• Usingana.lrtical techniques for every accident investigation lends consiste ncy
to yo ur safety program.
‘ Analytical tec hnic1ues will he lp yo u to ma ke a s moo th a nd co n siste n t
transition from facts to causal factors .
‘ The thoroughness of the analytical tec h niques wi ll give vou confidence
iba t ro ur invesugatio n dete rm ined wh at rc:-tll y happe ned a nd that your
rtrommcndations wi ll prevent future acc id ent s.
63
64
Port II: O,g,,uuZf,,g the lnrtshgaho11
Exhibit 6.2
ANALYTICAL TECHNIQUES FLOWCHART
Has th ere been a
chang e in the process?
Is the task recurring?
Has it been don e
accident -free?
Change Analysis
ls th ere a need to
evaluate the loss
control efforts or
~::g~;ef
Time Loss
Analysis
Is there a failure of a
system or hardware?
Could a systema tic
evaluation of failure
modes be usefu l?
Failure Modes and
Effects Analysis
Has there bee n a
deviation from the
requi reme nts? Can a
review of the codes,
requiremen t s, and
standard s be us eful ?
Design Criteria
Analysis
Is there a need for a
time-ba sed matrix of
all personnel at the
accide nt scene?
Is there sti ll a void In
the information? Can a
speci fic test or
tec hn ique fi ll th is void?
Other Speclalind
Techniques
Ad apted from OSHA In stitute 1995
Chapter 6: The A mi(yiral Prows
Summary
or circumstances that contribute to an accident are called causal
flu.’ eren:rreccion of these causa l factors_ at whatever I,evcl th~y may oc~ ur
factors . C rcicular incid ent will not recur. \Vhe n u sing analyacal
is whai ensur~s th ac_ a p,•ors must b e able ro disti nguis h betwee n ha zards
. es mves uga _ _ .
cechru~u ‘ U . causal analysis and anal ytical tec hruques will ma ke the
lf!Jf.ulure s. sing _
1n\·esug1ti on more effecuve.
REVIEW QUESTIONS
I. What is a ca usal factor?
2
Describe the four leve ls of accountability.
3. What is the difference between a hazard and a fa ilure?
4. Why is it advisa ble to use more th an one analytical tec hn ique to investigate
an acc ident?
65
1
Preserve/
Document
Scene
2
Collect
Information
3
Determine
Root
Causes
4
Implement
Corrective
Actions
United States Department of Labor
Occupational Safety and Health Administration
December 2015
i
TABLE OF CONTENTS
PURPOSE OF THE GUIDE – WHY INVESTIGATE? ………………………………………………………………………………….. 1
PRINCIPLES OF INCIDENT INVESTIGATIONS ……………………………………………………………………………………….. 1
The Language of Incident Investigations …………………………………………………………………………………….. 1
Investigate All Incidents, Including “Close Calls” ………………………………………………………………………….. 2
Investigate Programs, Not Behaviors ………………………………………………………………………………………….. 3
Focus on the Root Causes, Not Blame or Fault …………………………………………………………………………….. 4
ESTABLISH AN INCIDENT INVESTIGATION PROGRAM …………………………………………………………………………….. 4
CONDUCT INCIDENT INVESTIGATIONS – A FOUR‐STEP SYSTEMS APPROACH …………………………………………………. 6
Step 1. Preserve/Document the Scene ……………………………………………………………………………………….. 7
Step 2. COLLECT INFORMATION ………………………………………………………………………………………………………. 8
Step 3. DETERMINE ROOT CAUSES …………………………………………………………………………………………………… 9
Step 4. IMPLEMENT CORRECTIVE ACTIONS ……………………………………………………………………………………….. 10
RESOURCES …………………………………………………………………………………………………………………………. 12
REFERENCES ………………………………………………………………………………………………………………………… 14
APPENDIX A: INCIDENT INVESTIGATION FORM ……………………………………………………………………………………….
A‐1
APPENDIX B: INCIDENT INVESTIGATOR’S KIT ………………………………………………………………………………………….
B‐1
APPENDIX C: TIPS FOR VIDEO/PHOTO DOCUMENTATION …………………………………………………………………………..
C‐1
APPENDIX D: SKETCH THE SCENE TECHNIQUES ………………………………………………………………………………………
D‐1
APPENDIX E: COLLECT INFORMATION CHECKLIST …………………………………………………………………………………….
E‐1
APPENDIX F: SAMPLE QUESTIONS FOR IDENTIFYING INCIDENT ROOT CAUSES …………………………………………………..
F‐1
DISCLAIMER:
This guide was developed by OSHA’s Directorate of Training and Education and is intended to assist employers, workers, and others as they
strive to improve workplace health and safety. This guide is advisory in nature and informational in content. It is not a new standard or
regulation and does not create any new legal obligations or alter existing obligations created by OSHA standards or regulations or the
Occupational Safety and Health Act of 1970 (OSH Act). Pursuant to the OSH Act, employers must comply with safety and health standards and
regulations issued and enforced either by OSHA or by an OSHA‐approved state plan. In addition, the OSH Act’s General Duty Clause, Section
5(a)(1), requires employers to provide their workers with a workplace free from recognized hazards likely to cause death or serious physical
harm. Implementation of an incident investigation program in accordance with this guide can aid employers in their efforts to provide a safe
workplace.
Incident [Accident] Investigations: A Guide for Employers
December 2015 1
WHY INVESTIGATE?
Incident investigations
help employers:
Prevent injuries and
illnesses
Save lives
Save money
Demonstrate
commitment to health
and safety
Promote positive
workplace morale
Improve management
Your company experienced an incident that resulted (or almost resulted) in a worker
injury or illness…Now what?
As a responsible employer, you need to react quickly to the incident with a prescribed
investigation procedure for finding the root causes and implementing corrective actions.
Quick and planned actions demonstrate your company’s commitment to the safety and
health of your workers, and your willingness to improve your safety and health
management program to prevent future incidents.
PURPOSE OF THE GUIDE – WHY INVESTIGATE?
The purpose of this Incident Investigation Guide is to provide employers a systems approach to help
them identify and control the underlying or root causes of all incidents in order to prevent their
recurrence.
The Bureau of Labor Statistics reports that more than a dozen
workers died every day in American workplaces in 2013, and nearly 4
million Americans suffered a serious workplace injury. And tens of
thousands are sickened or die from diseases resulting from their
chronic exposures to toxic substances or stressful workplace
conditions. These events cause much suffering and great financial
loss to workers and their families, and also result in significant costs
to employers and to society as a whole. Many more “near misses” or
“close calls” also happen; these are incidents that could have caused
serious injury or illness but did not, often by sheer luck. Practically all
of these harmful incidents and close calls are preventable.
