An accident is defined as "an undesired, unplanned event resulting in physical injury or damage to property." A near miss is defined as "an event that doesn’t result in injury or damage, but has the potential to do so."
Investigating the cause of accidents and/or near misses is one tool in a comprehensive accident-prevention program. If an effective accident investigation is conducted, lessons can be learned and similar incidents can be avoided in the future.
Five basic elements of an accident-investigation program
To conduct an effective accident-investigation program:
- Immediately report all accidents and near misses to your company’s designated injury coordinator
- Have an effective accident-reporting form.
- Assign responsibilities for conducting the accident investigation. Report the findings to company management.
- Determine root cause(s).
- Identify corrective actions and ensure they are completed.
Immediately report all accidents
Immediately reporting all accidents is vital for your company to have an effective accident-investigation program. Common sense tells us that an accident has to be reported before it can be investigated. Any delay in reporting an accident may hinder the investigation because evidence at the scene of the accident can become disturbed and witnesses' memories can fade over time.
Have an effective accident-reporting form
Having an effective accident-reporting form helps ensure proper information is collected during the investigation.
Assign accident-investigation responsibilities
Assigning accident-investigation responsibilities helps ensure the accident investigation is conducted by someone who’s knowledgeable in the business and understands accident prevention. It also helps ensure all necessary personnel are involved in obtaining all pertinent information.
As with any task or responsibility, if it’s not clearly assigned, it’s unlikely to be completed.
Determine root causes
Determining root causes is perhaps the most critical element of an effective accident-investigation program. Also known as Root Cause Analysis (RCA), this element requires the investigator to not just look for the direct cause of the accident, but to dig a little deeper and also determine any indirect cause or causes.
In other words, RCA helps the investigator look beyond the employee who was "not paying attention," to see if there are other reasons/causes for the incident. Using RCA, the investigator will be in fact-finding mode, instead of the typical "fault-finding mode."
Determining the root cause is as simple as asking the question "Why?" at least five times. Typically, the root cause will surface after the fifth time the question is asked. Understanding why an event occurred is the key to developing effective recommendations for corrective action.
An example of how RCA may be used in an accident investigation
Incident: Henry received a steam burn to his arm and shoulder.
Root Cause Analysis: Ask “why” five times. Start with the question, “Why did this incident happen?” For every answer to that question, ask “why” again. Do this five times and you will have an enormous number of possibilities.
1. Why did Henry receive a steam burn to his arm and shoulder?
Because the gasket blew out on a flange coupling near where he was working.
2. Why did the gasket blow out on the flange coupling near him?
Because the safety valve did not release the excess pressure in the steam line.
3. Why did the safety valve fail to release?
Because it had not been inspected
4. Why was the safety valve not inspected?
Because there was no procedure to periodically inspect the valve.
5. Why was there no procedure to periodically inspect the safety valve?
Because no one thought it was important.
Solution: Develop a procedure to require safety valves to be periodically inspected, which should greatly reduce the potential for the exposure.
As this example shows, going beyond the obvious cause of the accident - gasket failure - results in determining the underlying causes that can increase the chance of preventing a recurrence of this incident.
Identify and ensure the completion of corrective actions
Identifying and ensuring the completion of corrective actions is vital to preventing repeat accidents and helping employees feel safe and respected within your organization.
The worst thing that can happen when trying to establish a safety culture is to conduct the accident investigation and not complete the corrective actions or not ensure they stay in place. This is why it’s important to assign responsibility for corrective actions and to track the progress of their completion.
The purpose of an accident-investigation program is to determine the cause of accidents, not find someone to blame and punish. By following the five elements of an accident-investigation program, you’ll reduce the likelihood of a recurrence, and your company will be a better place to work.