Its Saturday night of a three day weekend (the kind where people go away), an accident happens and someone was hurt. Who are you going to get to investigate? If the person is seriously injured, who are you going to get to secure the scene? Do you have anybody who knows what to do?
Well, I think that now, before an accident happens, we should seriously train our first line supervisors to conduct accident investigations. I can hear it now. “You have got to be kidding me. First, it was accident reports. Well okay that makes sense. But John, how do you think first line supervisors can investigate accidents? What the hell are you smoking and why aren’t you sharing (just kidding)? Why do we have a safety manager/risk manager? Isn’t this his job?”
Yes accident investigations are the responsibility of the safety manager or the risk manager. But, let’s face facts:
- The first line supervisors/managers are right there; and we are not.
- They will see (or can be trained to recognize) the hazards that may have contributed to the accident
- They can get perishable information that could be lost, if not obtained immediately
- They are the first people who can secure the scene.
- Someone needs to get the information to fill out the insurance forms before people forget facts.
- We can establish procedures for them to call for help.
- If OSHA shows up, they are going to be looking for the operations person in charge, and NOT the safety or risk manager.
So, I suggest that the first line supervisors should be the ones to start an accident investigation especially any accident where there are only minor injuries. Properly trained supervisors will quickly recognize when an incident is “above their pay grade” and will be eager to reach out for more experienced help. But remember they are there with the “first look” at routine accidents. You can train them to make a phone call for any accident that meets certain criteria – media presence, member of the public, death, serious injury, requires Emergency Services response, more than one person going to hospital, hazmat incident, regulatory agency on scene, etc.
The biggest and most important thing to remember is the purpose of an accident investigation. The objective of an accident investigation is NOT to find fault or place blame. It is NOT to cover your butt. The objective of an accident investigation is to prevent that type of accident from happening again.
Before we start an investigation, we need a few ground rules.
- Ensure that any injured party receives the appropriate medical attention.
- Make sure that the site is safe. If necessary, stabilize or eliminate (if needed) any IDLH condition.
- Assure the safety of others.
- Secure the site. I often tell first line supervisors to consider the accident scene as if it were a crime scene. Do not allow anyone to remove equipment or material from the area.
- Make all required notifications (follow your company procedures).
- Then you can start to investigate the accident.
The initial investigation is focused on gathering information. I think that the most important thing to remember while gathering information or when performing any accident investigation is to be open-minded and unbiased. If you approach an accident looking to find that the injured was at fault, then you will focus the investigation in such a way that you will find exactly what you are looking for. You need to try to leave your biases at home.
There are a few tools that any first line supervisor should have to gather information after an accident:
- A pad and pen or pencil (obviously helps to take notes or make sketches)
- A camera (most cell phone today are equipped with cameras)
- A draft copy of any required company, insurance carrier or state forms (helps you remember to gather all of the information required).
Any investigator or first line supervisor gathering information should size up the scene when approaching the accident site. This is when the camera first comes in handy. Take photos of the accident site from a distance from different angles – box the compass (take photos from the north, south, east, west, northeast, etc.). This allows others to examine the scene later if more in depth investigations are required. Obviously, you should take detailed photos of the accident site, but the distance shots allow a frame of reference for the detail shots. This might be a good place to start a sketch of the accident scene.
Gathering information requires us to ask questions – who, what, where, when, how and why.
- WHO: Who got injured? Who saw the accident (the witnesses)? Who was working with (or was with) the injured person(s)? Who else was present? Who was absent? Who was present at the safety briefing?
- WHAT: What was the injury (slip, trip or fall, struck-by, etc.)? What was the injured doing? What equipment or tools were being used? What did the witnesses see? What safety precautions were being followed? What instructions were given to the workers before the work started? What was the safety briefing before work started or re-started?
- WHERE: Where did the accident happen? Where was the injured when the accident happened? Where was the injured coming from? Where were any co-workers? Where were the witnesses? Where were the tools, that were being used, found after the accidents? Answers to all these questions should be added to the accident sketch.
- WHEN: When did the accident happen? When did the shift start? When did the injured change jobs? When was the safety briefing given? When did the supervisor check in on the job? When was the injured person trained to do the task that caused the injury? When was the equipment last maintained or repaired?
- HOW: How did the accident happen?
- WHY: Why did the accident happen? This is what we really want to find out. This is the last question that we are asking. We want to find the root cause(s). I have found in my experiences that there is rarely just one root cause to an accident, rather there are usually at least two root causes to an accident.
We know what information we want to find out. But it is important to know how to ask questions to gather the right information. If you ask direct questions, you will get yes, no or direct answers. You need to know how to ask open ended questions. As an example – rather than asking if someone witnessed the accident, you should ask where they were before the accident (add this information to your sketch). Ask them to describe what they were doing before the accident. Ask them to describe what they saw before the accident. Ask them to describe what they actually saw. Ask them to describe the scene after the accidents (where were the people found and where were things – tools, ladders, etc.). As they answer your questions, ask clarification questions to ensure that you understand everything that they can remember. Be like the old Peter Falk character, Lt. Colombo – I got just one more question. Chase the questions down the rabbit hole. A mentor of mine reminded me to be aggressively suspicious – never take any answer at face value. Always verify each answer, by asking the next logical question.
When your first line supervisors/managers finish their investigation, they should forward it to senior management, the safety department or the risk department before they leave for the day. Now, it is management’s (i.e., general manager, risk manager, safety manager, etc.) responsibility to review the report and conduct any follow up investigation required. Also, if there is no root cause identified, then the report needs to be finished. Management should communicate to everyone the root cause(s) of each accident and the changes that are being made to prevent the accident from happening again.
Obviously, there are situations where this will not work and where the accident investigation should be conducted by an independent third party. But there are more situations where this will work and your first line supervisors will learn from it. By conducting the accident investigation, they may be able to correct the situation on the post rather than waiting weeks for an “official” accident investigation report. They may not get it right the first time out of the box, but you gotta let‘em try.
(c) John Burke, CSP, ARM. 2013.