All incidents – regardless of size or impact – need to be investigated. The process helps employers look
beyond what happened to discover why it happened. This allows employers to identify and correct
shortcomings in their safety and health management programs.
OSHA created this Guide to help employers conduct workplace incident investigations using a four‐step
systems approach. This process is supported by an Incident Investigation Form, found in Appendix A,
which employers can use to be sure all details of the incident investigation are covered. Additional tools
to assist with the investigation process are found in Appendices B through F.
PRINCIPLES OF INCIDENT INVESTIGATIONS
The Language of Incident Investigations
Employers will notice this Guide uses the term “incident”, not “accident”, to describe a workplace event.
This is because the word “accident” has come to be considered as a random event that “oh, well, it just
Incident Investigations: A Guide for Employers
December 2015 2
happened” and could not have been prevented. However, the vast majority of harmful workplace
events do not “just happen.” On the contrary, most harmful workplace incidents are wholly preventable.
In short, the basic principle is that incidents do not have to occur; they can be prevented by addressing
the shortcomings in the programs that manage health and safety in the workplace.
The following are the key terms that are used throughout this guide:
Incident: A work‐related event in which an injury or ill‐health (regardless of severity) or fatality
occurred, or could have occurred.
Root Causes: The underlying reasons why unsafe conditions exist or if a procedure or safety rule
was not followed in a workplace. Root causes
generally reflect management, design, planning,
organizational or operational failings (e.g., a damaged guard had not been repaired; failure to
use the guard was routinely overlooked by supervisors to ensure the speed of production).
Close Call: An incident that could have caused serious injury or illness but did not; also called a
“near miss.”
Investigating a worksite incident— a fatality, injury, illness, or close call— provides employers and
workers the opportunity to identify hazards in their operations and shortcomings in their safety and
health programs. Most importantly, it enables employers and workers to identify and implement the
corrective actions necessary to prevent future incidents.
Incident investigations that focus on identifying and correcting root causes, not on finding fault or
blame, also improve workplace morale and increase productivity, by demonstrating an employer’s
commitment to a safe and healthful workplace.
Investigate All Incidents, Including “Close Calls”
OSHA strongly encourages employers to investigate all workplace incidents—both those that cause
harm and the “close calls” that could have caused harm under slightly different circumstances.
Investigations are incident‐prevention tools and should be an integral part of an occupational safety and
health management program in a workplace. Such a program is a structured way to identify and control
the hazards in a workplace, and should emphasize continual improvement in health and safety
performance. When done correctly, an effective incident investigation uncovers the root causes of the
incident or ‘close call’ that were the underlying factors. Most important, investigations can prevent
future incidents if appropriate actions are taken to correct the root causes discovered by the
investigation.
Effective incident investigations are the right thing to do, not only because they help employers prevent
future incidents, but because they help employers to identify hazards in their workplaces and
shortcomings in their safety and health management programs. Investigations also save employers
money, because incidents are far more costly than most people realize. The National Safety Council
estimates that, on the average, preventing a workplace injury can save $39,000, and preventing a
fatality more than $1.4 million, not to mention the suffering of the workers and their families. The more
obvious financial costs are those related to workers’ compensation claims, but these are only the direct
Incident Investigations: A Guide for Employers
December 2015 3
“One central principle…is the
need to consider the
organizational factors that
create the preconditions for
errors as well as the
immediate causes.”
‐Sidney Dekker (2006)
costs of incidents. The indirect costs are less obvious, but very commonly greater, and include lost
production, schedule delays, increased administrative time (for emergency response, investigations,
claim processing and others), lower morale, training of new or temporary personnel, increased
absenteeism, and damaged customer relations and corporate reputation.
Investigate Programs, Not Behaviors
As stated previously, incident investigations that follow a systems approach are based on the principle
that the root causes of an incident can be traced back to failures of the programs that manage safety
and health in the workplace. This approach is fundamentally different from a behavioral safety
approach, which incorrectly assumes that the majority of workplace incidents are simply the result of
“human error” or “behavioral” failures. Under a systems approach, one would not conclude that
carelessness or failure to follow a procedure alone was the cause of an incident. To do so fails to
discover the underlying or root causes of the incident, and therefore fails to identify the systemic
changes and measures needed to prevent future incidents. When a shortcoming is identified, it is
important to ask why it existed and why it was not previously addressed.
For example:
If a procedure or safety rule was not followed, why was the
procedure or rule not followed?
Did production pressures play a role, and, if so, why were
production pressures permitted to jeopardize safety?
Was the procedure out‐of‐date or safety training inadequate?
If so, why had the problem not been previously identified, or, if
it had been identified, why had it not
been addressed?
A systems approach always looks beyond the immediate causes of the incident. If a worker suffers an
amputation on a table saw, the investigator would ask questions such as:
Was the machine adequately guarded? If not, why not?
Was the guard damaged or non‐functional? If so, why hadn’t it been fixed?
Did the guard design get in the way of the work?
Had the employee been trained properly in the procedures to do the job safely?
In a systems approach, investigations do not focus primarily on the behaviors of the workers closest to
the incidents, but on the factors [program deficiencies] that prompted such behaviors. The goal is to
change the conditions under which people work by eliminating or reducing the factors that create
unsafe conditions. This is typically done by implementing adequate barriers and safeguards against the
factors that cause unsafe conditions or actions.
Root causes often involve multiple deficiencies in the safety and health management programs. These
deficiencies may exist, for example, in areas such as workplace design, cultural and organizational
factors, equipment maintenance and other technical matters, operating systems and procedures,
Incident Investigations: A Guide for Employers
December 2015 4
staffing, supervision, training, and others. Eliminating the immediate causes is like cutting weeds, while
eliminating the root causes is equivalent to pulling out the roots so that the weed cannot grow back.
Focus on the Root Causes, Not Blame or Fault
A successful incident investigation must always focus on discovering
the root causes. If an investigation is focused on finding fault, it will
always stop short of discovering the root causes. It is essential to
discover and correct all the factors contributing to an incident, which
nearly always involve equipment, procedural, training, and other safety
and health program deficiencies.
Addressing underlying or root causes is necessary to truly understand
why an incident occurred, to develop truly effective corrective actions, and to minimize or eliminate
serious consequences from similar future incidents.
Moreover, if an investigation is understood to be a search for “someone to blame,” both management
and labor will be reluctant to participate in an open and forthright manner. Workers will be afraid of
retaliation and management will be concerned about recognizing system flaws because of potential
legal and financial liabilities.
