One of the best ways to prevent accidents is to investigate the causes of the accidents that do occur. A prompt thorough investigation of any incident, large or small, is an important part of any good safety program. In some ways, a good investigation of a workplace accident resembles a police investigation of a crime. We try to get in and check the scene before anything has been moved or changed, and we try to assemble the evidence and interview the witnesses while the experience is still fresh in their minds.
There is, however, one big difference between a workplace accident investigation and a police crime investigation. We’re not looking for a criminal and we’re not trying to blame the accident on anyone. What we are doing is finding out what happened, why it happened, and how we can prevent another similar accident from occurring.
Investigate all accidents and near misses, not just the incidents where people get injured and which have to be reported to OSHA. What exactly is a near miss? Just about anything that makes you say, “whew, that was close.” Near misses are warnings that help us identify problems and patterns that can lead to more serious accidents. By following through on the causes of near misses, we can make changes or corrections that will prevent injuries, illnesses, or damage to equipment.
OSHA requires employers to record all occupational injuries and illnesses on what it calls the OSHA 200 log or a similar form. In Oklahoma we use the OK No. 200 log required under the Oklahoma Occupational Health and Safety Standards Act of 1970. The purpose of this requirement is to develop information regarding the causes and prevention of occupational accidents and illnesses and to help develop and maintain statistical information on areas that can cause workplace safety hazards.
All work-related deaths and illnesses must be recorded, while only those injuries which require medical treatment (other than first aid), or involve loss of consciousness, restriction of work or motion, or transfer to another job are recordable. The distinction between injuries and illnesses, therefore, has significant record keeping implications.
The determination of whether a case involves an injury or illness focuses on the nature of the original event or exposure that caused the case.
An occupational injury is an injury such as a cut, fracture, sprain, amputation, etc., which results from a work accident or from an exposure involving a single incident in the work environment.
An occupational illness of an employee is any abnormal condition or disorder, other than one resulting from an occupational injury, caused by environmental factors associated with employment. It includes acute and chronic illnesses or diseases that may be caused by inhalation, absorption, ingestion or direct contact. The back of the OK 200 log and summary gives seven categories of occupational illnesses and disorders that are utilized in classifying recordable illnesses. Each category lists several examples, but these are not to be considered a complete listing of the types of illnesses and disorders that are to be included under each category.
Once you determine that a case is recordable, you must determine whether or not it involves lost workdays. Employees do not have to be physically absent from work as a result of a work related in-jury or illness to be counted as having lost work days; days of restricted work activity are also included. Lost workdays include all normally scheduled workdays on which the ill or injured employee:
could not work
worked at another job on a temporary basis
worked at a permanent job less than full-time
worked at a permanently assigned job but could not perform all duties normally connected with it
The number of lost workdays should not include the day of injury or onset of illness, or any days on which the employee would not have worked even though able to work. Each recordable illness must have an entry in the appropriate illness column of the form.
All employers are required to report accidents resulting in one or more fatalities or the hospital-ization of five or more employees. The report is to be made to the Public Employees Occupational Safety and Health (PEOSH) of the Oklahoma Department of Labor.
The report should be made within 48 hours after the occurrence of the accident or the fatality, regardless of the time lapse between the occurrence of the accident and the eventual death of an employee. The information has to be entered into the OK 200 log. During 1999 you are required to maintain a record of recordable occupational injuries and illnesses on the OK 200 Log and Summary of Occupational Injuries and Illnesses form.
The OK-200 log and summary covering the previous calendar year must be posted no later than February 1, and shall remain in place until March 1.
A failure to post a copy of the OK-200 log and sum-mary may result in criminal sanctions.
Because accident reports and investigations are such an important tool in preventing accidents, OSHA takes this regulation seriously. In fiscal year 1993 OSHA cited employers for over 5,000 violations related to these requirements. Most of the violations had to do with a failure to maintain both the log and the summary of occupational injuries and illnesses (nearly 4,000 violations). This was followed by failing to certify and post the annual summary (over 600 violations).
A good accident investigation is aimed at discovering what happened, what caused it to happen and why, and how to prevent future occurrences. The investigation tries to identify the hazards that led to the accident and any other related hazards that could lead to accidents in the future.
When there’s an accident the first thing you do, of course, is to make sure that anyone who’s injured or ill gets proper medical treatment. If there’s some-thing like a spill or leak, it has to be stopped before it spreads. In some cases, we may have to barricade or rope off an accident site to keep people from harm and to preserve the evidence.
