one was injured, but were accidents none the less. Why? Every event that we could call a “near miss” should be seen as a free warning, to induce us to take whatever measures apply to prevent a more serious event from happening.
Take for example a worker who is assigned to change a burned out light bulb, over a windowless, side door to the building. The worker is only going to be a couple of rungs up the ladder, and only for a few moments, so doesn’t take the time to put a warning sign on the other side of the door. While removing the fixture’s cover to access the bulb, another worker opens the door from the inside. Fortunately, the guy changing the light bulb had just climbed down, and wasn’t actually on the ladder at the moment the door was opened and the ladder was tipped over, but what if. . . . .
This event should be seen as a reminder that when ever working in an area where there is expected to be other workers passing through, we always should set up either warning signs or even temporarily barricade, restricting access to the area, until the work is finished.
Following are some of the reasons why the four basic steps listed should be taken, following an accident, and in the order presented:
Immediate actions: For most of us, a call to 9-1-1 is the first priority – get trained help on the way. Determine if the scene is safe for responders to enter, then address the first aid needs of any who were injured. Also determine if the scene can be isolated, preventing the possibility for the damage to spread. A second reason to isolate the scene is to prevent things from being moved or disturbed. Examination of the evidence left behind can often tell the investigator what happened; if things are moved or debris is cleaned up, a piece of the story may be gone and not be able to be recaptured.
Determine the facts: No one will be able to tell you everything that happened, so you will have to get pieces of the story from various sources. Interview witnesses, and if able, interview the person(s) directly involved. Take your own notes, photographs, and even draw a sketch of the area. NOTE: sketches are not to scale and should be so noted on the sketch, but do show the general relationship and location of objects and personnel at the time of the event. Paper documentation may also help: things such as time sheets, training records, and maintenance records may reveal contributing factors to the cause of the event.
Establish causes: Once all the data is gathered and evaluated, the cause can usually be identified. Remember – accidents seldom have a single cause, but are usually the result of several contributing factors, all coming together at the wrong time. Keep in mind the goal in this step is to establish the cause(s) and learn how to prevent those factors from coming together again.
Recommend and implement corrective actions: Once the determination has been made as to what factors came together to cause the event, take steps to reduce or eliminate the possibility of a reoccurrence. This may include
• Eliminating the process altogether
• Substitute a less hazardous item or chemical for the more dangerous one An example would be use a non-flammable solution for parts cleaning rather than a flammable petroleum product.
• Isolate the hazard that precipitated the event, such as enclose the item in an area where people can not come into contact with it, or be affected by it (such as enclosing a noisy machine in an insolated room).
• Engineering controls; such as a change to equipment, a change to eliminate the need for human intervention to control the process. Add guards, or interlocks to prevent a human operator from placing their hands in the operational part of the machine.
• Administrative changes: change operating procedures or company safety policies, for example to insure that no one works alone in a particularly hazardous area. Paint lines around a machine and require that only the operator be “inside the line” while the machine is in operation.
• PPE. As a last line of defense, what PPE should be worn by the employee when performing the task in question? Was the employee aware of the PPE need? Was the employee trained in the use and care of the PPE?
We must take the time to learn from seemingly inconsequential everyday events, and take the appropriate actions indicated to prevent accidents before they happen.
Evergreen Safety Council offers a class on Accident Investigation as part of our