Investigations that focus on identifying and correcting the real
underlying causes not only prevent future incidents, but can also
improve workplace morale and productivity, by demonstrating an
employer’s commitment to a safe and healthful workplace.
ESTABLISH AN INCIDENT INVESTIGATION PROGRAM
When a serious incident occurs in the workplace, everyone will be busy
dealing with the emergency at hand. Therefore, it is important to be
prepared to investigate incidents before they occur. An incident
investigation program should include a clearly stated, easy‐to‐follow
written plan to include guidelines for:
How and when management is to be notified of the incident
Notifying OSHA, which must comply with reporting
requirements that are:
o All work‐related fatalities within 8 hours
o All work‐related inpatient hospitalizations, all
amputations, and all losses of an eye within 24 hours
Who is authorized to notify outside agencies (i.e., fire, police,
etc.)
Who will conduct investigations and what training they should have received
Timetables for completing the investigation and developing/implementing recommendations
Who will receive investigation recommendations
Effective Incident
Investigation Programs:
Clearly state easy‐to‐ follow
written procedures
Provide for personnel to be
trained on incident
investigation and company
procedures
Offer collaboration
between workers, worker
representatives, and
management
Focus on identifying root
cause(s), not on
establishing fault
Emphasize correcting root
cause(s)
Implement timely
corrective actions based on
investigation findings
Provide for an annual
program review to identify
and correct program
deficiencies and identify
incident trends
Eliminating the immediate
causes is like cutting weeds,
while eliminating the root
causes is equivalent to pulling
out the roots so that the weed
cannot grow back.
Incident Investigations: A Guide for Employers
December 2015 5
Who will be responsible for implementing corrective actions
Although a supervisor sometimes conducts incident investigations, to be most effective investigations
should be conducted by a team in which managers and employees work together, since each brings
different knowledge, understanding, and perspectives to an investigation. Working together will also
encourage all parties to “own” the conclusions and recommendations and to jointly ensure that
corrective actions are implemented in a timely manner.
Where the incident involves a temporary worker provided by a staffing agency, both the staffing agency
and the host employer should conduct an incident investigation. Where the incident involves a multi‐
employer worksite, the incident investigation should be shared with each employer at the worksite. It is
a fundamental principal that temporary workers are entitled to the same protections under the OSH Act
as all other covered workers. Therefore, if a temporary worker is injured and the host employer knows
about it, the staffing agency should be informed promptly, so the staffing agency knows about the
hazards facing its workers. Equally, if a staffing agency learns of an injury, it should inform the host
employer promptly so that future injuries might be prevented, and the case is recorded appropriately.
Both the host employer and staffing agency should track and where possible, investigate the cause of
workplace injuries.
As we now know, investigations are to focus on identifying root causes, not establishing fault. Employers
can reinforce a systems approach by stressing it in their written program as well as their investigation
procedures. Identifying and correcting root causes should always be the key objective.
Incident Investigations: A Guide for Employers
December 2015 6
“Human error is not the
conclusion of an investigation.
It is the starting point.”
‐Sidney Dekker (2006)
“Errors are seen as
consequences rather than
causes”
‐James Reason (2000)
CONDUCT INCIDENT INVESTIGATIONS – A FOUR‐STEP SYSTEMS APPROACH
One of the biggest challenges facing the investigators is to
determine what is relevant to what happened, how it happened,
and especially why it happened. This involves conducting a systems
approach incident investigation
that focuses on the root causes
of the incident to really help prevent them from happening again.
This section of the guide assists the employer to implement a four‐
step approach to conduct a successful incident investigation. Included
is a set of appendices that can serve as tools for employers to use when conducting investigations. They
are:
Appendix A: Incident Investigation Form – previously introduced; will be used to walk the
employer through the four incident investigation steps
Appendix B: Incident Investigator’s Kit – lists the equipment recommended to have ready at all
times to be prepared to conduct the investigation
Appendix C: Tips for Video/Photo Documentation
Appendix D: Sketch the Scene Techniques
Appendix E: Collect Information Checklist
Appendix F: Sample Questions for Identifying Incident Root Causes – Sample questions to ask in
a systems approach process
The four‐step systems approach in this guide is supported by
the Incident Investigation Form [Appendix A] and other tools.
This approach will assist employers through the incident
investigation and help to ensure the implementation of
corrective measures based on the findings.
The steps are:
1. PRESERVE/DOCUMENT THE SCENE [see Appendices A, B, C
and D]
2. COLLECT INFORMATION [see Appendix E]
3. DETERMINE THE ROOT CAUSES – All the ‘Whys’ the incident occurred [see Appendix F]
4. IMPLEMENT CORRECTIVE ACTIONS –Prevent Future Incidents
Safety First
Before investigating, all emergency response needs must be completed and the incident site must be
safe and secure for entry and investigation.
Incident Investigations: A Guide for Employers
December 2015 7
With an effective safety and health management program in place, all the involved parties are aware of
the roles they play during the investigation. This helps the transition from emergency response and site
safety to preserving the scene and documenting the
incident.
Now is the time an employer’s incident investigation program’s written plan goes into effect and the
incident investigation begins.
Step 1. Preserve/Document the Scene
Preserve the Scene:
Preserve the scene to prevent material evidence from being removed or altered; investigators can use
cones, tape, and/or guards.
Document the Scene:
Document the incident facts such as the date of the investigation and who is investigating. Essential to
documenting the scene is capturing the injured employee’s name, injury description, whether they are
temporary or permanent, and the date and location of the incident. Investigators can also document the
scene by video recording, photogaphing and sketching.
Tools provided to help with Step 1 are:
Appendix A: Incident Investigation Form [applicable sections pictured at all steps]
Appendix B: Incident Investigator’s Kit
Appendix C: Tips for Video/Photo Documentation
Appendix D: Sketch the Scene Techniques
Incident Investigations: A Guide for Employers
December 2015 8
Step 2. COLLECT INFORMATION
Incident information is collected through interviews, document reviews and other means. Appendix E
provides a checklist to use to help ensure all information pertinent to the incident is collected.
In addition to interviews, investigators may find other sources of useful information. These include:
Equipment manuals
Industry guidance documents
Company policies and records
Maintenance schedules, records and logs
Training records (including communication to employees)
Audit and follow‐up reports
Enforcement policies and records
Previous corrective action recommendations
Interviews can often yield detailed, useful
information about an incident. Since memories fade,
interviews must be conducted as promptly as
possible: preferably as soon as things have settled
down a bit and the site is both secure and safe. The
sooner a witness is interviewed, the more accurate
and candid his/her statement will be.