But aside from taking necessary actions like these, it’s best to leave the accident scene untouched so you can study the evidence. If, for instance, there was a spill, you would want to check the evidence to find out what spilled, where it spilled from and where it went. If a machine was involved, you want to be able to check the settings and materials in the area and whatever else might be relevant. In a more serious accident, you might have to take measurements of the area or even take photos or videos of the accident scene to be studied later.
Another thing we do early in the investigation is to interview people who were present when the incident occurred or who know something useful about the operation, machine, substance, etc. in question. Usually, witnesses are interviewed one at a time right after the incident, often at or near the place where it happened so they can point out or show what they’re talking about. We try to get eye witness reports right away in order to get immediate impressions of what happened before an eyewitness has a chance to confuse it with other similar incidents or with what other people say.
These interviews are not intended to put anyone on trial or to find someone to blame. They’re strictly for the purpose of getting as many facts and as much information on what happened as possible. You may want to ask employees to act out how it happened—without, of course, repeating the accident itself.
You may also ask employees what they think caused the problem and how they think we could prevent something similar from happening in the future. Part of the fact gathering will also involve the specific information that’s required for filling out reports. Again, we’re after facts here—not opinions. We need to ask the details of the incident such as:
What time did the incident occur?
Exactly where did it occur?
Who was injured or made ill and what was the type and severity of the injury or illness?
How did the accident occur? What were the people involved doing before it happened? What materials, machinery or substances were involved or in the area? What led up to the accident and what exactly happened during the accident itself?
The answers to these questions will usually involve a sequence of events.
Since the purpose of accident investigations is accident prevention, getting the facts is just the beginning. You have to use the facts to find out why the accident happened and then what can be done to prevent future accidents.
This can be easier said than done. Many accidents have more than one cause. Sometimes what seem to be causes are actually symptoms of the real problem. For example, an accident that appears to be caused by a missing machine guard may actually be caused by a machine that’s not working properly or by poor machine design or workplace layout that led someone to remove the guard. Many times an unsafe act that led to an accident may be a symptom of inadequate training. In cases like these, we have to deal with the symptoms and the underlying causes.
In addition, when we keep track of all accidents and their causes, we can often identify patterns. We may find specific materials, machines, or jobs are involved in accidents again and again.
If a number of people injure their backs lifting boxes, we may need more specialized training on how to lift properly and/or more material handling equipment to reduce the need for manual lifting and/or boxes of a different size or shape that are easier to handle.
If we have several near misses involving spills from similar containers, we’d consider switching to a safer kind of container or finding a new way to remove liquids from those containers.
The most valuable resource for preventing accidents is often the people who actually work the jobs and know them best. They know the jobs, equipment, and the substances being used. They may already be making corrections on a piece of equipment or a task without thinking about why they do it. They may be aware that some equipment isn’t being maintained on a regular basis. They may have noticed that a particular type of protective clothing has a tendency to rip or tear. Listen to the people who work the jobs and operate the equipment. They often can provide you valuable suggestions for changes and improvements. The more input we have from everyone, the better. With complete information, we can do a good analysis of our potential hazards and develop ways to make our workplace safer.
It’s essential for employees to report any accident or near miss immediately. Small, seemingly minor incidents should send up a warning flag that something is wrong, whether it’s in the way a job is performed or in the materials and equipment used to perform the job. We don’t want to miss these warnings, because they allow us to fix small problems before they become big ones.
Don’t brush off any incident as too minor to bother with. Report it immediately, along with all the facts you have on what did happen or could have happened. Be sure to make your reports promptly even if no one was hurt. Remember, the longer you wait the colder the evidence trail gets.
It can take a while to complete a report on an accident and an analysis of what happened and why. But once that’s done, we’re ready to move on to the final and most important stage: correcting the problem. If an accident is very serious, or is part of a pattern of similar accidents, we may have to make a whole series of changes in order to improve the safety of our workplace.
If, for instance, we have an abundance of slips and falls in one particular area, we might decide to reorganize our storage areas, increase our attention to housekeeping, provide training on proper lifting and carrying, improve the lighting, etc.
Changes made to the workplace will only improve health and safety if everyone buys into them and takes them seriously. We need our employees’ help not only to investigate accidents but also to take the corrective actions that will prevent future accidents.