Unraveling the root cause

A worker has just been injured on your job site. What do you do? Provid- ing immediate medical assistance is the logical and correct first step. The next task is to protect workers and property by finding the root cause of the accident and by preventing a reoccurrence. That’s a far more complex challenge.

Accidents are seldom the result of a single factor. Just as fire needs a chemical chain reaction of fuel, heat and oxygen to develop, accidents happen when numerous causal factors are in sync.

Unraveling these factors and determining the cause requires a comprehensive and detailed fact-gathering process, managed by an objective and experienced accident investigator.

At its core, the accident investigation process focuses on people, position, parts, paper and prevention. Within each of these areas are many investigative avenues to pursue, with no direct path from point A to point B. With each finding, the investigation can be propelled in a new direction. The important thing is to stick to the process, follow the facts and focus on the ultimate goal of protecting lives.
 

People: Investigators and witnesses

The best accident investigator for the job is someone who understands the work site, machinery, materials and processes. This gives the investigator important insights and enables the investigation to proceed more rapidly. At the same time, it’s important that an accident investigator be objective, focused only on fact-finding and reoccurrence prevention, without prejudice toward the company, workers, insurance companies or legal issues.

Witnesses to the accident must be interviewed, a process that requires a unique skill set combined with excellent interpersonal abilities. The investigator should locate and interview witnesses individually as soon as possible. It’s important to speak with witnesses before they might be influenced by other workers or by the words or actions of medical and rescue personnel or the media.

Questions should be asked respectfully and without any insinuation of blame. At the same time, the investigator will need to consider factors that can affect the way a witness recalls events or explains those recollections. For example, men and women often interpret events in a more or less emotional way. The worker’s position in the company could create a fear of reprisal, or his relationship to the injured party could influence his answers.

Communication barriers related to language or literacy could affect the ability of the witness to answer clearly.

Other factors affecting witness recollections could be related to fatigue, visual impairments, sensory illusions caused by medications and even time of day if the accident area was in shadow or if bright sun could have blocked sight lines.

Whatever the challenges, the investigator must be sure never to lead the witness but to strive to construct a true picture of the accident scenario.
 

Position: Analyzing the accident scene

An evaluation of the accident scene should be done as quickly as possible, with the goal of maintaining the scene as it was at the time of the accident. The scene should be mapped out to provide a detailed perspective on where people, equipment, materials and other items were located or positioned after the accident. This can then be compared with how things should have been under normal conditions.

Every element of the scene, including time of day and weather conditions when the accident occurred, must be considered.

If news media reported on the accident, there’s a good possibility that they may have arrived at the scene before the accident investigator. Photos, videos and firsthand reports may be available that can help reconstruct the accident scene.
 

Parts: Evaluating physical factors

Building structure, work surfaces, equipment and materials should be inspected to detect any obvious defects or hazards, such as slippery conditions or the absence of machine guards. Investigators will determine if personal protective equipment was used by the injured worker. Manufacturing equipment specifications will be reviewed.

If a problem or deviation from procedures or specifications is found, the investigator can work backward to determine how that hazardous condition developed.
 

Paper: Reviewing documentation

The paper trail is often one of the most revealing aspects of an accident investigation. The accident investigator should review any and all documentation that could factor into the cause of the accident. Machine operating procedures, installation instructions, recent repairs or maintenance reports, company health and safety policies, hazard analyses, safety training procedures, employee job descriptions and more all can contribute to putting the accident puzzle together.
 

Prevention: Correcting safety issues

While accident investigation is primarily focused on determining how an accident occurred, the ultimate goal is to use that information to prevent future injuries, property damage or negative effects on company operations. Recommendations for corrective action are always the final step in the investigation process.
 

Creating safer work places

The National Safety Council estimates that in the United States, nearly 11 workers die on the job every day and 5 million are injured. Even one death or injury is too many—both in the human suffering it causes and in the impact it can have on business viability.

While health and safety programs to prevent accidents are essential, so too is the need for a diligent, comprehensive and fully objective investigation when an accident occurs.

Martin J. Davis is principal safety consultant with HazTek Inc., http://haztekinc.com, a leading occupational health and safety firm providing consulting, training and support.