An incident investigation always involves interviewing
and possibly re‐interviewing some of the same or
new witnesses as more information becomes available, up to and including the highest levels of
management. Carefully question witnesses to solicit as much information as possible related to the
incident.
Since some questions will need to be designed around the interviewee, each interview will be a unique
experience. When interviewing injured workers and witnesses it is crucial to reduce their possible fear
and anxiety, and to develop a good rapport. When conducting interviews, investigators should:
Conduct the interview in the language of the employee/interviewee; use a translator if needed
Clearly state that the purpose of the investigation and interview is fact‐finding, not fault‐finding
Emphasize that the goal is to learn how to prevent future incidents by discovering the root
causes of what occurred
Establish a climate of cooperation, and avoid anything that may be perceived as intimidating or
in search of someone to blame for the incident
Let employee know that they can have an employee representative (e.g., labor representative),
if available/appropriate
Ask the individuals to recount their version of what happened
Not interrupt the interviewee
Incident Investigations: A Guide for Employers
December 2015 9
Take notes and/or record the responses; interviewee must give permission prior to being
recorded
Have blank paper and or sketch available for interviewee to use for reference
Ask clarifying questions to fill in missing information
Reflect back to the interviewees the factual information obtained; correct any inconsistencies
Ask the individuals what they think could have prevented the incident, focusing on the
conditions and events preceding the injury
Step 3. DETERMINE ROOT CAUSES
The root causes of an incident are exactly what the
term implies: The underlying reasons why the
incident occurred in a workplace. Root causes
generally reflect management, design, planning,
organizational and/or operational failings (e.g.,
employees were not trained adequately; a
damaged guard had not been repaired).
Determining the root cause is the result of persistently asking “why”
Determining the root cause is the most effective way to ensure the incident does not happen again
Finding the root causes goes beyond the obvious proximate or immediate factors; it is a deeper
evaluation of the incident. This requires persistent “digging”, typically by asking “Why” repeatedly.
Conclusions such as “worker was careless” or “employee did not follow safety procedures” don’t get at
the root causes of the incident. To avoid these incomplete and misleading conclusions in the
investigative process, investigators need to continue to ask “why?” as in, “Why did the employee not
follow safety procedures?” If the answer is “the employee was in a hurry to complete the task and the
safety procedures slowed down the work”, than ask “Why was the employee in a hurry?” The more and
deeper “why?” questions asked, the more contributing factors are discovered and the closer the
investigator gets to the root causes. If a procedure or safety rule was not followed, why was the
procedure or rule not followed? Did production pressures play a role, and, if so, why were production
pressures permitted to jeopardize safety? Was the procedure out‐of‐date or safety training inadequate?
If so, why had the problem not been previously identified, or, if it had been identified, why had it not
been addressed?
It cannot be stressed enough that a successful incident investigation must always focus on discovering
the root causes. Investigations are not effective if they are focused on finding fault or blame. If an
investigation is focused on finding fault, it will always stop short of discovering the root causes, because
it will stop at the initial incident without discovering their underlying causes. The main goal must always
be to understand how and why the existing barriers against the hazards failed or proved insufficient, not
to find someone to blame.
Incident Investigations: A Guide for Employers
December 2015 10
The questions listed below are examples of inquiries that an investigator may pursue to identify
contributing factors that, in turn, can lead to root causes:
If a procedure or safety rule was not followed, why was the procedure or rule not followed?
Was the procedure out of date or safety training inadequate? Was there anything encouraging
deviation from job procedures such as incentives or speed of completion? If so, why had the
problem not been identified or addressed before?
Was the machinery or equipment damaged or fail to operate properly? If so, why?
Was a hazardous condition a contributing factor? If so, why was it present? (e.g., defects in
equipment/tools/materials, unsafe condition previously identified but not corrected,
inadequate equipment inspections, incorrect equipment used or provided, improper substitute
equipment used, poor design or quality of work environment or equipment)
Was the location of equipment/materials/worker(s) a contributing factor? If so, why? (e.g.,
employee not supposed to be there, insufficient workspace, “error‐prone” procedures or
workspace design)
Was lack of personal protective equipment (PPE) or emergency equipment a contributing
factor? If so why? (e.g., PPE incorrectly specified for job/task, inadequate PPE, PPE not used at
all or used incorrectly, emergency equipment not specified, available, properly used, or did not
function as intended)
Was a management program defect a contributing factor? If so, why? (e.g., a culture of
improvisation to sustain production goals, failure of supervisor to detect or report hazardous
condition or deviation from job procedure, supervisor accountability not understood, supervisor
or worker inadequately trained, failures to initiate corrective actions recommended earlier)
Additional examples of questions to ask to get to the root causes are listed in Appendix F.
Step 4. IMPLEMENT CORRECTIVE ACTIONS
The investigation is not complete until corrective actions are implemented that address the root causes
of the incident. Implementation should entail
program level improvements and should be
supported by senior management.
Note that corrective actions may be of limited
preventive value if they do not address the
root causes of the incident. Throughout the
workplace, the findings and how they are
presented will shape perceptions and
subsequent corrective actions. Superficial
conclusions such as “Bob should have used
common sense,” and weak corrective actions such as “Employees must remember to wear PPE”, are
unlikely to improve the safety culture or to prevent future incidents.
Incident Investigations: A Guide for Employers
December 2015 11
In planning corrective actions and how best to implement them, employers may find that some root
causes will take time and perseverance to fix. Persisting in implementing substantive corrective actions,
however, will not only reduce the risk of future incidents but also improve the company’s safety, morale
and its bottom line.
Specific corrective actions address root causes directly; however, some corrective actions can be
general, across‐the‐board improvements to the workplace safety environment. Sample global corrective
actions to consider are:
Strengthening/developing a written comprehensive safety and health management program
Revising safety policies to clearly establish responsibility and accountability
Revising purchasing and/or contracting policies to include safety considerations
Changing safety inspection process to include line employees along with management
representatives
Implementing a systems approach will help ensure all incident investigations are successful.
Thank you for your commitment to the safety and health of the American workforce!
Incident [Accident] Investigations: A Guide for Employers
December 2015 12
RESOURCES
OSHA Training Institute Education Centers: http://www.osha.gov/otiec
The OSHA Training Institute (OTI) Education Centers are a national
network of non‐profit organizations authorized by OSHA to deliver
occupational safety and health training to public and private sector
workers, supervisors and employers on behalf of OSHA. Relevant
courses are:
OSHA #7500 Introduction to Safety and Health Management
Description: This course covers the effective implementation of a company’s safety and health
management system. The course addresses the four core elements of an effective safety and health
management system and those central issues that are critical to each element’s proper management.
