Conducting an Accident Investigation
Course 102
Safety Certified Supervisor Series

INTRODUCTION

The employer's mandate: Analyze to fix the system...Don't investigate to fix the blame

Unfortunately, some employers believe that the investigation process ends once blame as been established. The problem, here, is that once the purpose of the analysis process has been achieved, analysis stops. When employers investigate to place blame, no further analysis is conducted to fix the underlying safety management system weaknesses that contributed to the accident.

According to OSHA's Safety & Health Program Management Guidelines, para (c)(2)(iv), the employer's primary purpose for investigating accidents is primarily, "so that their causes and means for preventing repetitions are identified."

OSHA goes on to say this about the investigation process:

"Although a first look may suggest that "employee error" is a major factor, it is rarely sufficient to stop there. Even when an employee has disobeyed a required work practice, it is critical to ask, "Why?" A thorough analysis will generally reveal a number of deeper factors, which permitted or even encouraged an employee's action. Such factors may include a supervisor's allowing or pressuring the employee to take short cuts in the interest of production, inadequate equipment, or a work practice which is difficult for the employee to carry out safely. An effective analysis will identify actions to address each of the causal factors in an accident or "near miss" incident."

Bottom line. The output of the employer's accident investigation process should not end with merely identifying violations of employer safety rules. The final report should focus on identifying safety management system weaknesses. Following this policy will help make sure the accident analysis process is a "profit center" activity for the company. It will result in long-term returns that are substantially greater than the investment put into the process.

The most effective employer accident investigations address liability only after an honest evaluation by a qualified person concludes that all relevant elements of the safety management system are effectively designed and implemented.

A quick reprimand almost guarantees adequate evaluation was not conducted.