Accident Investigation: Back to Reality

By Sorrell, Larry W. | Occupational Hazards, September 1998 | Go to article overview

Accident Investigation: Back to Reality


Sorrell, Larry W., Occupational Hazards


Could the incorrect identification of causes lead your investigators into the "twilight zone" of accident investigation?

You safety guys are always slowing down production and driving up costs by demanding those pointless accident reports for every little thing that happens. When are you guys going to get real so that we can get back to work?

Sound familiar? If so, comments like these from your line organization may be more than just whiny excuses or good-natured banter. They might be indications of something gone wrong with your accident investigation program.

Obviously, not investigating accidents would be a major blunder to any safety program, were this element not included as one of the most critical for success. On the other hand, I believe that in some instances, the accident investigation process can lose sight of reality and become a detriment to a company's safety improvement program.

Reasons to Investigate

Should we investigate all accidents? Contrary to how it may sound in the paragraphs above, I believe the answer to this question is a resounding "yes." I'll even go a step farther: I believe that all hazards, even concerns, should be investigated to determine all the causes for their existence. Why? To take corrective action in order to prevent an accident from happening or happening again. Accidents are caused by unsafe acts and conditions. Accidents are prevented by eliminating or controlling unsafe acts and/or conditions. Knowing even one act or condition that hasn't been eliminated or controlled is being aware of an accident waiting to happen. Although there is always a priority list with our work loads, not making a conscious effort to do our best at the above would be negligent.

There are two other reasons for investigating all accidents. The first is to ensure that injured personnel receive the workers' compensation benefits that they are entitled to when injured on the job. Like any insurance program, it is there for use when needed, and it is a no-fault system. A poorly written report with improperly identified causes can result in an injured employee's claim being denied.

The other reason to investigate all accidents is to protect your company (and yourself) from false claims. Whenever an accident is reported, it must be investigated and a report written, even if the outcome is that nothing occurred. Your investigation report stating this conclusion can become a very important document. Yes, all accidents must be investigated. There can be no other answer.

If all accidents are being investigated, what's the problem? I believe it is the identification of causes that leads some investigators off the path of reality and into the "twilight zone" of accident investigation.

Definitions

I am often amazed that, even among safety professionals, there are different definitions for what should be basic terminology for the profession. Let's make sure that we are all speaking the same language.

ACCIDENT - There are probably as many definitions for this term as there are companies. The dictionary defines it as "an unexpected and undesirable event." I like to say that an accident is something that happened that you didn't want to happen and you don't want to happen again. Many words say the same thing, but my definition does emphasize the need for prevention (thus, why we investigate).

You will notice that neither definition says anything about losses. An accident that did not result in a loss is still an accident, and could have resulted in a loss, aka "near miss." I hate the term "near miss" because some people equate it with something insignificant when, in reality, it may very well be the opposite. Even if a particular near miss could never result in a major loss, the same causes, if allowed to go uncontrolled, could result in other, much more significant problems.

IMMEDIATE CAUSES - These are the unsafe acts and conditions that resulted in or could have resulted in an accident. …

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