This course is an interactive training session focusing on class discussion and workshops. Upon course
completion students will have the ability to evaluate, develop, and implement an effective safety and
health management system for their company. Minimum student contact hours: 5.5
OSHA #7505 Introduction to Incident [Accident] Investigation
Description: This course covers an introduction to basic incident investigation procedures and describes
analysis techniques. Course topics include reasons for conducting incident investigations, employer
responsibilities related to workplace incident investigations, and a four‐step incident investigation
procedure. The target audience is the employer, manager, employee or employee representative who is
involved in conducting incident and/or near‐miss or close call investigations. Upon course completion
students will have the basic skills necessary to conduct an effective incident investigation at the
workplace. Minimum student contact hours: 7.5
OSHA Website: www.osha.gov
Incident Investigation Webpage
http://www.osha.gov/dcsp/products/topics/incidentinvesti
gation/index.html
Injury and Illness Prevention Programs Webpage
http://www.osha.gov/dsg/topics/safetyhealth/index.html
This webpage provides information relevant to Injury and Illness Prevention Programs in the
workplace. To learn more about Injury and Illness Prevention Programs, refer to:
http://www.osha.gov/Publications/OSHA3665 and
http://www.osha.gov/dsg/topics/safetyhealth/OSHAwhite‐paper‐january2012sm
Incident Investigations: A Guide for Employers
December 2015 13
OSHA’s “$afety Pays” program
This online tool can help employers assess the impact of
occupational injuries and illnesses on their profitability. To
learn more about OSHA’s “$afety Pays” program, visit
http://www.osha.gov/dcsp/smallbusiness/safetypays/
Other: UK Health and Safety Executive
Investigating Accidents and Incidents: A Workbook for employers, unions, safety representatives,
and safety professionals. 2004. http://www.hse.gov.uk/pubns/hsg245
Incident Investigations: A Guide for Employers
December 2015 14
REFERENCES
Center for Chemical Process Safety publication, Guidelines for Preventing Human Error in
Process Safety, Center for Chemical Process Safety (CCPS), 1994.
Conklin, T., Pre‐Accident Investigations: An Introduction to Organizational Safety, Ashgate
Publishing Company; 1 edition (September 28, 2012), ISBN‐10: 1409447820, ISBN‐13: 978‐
1409447825
Dekker, S., The Field Guide to Understanding Human Error, Ashgate Publishing Company; 1
edition (June 30, 2006), English, ISBN‐10: 0754648265; ISBN‐13: 978‐0754648260
National Safety Council, http://www.nsc.org/pages/home.aspx
Reason, J., Human error: models and management, BMJ 2000;320:768
Incident Investigations: A Guide for Employers
A‐1
APPENDIX A: INCIDENT INVESTIGATION FORM
Form Section Systems Approach
Section A: Information Step 1
Company Name: _______________________________________ Date: ____________
Investigator (or) Team Name (s) and Titles:
Name Title
_________________________________ _____________________________________
_________________________________ _____________________________________
_________________________________ _____________________________________
_________________________________ _____________________________________
Section B: Incident Description/Injury Information Step 1 and Step 2
1) Name and Age of Injured Employee: _______________________________________________
Employee’s first language: ________________________________________________________
Employees Job Title: _____________________________________________________________
Job at time of injury: ____________________________________________________________
Type of employment: Full‐time Part‐time Temporary Seasonal Other: ________
Length of time with Company: ____________________________________________________
Length in current position at the time of the incident: _________________________________
Description and severity of injury: _________________________________________________
2) Date and time of incident: _______________________________________________________
3) Location of Incident: ____________________________________________________________
NOTE: Items 4, 5, and 6 are used for both Step 1 and Step 2
4) Detailed description of incident: Include relevant events leading up to, during, and after the
incident. (It is preferred that the information is provided by the injured employee.)
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Use additional pages if needed
Incident Investigations: A Guide for Employers
A‐2
5) Description of incident from eye witnesses, including relevant events leading up to, during and
after the incident. Include names of persons interviewed, job titles and date/time of interviews.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Use additional pages if needed
6) Description of incident from additional employees with knowledge, including relevant events
leading up to, during and after the incident. Include names of persons interviewed, job titles and
date/time of interviews.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Use additional pages if needed
Incident Investigations: A Guide for Employers
A‐3
Section C: Identify the Root Causes: What Caused or Allowed the Incident to Happen? Step 3
The Root Causes are the underlying reasons the incident occurred, and are the factors that need to
be addressed to prevent future incidents. If safety procedures were not being followed, why were
they not being followed? If a machine was faulty or a safety device failed, why did it fail? It is
common to find factors that contributed to the incident in several of these areas:
equipment/machinery, tools, procedures, training or lack of training, and work environment. If
these factors are identified, you must determine why these factors were not addressed before the
incident.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Use additional pages if needed
Section D: Recommended Corrective Actions to Prevent Future Incidents Step 4
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Use additional pages if needed
Section E: Corrective Actions Taken/ Root Causes Addressed Step 4
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Use additional pages if needed
Incident Investigations: A Guide for Employers
B‐1
APPENDIX B: INCIDENT INVESTIGATOR’S KIT
Sample list of items to use to conduct the investigation:
Camera
Charged Batteries (for phones, cameras, equipment, etc.)
Video / Audio recorder
Measuring devices in various sizes
Leveling rod
Clipboard and writing pad
Pens, pencils, markers
Graph paper
Straight‐edge ruler (Can be used as a scale reference in photos)
Incident investigation forms
Flashlight
Strings, stakes, warning tape
Photo marking cones
Personal protective equipment: Gloves, hat, eyewear, ear plugs, face mask, etc.
Magnifying glass
High visibility plastic tapes to mark off area
First aid kit
Latex gloves
Sampling [holding] containers with seals (Various types: bags, jars, containers, etc.)
Identification tags
Variety of tape: Scotch, masking, duct
Compass
Carpenters ruler
Hammer
Paint stick (yellow/black)
Chalk (yellow/white)
Protractor
Clinometer
Incident Investigations: A Guide for Employers
C‐1
APPENDIX C: TIPS FOR VIDEO/PHOTO DOCUMENTATION
Note: Interviewees must be aware that they are being video recorded and/or photographed. It
is recommended that investigators obtain permission from the interviewee prior to the
interview.
Tips for Video Documentation:
Video the scene as soon as possible; doing this early on will pick up details that may
later add valuable information to the investigation
Scan slowly 360 degrees left and right to establish location
Narrate what is being taped, and describe objects, size, direction, location, etc.
