Although the primary purpose of a safety program is to prevent accidents from happening, it should also include what to do when they do happen. Of course, accidents don’t just happen; they are caused. That is why it is imperative to perform a post-accident investigation to determine the causes. Once the causes have been discovered, they can be addressed and corrected to ensure that they do not
occur again.

Accident Investigation Basics

The goal of the investigation is to determine how and why the accident happened. The following is a quick review of some basic accident investigation terminology:

• An accident is defined as an unplanned, unwanted event or sequence of events that causes illness, injury or death to persons and/or damage to materials, property or equipment.
  
• A near miss is an unplanned event that did not result in injury, illness, death or damage — but had the potential to do so. Only a fortunate break in the chain of events prevented it from happening. Example: A rock falls into a trench box, but does not hit a worker because he or she saw it coming and moved out of the way. Even a near miss is an accident that should be investigated. Think of it as a second chance to get it right.
  
• Accidents are caused by unsafe acts or unsafe conditions and generally involve a combination of the two.

An unsafe act is defined as a violation of a commonly accepted safety procedure. Unsafe acts include but are not limited to: violations of safety rules, nullifying safety devices, failing to use personal protective equipment, using defective equipment, substance abuse and/or horseplay.

An unsafe condition is the physical or environmental condition that exposed the worker to a hazard or damaged material or equipment. Unsafe conditions include but are not limited to: defective equipment; unguarded machinery; inadequate guards and devices; fire and explosive hazards; lack of shoring, shielding or sloping; improper storage or placement of materials; and/or hazardous atmosphere.

• A root cause is an initiating cause in a chain of events that leads to an undesirable outcome or effect.
  Frequently, the obvious conditions or the actions of the employees identified and reported following the accident are not the root causes. Root causes are what precipitated the observable conditions or actions.
  They include but are not limited to: lack of knowledge due to inadequate training; physical impairment not identified; inadequate or incomplete safety procedures; failure to make protective equipment available; inadequate design; inadequate purchasing standards; normal wear and tear; lack of preventive maintenance; and/or abnormal usage or overloading.

Who Should Investigate Accidents?

Who will investigate the accident will generally depend on its severity. Minor accidents and near misses should be investigated by the foreman/supervisor since they are in the best position to know the workers and the nature of the work being performed. In general, they are also in the best position to gather the facts, find a practical solution to the problem and take immediate corrective action.

Severe accidents call for more detailed investigations and more experienced investigators such as safety directors, insurance personnel, law enforcement personnel and sometimes OSHA compliance officers. In these cases, it is very important that the investigation be performed properly and the evidence preserved. The foreman/supervisor should be a partner in the investigation since he or she is still in the best position to know what was taking place at the time of the accident and may be able to provide important information that is needed to complete the investigation.

Accident Investigation Plan

Accidents should be investigated immediately if possible, but always within 24 hours to prevent evidence from being disturbed, moved, lost, destroyed or thrown away.

Every company should establish a documented accident investigation plan to ensure that the proper procedure is
followed when an accident occurs. While it is to be hoped that the plan will never have to be implemented, after an accident occurs is not the time to decide how the investigation will be performed.

Therefore, the following steps should be taken when planning an accident investigation procedure:

1. Establish a company policy requiring that all accidents, including near miss accidents, be investigated for cause.
   
2. Assign responsibility for ensuring that investigations are completed; this responsibility generally falls on the safety director or risk manager.
   
3. Establish emergency procedures and ensure that employees know what they are expected to do if an accident occurs and that all accidents and near misses are reported to the foreman/supervisor or management immediately.
   
4. Develop an accident investigation procedure.
   
5. Prepare or obtain an investigation form. Send completed reports to the safety/risk management department for review and analysis.
   
6. Provide training for all personnel who will be expected to perform investigations.
   
7. Make sure forms and the necessary equipment for investigations are available at all worksites or in vehicles.
   
8. Audit investigation activities to ensure proper implementation.
   
9. Periodically perform loss analysis, summarizing accident types, causes and costs.
   
10. Require managers, supervisors and foremen to give extra attention to problem areas.

Your insurance company is a good resource for information, training and help with preparing an accident investigation program. It is also a good practice to consult your attorney because they are often concerned about how accident reports are documented and handled, especially when a serious accident occurs.

It is essential that employers do everything in their power to prevent accidents. However, when an accident does occur, it is just as important to determine the facts about what caused the accident. Without the facts, hazards cannot be eliminated or controlled and another, possibly more tragic accident could occur in the future due to
similar causes.

Accident Investigation Procedure

The accident investigation procedure includes obtaining all the facts about what led up to and caused the accident. All information should be based on facts that can be verified. Avoid speculation, hearsay and unfounded information.
It is important to note that accident investigations should not be used to fix blame. The objective is to learn the what, when, where, why and how of the circumstances that led to the accident. Ultimately, a properly performed investigation will identify what needs to done to prevent a reoccurrence.

Never have workers demonstrate how the accident occurred because demonstrations can be dangerous and often cause additional injuries. The investigator should ask appropriate questions, observe the scene of the accident, inspect equipment involved and note any additional information that might prove helpful. A thorough description of the accident should be provided, pictures should be taken, measurements made when appropriate and evidence preserved.

Accidents should be investigated immediately if possible, but always within 24 hours, to prevent the evidence from being disturbed, moved, lost, destroyed or thrown away. This also ensures that the details of what occurred will be fresh in people’s minds and that witnesses don’t influence one another by talking about the accident.

It takes training and practice to perform an effective accident investigation. Since most foreman/supervisors don’t regularly have to perform investigations, it is important to establish a step-by-step procedure for them to follow.

The following steps should be taken after an accident:

1. Provide immediate care and arrange for transport (ambulance) of the injured, if necessary.
   
2. Keep unnecessary people away from the scene of the accident to prevent additional injuries and to preserve the evidence.
   
3. Protect property and equipment from further damage.
   
4. Secure the scene of the accident until the investigator can observe the scene, take pictures, take measurements and make sketches. Do not touch or remove anything from the scene of the accident. Preserve the evidence.
   
5. Ask witnesses and individuals in the vicinity of the accident not to discuss what happened until they have been interviewed by the investigator.
   
6. Interview any injured persons as soon as it is reasonably possible.
   
7. Keep accurate and complete notes of what you learn and use them when it is time to complete the report.
   
8. Review training records to determine if the employees involved were properly trained.
   
9. Review inspection records, including equipment records and maintenance reports.
   
10. Complete the accident report form and deliver it to the designated person (owner, safety director, risk manager or attorney). Investigation reports should not be released to any unauthorized persons.
    
11. The report should be used to identify the cause(s) and take the appropriate corrective action as soon as possible to prevent a similar occurrence.

Accident investigations are tools that can be used to help determine how accidents are happening and why. It is up to managers to take proactive steps to prevent accidents, but there are times when things don’t go the way they are supposed to. This is not an excuse, but a reality, and there is a cause. Find out what it is and don’t let it happen again.

George Kennedy is NUCA Vice President of Safety.