If vehicles were involved, record direction of travel, going and coming
Tips for Photograph Documentation:
Always make notes about the photos taken
Start by taking distance shots first then move in to take closer photos of the scene
Take photos at different angles (from above, 360 degrees of scene, left, right, rear)
to show the relationship of objects and minute and/or transient details such as ends
of broken rope, defective tools, drugs, wet areas, or containers
Take panoramic photos to help present the entire scene, top to bottom ‐ side to side
Take notes on each photo; these should be included in the incident investigation file
with the photos
Identify and document the photo type, date/time/location taken, subject, weather
conditions, measurements, etc.
Place an item of known dimensions in the photo to add a frame of reference and
scale (e.g., a penny, a pack of cards)
Identify the person taking the photo
Indicate the locations where photos were taken on sketches (See Appendix D)
Incident Investigations: A Guide for Employers
D‐1
APPENDIX D: SKETCH THE SCENE TECHNIQUES
1. Make sketches large; at least 8” x 10” and clear, be sure to print legibly
2. Include “Incident Details” (i.e., time, date, injured, location, conditions, etc.)
3. Include measurements (i.e. distances, heights, lengths, etc.) and use permanent points (e.g.,
telephone pole, building) to clearly present the measurements
4. Indicate directions – N= North; E= East; W= West; S= South
5. Make notes on sketch to provide additional information such as the photo location and/or
where people were at the time of the incident
Note: The sketch can be used during interviews to help interviewees identify their location before,
during or after the incident
Incident Investigations: A Guide for Employers
E‐1
APPENDIX E: COLLECT INFORMATION CHECKLIST
Investigators should be sure their investigation answers the following questions:
WHO? WHERE?
Who was injured?
Who saw the incident?
Who was working with the employee?
Who had instructed/assigned the employee?
Who else was involved?
Who else can help prevent recurrence?
Where did the incident occur?
Where was the employee at the time?
Where was the supervisor at the time?
Where were fellow workers at the time?
Where were other people who were involved at
the time?
Where were witnesses when incident occurred?
WHAT? WHY?
What was the incident?
What was the injury?
What was the employee doing?
What had the employee been told to do?
What tools was the employee using?
What machine was involved?
What operation was the employee performing?
What instructions had the employee been given?
What specific precautions were necessary?
What specific precautions was the employee given?
What protective equipment should have been
used?
What protective equipment was the employee
using?
What had other persons done that contributed to
the incident?
What problem or questions did the employee
encounter?
What did the employee or witnesses do when the
incident occurred?
What extenuating circumstances were involved?
What did the employee or witnesses see?
What will be done to prevent recurrence?
What safety rules were violated?
What new rules are needed?
Why was the employee injured?
Why and what did the employee do?
Why and what did the other person do?
Why wasn’t protective equipment used?
Why weren’t specific instructions given to the
employee?
Why was the employee in the position?
Why was the employee using the tools or machine?
Why didn’t the employee check with the supervisor
when the employee noted things weren’t as they
should be?
Why did the employee continue working under the
circumstances?
Why wasn’t the supervisor there at the time?
WHEN? HOW?
When did the incident occur?
When did the employee start on that job?
When was the employee assigned on the job?
When were the hazards pointed out to the
employee?
When was the employee’s supervisor last check on
job progress?
When did the employee first sense something was
wrong?
How did the employee get injured?
How could the employee have avoided it?
How could fellow workers have avoided it?
How could supervisor have prevented it ‐ could it
be prevented?
Incident Investigations: A Guide for Employers
F‐1
APPENDIX F: SAMPLE QUESTIONS FOR IDENTIFYING INCIDENT ROOT CAUSES
QUESTIONS
1. Did a written or well‐established procedure exist for employees to follow?
2. Did job procedures or standards properly identify the potential hazards of job performance?
3. Were there any hazardous environmental conditions that may have contributed to the incident?
4. Were the hazardous environmental conditions in the work area recognized by employees or
supervisors?
5. Were any actions taken by employees, supervisors, or both to eliminate or control environmental
hazards?
6. Were employees trained to deal with any hazardous environmental conditions that could arise?
7. Was sufficient space provided to accomplish the job task?
8. Was there adequate lighting to properly perform all the assigned tasks associated with the job?
9. Were employees familiar with job procedures?
10. Was there any deviation from the established job procedures?
11. Were the proper equipment and tools available and being used for the job?
12. Did any mental or physical conditions prevent the employee(s) from properly performing their jobs?
13. Were there any tasks in the job considered more demanding or difficult than usual (e.g., strenuous
activities, excessive concentration required, etc.)?
14. Was there anything different or unusual from normal operations? (e.g., different parts, new or
different chemicals used, recent adjustments/maintenance/cleaning on equipment)
15. Was the proper personal protective equipment specified for the job or task?
16. Were employees trained in the proper use of any personal protective equipment?
17. Did the employees use the prescribed personal protective equipment?
18. Was personal protective equipment damaged or not properly functioning?
19. Were employees trained and familiar with the proper emergency procedures, including the use of
any special emergency equipment and was it available?
20. Was there any indication of misuse or abuse of equipment and/or materials at the incident site?
21. Is there any history of equipment failure, were all safety alerts and safeguards operational and was
the equipment functioning properly?
22. If applicable, are all employee certification and training records current and up‐to‐date?
23. Was there any shortage of personnel on the day of the incident?
24. Did supervisors detect, anticipate, or report an unsafe or hazardous condition?
25. Did supervisors recognize deviations from the normal job procedure?
26. Did supervisors and employees participate in job review sessions, especially for those jobs
performed on an infrequent basis?
27. Were supervisors made aware of their responsibilities for the safety of their work areas and
employees?
28. Were supervisors properly trained in the principles of incident prevention?
29. Was there any history of personnel problems or any conflicts with or between supervisors and
employees or between employees themselves?
30. Did supervisors conduct regular safety meetings with their employees?
31. Were the topics discussed and actions taken during the safety meetings recorded in the minutes?
32. Were the proper resources (i.e., equipment, tools, materials, etc.) required to perform the job or
task readily available and in proper condition?
33. Did supervisors ensure employees were trained and proficient before assigning them to their jobs?
CHAPTER13
Recommending
Corrective Actions
T he subject of thi s chapter seldo m receives the attention it deserve s. The
purpose of an accident inves tiga tion is to prevent recurrence of the sa me
accident or a similar accident and to correct problems in the safety program
50 that other types of accid ents can be avoided. The important steps of any
accident investigation are gathering evidence, discovering and analyzi ng th e
accident sequence, determining causal factors, and fi nding corrective
actions
imt will prevent future accidents. The last three steps arc linked to the steps
before them : Once all of the facts are ga thered and analyzed, the accident
sequence is determined. Once the accident sequence is determined, rnu sa l
facmrs become clear. And once the causal factors are established, correcthre
actions can be developed.
Causal Factors
A causal factor is an event or circ um stance th at he lped to cause an accid ent.
An investigator must exam in e causa l factors at al.I levels-manage mern,
•·orker, engineering (design), and policy-in order to to provide corrective
actio ns and accountabili ty for tho se corrective actio ns . Use an evcnrs and
cau 5al factors chart to develop the ca usa l factors, and ensure that none arc
139
Part JV- Pm YnlingArcidmt.s
140
missed. All poss ible cau sal fa ctors should be li sted
. . , n o matter ho
seem, so that when co rrecave actions are developed th . w minor th
. . , e 1nve · ev
pos mve th at all o f the causal factor s hav e been addressed. stlgator can b~
T eaching a worker who has been involved in an .
accident to
sa fely will probably prev ent that worker from rep . Work mo, eattng the . e
causal fa ctors frequently go b eyond the worker level. If the accident, but
li · d · · th causal fa . po cy issue o r a e s1gn issue , en the corrective act1· Ctor 1s a
. . on must be d
at th at level m o rder to av01d future accidents. An a .d . a dressed
ca ent mvesti .
a chance to look at failures in the safety program and c ganon is
. . orrect them It .
a rune to place blame or attnbute human error but to I k · is not
the human error. ‘ 00 at what caused
Corrective Actions
Although companies use different terms to describe fixing the problems
that cau sed accidents, “recommendations” and “corrective actions” seem
to b e the mo s t widely used. A corrective actio n, if implemented, should
” fix” a cau sal factor-prevent it from causing another accident. Corrective
actions can take the form of engineering redesigns, task redesigns, policy or
procedure change s, and equipment changes, among others. Any action that
can b e taken to prevent future accident s is a corrective action, as shown in
E.mibit 13.1.
T o be effective in preventing future accidents, corrective actions should
be implemented u sing the three-step process shown in Exhibit 13.2.
1. Develop the corrective actions after the investigation produces causal
fac tors.
· f 1 • organizing and 2. Track the corrective actions. A database 1s use u ,or
tracking in fo rmation about the co rrective actions.
. . h been followed as
3. Follow up to ensure that the co rrective acno ns ave . . not
ini tiated. If a corrective actio n is n o t used, accident prevenuon is
ens ured.
Chapter 13: Rerommmdi11g Corrective A r/ions
. . .1
ORRECTIVE ACTIONS TO PREVENT ACCIDENTS
l H=RDS l
G8
Develop corrective
actions to prevent
accidents
Developing Corrective Actions
A corrective action should fix a problem and prevent accidents. All causal
haors should have at least one corrective action (DOE 1999).
lips for Developing Corrective Actions
‘ Every accident should h ave at least one causal factor.
‘ Develop at least one corrective action for each causal factor.
‘ Communicate corrective actions clearly.
141
p,;r1 / I :· />m ‘!nti,,g .,~!milert/J
142
Exhibit 13.2
THREE-STEP, PROCESS FOR CORRECTIVE
A
CTIONs
Develop corrective
(
actioa~~:.;..~~vent
CORRECTIVE
ACTION PROCESS
Track corrective
actions Follow up corrective
actions
i\lake causal factors and corrective action s ve ry specific so that the worker,
superviso r, or manager knows exac tly w h at the problem is and how to fL,
it. ” Hwnan error” as a causal factor and ” training” as the corresponding
corrective action, fo r example, are too ge n e ral to be of use. Examples of
usefu17 specific corrective actions are ” D esign a metal guard that prevents
contact with the blade ” ; “Provide e lectrical training for all maintenance
worke rs, incl uding loc kout/tagout procedures”; and “lncrease the
corporate in spec tor’s audit scheduJ e to include warehouse activiries.” The
more specifics included in the corrective action, the better the chance that
accidents \vl.ll be preve nted.
Recommending Corrective Actions that Eliminate Hazards
There are usually several ways to fo< a problem, a nd some ways are m~re
likely to prevent acciden ts than oth e rs . Try to choose a corrective ac~oo
th ·u li · f h d reducoon at ,vi e mm ate a h azard when p ossible. Two types o azar ,rd
Slrategl es \vork well to d evelop co rrec tive action s and fix prob1ems-haz
Chapter 13: Recommending Comrlive Arliom
d
which is w idely used and accepted in the safety area and
I prece eoce, . . ‘
con”0 f om epidemiology called ‘IIJ”‘Y control.
reg)’ taken r
””‘ d ntrol precedence shows the order in which hazard control
‘fhe hazar co d A h f th Ii . Ii . Id b e considere . t t e top o e st is e rrunating the
hods shou . _
rnet that usually involves design or redesign. The next step is
. .
hj Z . c minimum ri sk or, m som e cases, substtrute a less hazardous
design ,or . 10 . N tis to design in sa fe ty d evices such as guards, although they do
ltenal. l ex
rn duce or eliminate the hazard but simply cover it up. Warning d evices,
110
\~enal protective equipme nt, procedures, and training also do not eliminate
P” d the hazard so they are toward the b ottom of the list. If none of
orre uce ‘ . . . .
Jheearlier steps works, the last choice is to _accept the nsk. Accepting the
nsk is usuall}’ n ot considered a correcttve action and 1s not used m accident
mmcigacions (System Safet y Society 1997) . There has already been one
acci dent and having another is n ot acceptable. Exhibit 13.3 outlines the
h1zard control precede nce.
Exhibit 13.3
HAZARD: coNTROL PRECEDENCE
PRIORITIES IN SEEKING A HAZARD CONTROL SOLUTION
1. Design to eliminate hazard conditions.
2. Design for minimum risk.
3. Design in safety devices.
4. Design separate warning devices.
5. Develop operating procedures (including protective clothing,
equipment, and devices) and train personnel to use them.
6. Develop administrative rules.
7. Require management to accept risk.
~is precedence emphasizes building safety into the system. a.nd minimizing
reliance on human input. Safety as part of the design makes it integral to the
‘Ystem· (System Safety Society 1997, 1-3).
143
144
Part fl /_· Pm’f’11ti11gAmdmtJ
The seco nd hazard reducti o n strategy, based 00 epiderniolo
con:1’~1, w:1s developed by William Hadd o n.Jr. (1970) and lis ~ · and !n)llt}
for tnJUC)’ control: ts ten 5ftategi~
1. Prevent the creation of the ha zard in the first place. E xample- D
th~ ~1~nufacrure of p~rticularly hazardous vehicles such ~s O not al!o..
numbtkes, o r all-terrain ve hicles. motorcycles,
2. RedHce the amOl(JJt of the_ hazard bro~~ht into being. E xample: Allow th ,
handguns o nl y tO p o lice and military units. c_:i.Jcof
3. Prevent the release ef a hazard that alrratfy e..,7Sts. Example: Im rove th
power of motor vehicles. p e bnkmg
4. Modify the release ~r spah·al _d1Stn’bution of release of the hazard from JI; Jci;rrt
Example: Use child restramts and seat belts in motor ve hicles.
5. Separate, 1/1 litm or space, the hazard and that which IS to be protrrtrd. Exam 1c:
Remove roadside trees and poles. p.
6. S eparale the hazard and that which is to be protrcted I!) intt,pos,iion of
O
ma:rr..;:
bam·er. Exa mple: Install air bags in passenger vehicles.
7. Af.odify basic relevant qualities ef the hazard. Example: Eliminate sharp points
and edges on ve hicle exteriors.
8. i\1ake 1llhal is to be protected more resistant to da111agefro11J the hazard faamp!e:
Require physical conditioning before participation in sports th arprod uce
conditioning -re lared injuries.
9. Begin lo counter the dafllage alreatf.y dom l!J the mvironnu!llal hazard E:umple:
Increase the u se of s moke detectors and carbon monox.ide de trctors.
10. Stabilize) repair, afld rehab1iitale the oiject ef the da111agt. Example: Proiide
prosthetic d evices for amputees .
(Adapted from Haddon 19;~
Haddo n ‘s list is made up o f ba sic injury control strategies as oppasrcl
10
workplace hazard control stra tegies . The list provides a basic und ersr:uidmg
of how to prevent inju ry. Find out more about injury control by rr.id!n.?
Haddon ( 1970) and Robens on (1998).
Chapter I J: lvro111111md111g Corrrrlire Artio,11
king Corrective Actions
rrac • e ac tion s has bee n developed , th e action s mus t be
e l of correct1v , . . . .
once a ~ied . le does no good to conduct an c x~e Uent ~cc1d~nt m vesagat10n ,
1~ipkm:sal facror s, and develop u se ful corrective actions 1f yo ur company
t111d ca h corrective actions o r impl e ments th e m very s lowly.
fails ro irnplemenl t ;e that corrective actions are act ed on is to track them.
The best way to e n su
Tips for Tracking Corrective Action s
Establish a timetable for each co rrective action. If all the a~tions are assi~ed
to a specific department or individual, they are u sually imp lemented m a
timel}’ manner.
Consider using a database to track corrective ac ti o n s. Include field s for
a description of the action, an anticipated completion dat e, and the p a rty
responsible for carrying out the action.
Conduct a follow-up to make sure the corrective actions are in p lace a nd
working correctly. Thi s will be discussed further in C hapte r 12.
Exa m p le Scenario
Exhibit 13.4 shows th e completed events and causal factors analysis for th e
for klift -and -ladde r accident. The causal factors found for th.is acc ide nt are
bck of barricades; management’s failure to plan, schedule, and communicate
1he job; th e corpora te culrure o f getting jobs done quickly (including upper
management’s lac k of e nforce m e nt of policies and proced ures); and failure tO
follow policies a nd procedures. Th e events and causaJ facwrs analysis, barrier
analysis, and c ha nge analysis earlier in this b ook make it clear that this accident
15
more compli cated than jus t a “fo rgo t ro barricade’ ‘ iss ue. If th e accident
invesrigato r had a nal yzed o nl y the barricade iss ue, m any important prevention
st
eps woul
146
Pllrt t r/.· Pnw nli11gA mdn1ls
A
Exhi bit 13.4
SCENARIO EVENTS AND CAUSAL FACTO
New wing of
wa rehouse
finished.
1/6/ 11
Bill received
promot ion to
f——, wa rehou se
supervisor.
1/23 /11
Bill arrived at
work.
2/ 5/ 11 , 7:35
Bill retrieved
a ladder.
2/ 5/ 11,7:41
Chapter 13: R.i’ron1111e11di11g Correrllve Artio11s
SCENARIO EVENTS AND CAUSAL F~
C
Forklift hit
ladder.
2/ 5/11
7:45
Forklift driver
loaded last
load of the
day.
2/5/ 11, 7:44
Bill fell off
ladder.
2/ 5 / 11
7:45
Forklift driver
immediately
notified
medical.
2/ 5/11
7 :46
Par1 Ir ‘: Pm”t11t111t ,..lmdtnJJ
148
Exhibit 13.5
CAUSAL FACTORS AND CORRECTIVE ACTIONS FOR EXAMP LE SCENARIO
CAUSAL FACTORS
1. Lack of barricades
2 Management failure to plan,
schedule, and communicate job
3. Corporate culture to get jobs done
quickly (upper management’s lack
of enforcement of policies and
procedures)
CORRECTIVE ACTIONS
1. Train worke~s ands~
how to barricade aisles.
2. De~elop managemen~
train management on planning,
;~::~~~nt~,
5
~ d communicating
3. Develop a~ auditing system~
for su pervisors, managers, and
corporate employees that include
enforcing policies and procedures~
4. Forklift policies and procedures not 4 . Tra in supervisors and forklift d;;;;;
followed. on policies and procedures and
develop en forcem ent audits.
The example scenario is an example of manage ment and policy failur e.
Since the accident occurred while someone was pe rforming a non-recurring
job, engineering fiires are not appro priate, bul there may be ha zard elimination
strategies thar could be used. Can rou think of a ny?
Summary
Correctfre actio ns-the actio ns that will prevent recurrence of the accident-
are the backbone of the accident in ves tigation. Corrective actions must be
based on the causal factors, developed cl earl y :md objectively, tracked u~cil
completion, and followed up w ensure that they a re in place and wo rking
correctly. If a corrective action is not mitiared, it can not prevent :1.ccidencs.
Corrective actions should be developed at all level s of accountability arid ar
th
e highest Jeyel of hazard control precede nce possible to en sure th at rhe
hazard is controlled.
Chapter I J: fvrommmdmg Comm,., A rno,u
REVIEW QUESTIONS
I. What is a corre ctive action?
2. What is the relationship between a causal factor and a corrective action7
3. Haw must a corrective action be w ritt en?
4• Us! the hazar d control precedence.
5 Why should a company track corrective actions?
6. For the example scenario, try to fi nd more causal factors and corrective
w:ions tha t will prevent accid ents.
149
