This material is for training purposes only.

Its purpose is to inform Oregon employers of best practices in occupational safety and health and general
Oregon OSHA compliance requirements. This material is not a substitute for any provision of the Oregon Safety Employment Act or any standards issued
by Oregon OSHA.

INTRODUCTION

Workplace accidents occur each and every day all across the Country. Each Year the
Bureau of Labor Statistics (www.bls.gov) publishes a statistical summary of injuries
and illnesses (See summary below) that emphasizes this fact.

The failure of people, equipment, supplies, or surroundings to behave or react as

expected causes most of the accidents. Accident investigations determine how and
why these failures occur. By using the information gained through an investigation,
a similar or perhaps more disastrous accident may be prevented. Conduct accident
investigations with accident prevention in mind. Investigations are NOT to place
blame.

BLS Summary: Workplace Injuries and Illnesses in 2000 A total of 5.7 million injuries and illnesses were reported in
private industry workplaces during 2000, resulting in a rate of 6.1 cases per 100 equivalent full-time workers, according to
the Bureau of Labor Statistics, U.S. Department of Labor. Employers reported about the same number of cases compared
with 1999 and a 2 percent increase in the hours worked, reducing the case rate from 6.3 in 1999 to 6.1 in 2000. The rate for
2000 was the lowest since the Bureau began reporting this information in the early 1970s.

Of the 5.7 million total injuries and illnesses reported in 2000, about 2.8 million were lost workday cases, that is, they
required recuperation away from work or restricted duties at work, or both. The remaining 2.9 million were cases without
lost workdays. The incidence rate for lost workday cases was the same in 2000 as in 1999 (3.0 cases per 100 workers),
while the rate for cases without lost workdays decreased from 3.3 cases per 100 workers to 3.2 cases per 100 workers.

This course introduces you to basic accident investigation procedures and describes accident analysis techniques.
Throughout the course, you'll be taking what you've learned throughout the course to analyze a hypothetical
accident!

What is an accident?

An accident is the final event in an unplanned process that results in injury or illness to an employee and
possibly property damage.

An "event," occurs when one "actor" (one person/thing) performs an "action" (does something). In this definition,
a person or thing will do something that results in a change of state (an injury). An accident may be the result of
many factors (simultaneous, interconnected, cross-linked events) that have interacted in some dynamic way.

Why conduct an "investigation"?

The answer to this question is key to the success of the entire program. Does your organization conduct
accident investigations for the same reason as Oregon OSHA? It shouldn't be. To determine the purpose of
a process, it's important to look at the "output" of that process. The fatality investigation report is the output of
the investigation process, so let's take a look at the sample given in OSHA Instruction CPL 2.113, Appendix C:
 MEMORANDUM FOR: Regional Administrator
FROM: Area Director
SUBJECT: Results of Fatality Investigation

The following information supplements the OSHA-170, regarding investigation of the accident at _____ Company, Inc.,
which occurred on June 15, 1995.

Establishment Information: ____ Company, Inc., located at Grainfield Road, Grossfield, USA, has no previous inspection
history. The company has a work force of 32 employees and operates on a seasonal basis, usually June to November.

Family Involvement: The next of kin information was obtained from the company and the CSHO telephoned to verify the
information and advise the family that an investigation is in progress. The standard information letter was sent. There has
been no further contact from the family.

Union Involvement: There is no union at this location.

Proposed Action: Issue citations for serious and other violations of machine guarding, open floor holes, hazard
communication and recordkeeping with a penalty total of $5,475. A 5(a)(1) letter outlining the hazards to be corrected
which were not clearly addressed by 29 CFR 1928 Safety and Health Standards for agriculture and for which other OSHA
Standards are not applicable will also be mailed to the company.

The message in this document reflects the intent of OSHA to conduct accident investigation primarily to
determine if violations in OSHA law caused the accident: To establish employer liability - place blame, if you will.
The law mandates this approach. However, the law does not require your organization to carry out accident
investigations for the same reason.

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.

Are accidents always unplanned?

We like to think that accidents are unexpected or unplanned events, but sometimes, that's not necessarily so.
Some accidents result from hazardous conditions and unsafe behaviors that have been ignored or tolerated for
weeks, months, or even years. In such cases, it's not a question of "if" the accident is going to happen: It's only
a matter of "when." But unfortunately, the decision is made to take the risk.

A competent person can examine workplace conditions, behaviors and underlying systems to predict closely what
kind of accidents will occur in the workplace. Technically, we can't say an accident is always unplanned. Like any
system, a safety management system is designed perfectly to produce what it produces. Consequently,
written safety plans may be (unintentionally) designed such that they create circumstances that cause accidents.

In companies that decide to take the risk, it's likely their attitude about accidents is that, "accidents just happen;
there's nothing we can do about them." Of course, that's an unacceptable notion in any effective safety culture.
Employers with a healthful attitude about accidents consider them to be "inexcusable," and demand that hazards
be corrected before they cause an accident.

Accidents and incidents

Accidents are part of a broad group of events that adversely affect the completion of a task. These events are
incidents. For simplicity, the procedures discussed in this course apply most appropriately to accidents, but they
also applicable to all incidents in general.

Characteristics of effective incident/accident analysis program

● The program will be guided by written plan that identifies specific procedures and responsibilities. It's
important to make sure procedures are clearly stated and easy to follow in a step-by-step fashion.

● The plan clearly assigns responsibility for conducting accident investigations. It's up to the employer to
determine who conducts accident investigations. Usually a supervisor, management/labor team, or safety
committee member conducts the investigation. Whoever conducts the investigation, needs to understand
his or her role as an accident investigator. Usually, two heads work better than one, especially when
gathering and analyzing material facts about the accident. We recommend a team approach.

● All accident investigators will be formally trained on accident investigation techniques and procedures.
Investigators may attend accident investigation training presented by OR-OSHA, private educational
institutions, or in-house training conducted by a qualified person.

● Accident investigation must be perceived as separate from any potential disciplinary procedures resulting
from the accident. The purpose of the accident investigation is to get at the facts, not find fault. The
accident investigator must be able to state with all sincerity, that he or she is conducting the investigation
only for the purpose of determining cause, not blame.

● The accident investigation report will be in writing and will make sure that the surface causes and root
causes of accidents are addressed. Most accident reports are ineffective precisely because they neglect to
uncover the underlying reasons or factors that contribute to the accident. Only by digging deep, can you
eliminate the hazardous conditions and work practices that, on the surface, caused the accident.

● The accident investigation report will make recommendations to correct hazardous conditions and work
practices, and those underlying system weaknesses that "caused" them into existence. In many instances,
the surface causes for the accidents are corrected on the spot, and will be reported as such. But the
investigator must make recommendations for long-term corrections in the safety and health system to
make sure those surface causes do not reappear.

● Follow-up procedures to make sure short and long-term corrective actions are completed.

● An annual review of accident reports. A couple of safety committee members evaluate accident reports for
consistency and quality. They must make sure root causes being addressed and corrected. Information
 about the types of accidents, locations, trends, etc., can be gathered.

MODULE 1: INITIATING THE PROCESS

Introduction

In this first module our goals are to understand what basic OR-OSHA law regarding employer responsibilities to
conduct accident investigation. We'll also learn why it's important to begin the investigation early-on, when it's
"safe" to investigate, finally "how" to secure the accident scene once the investigation has been initiated. Finally,
you'll learn what the law says about reporting accidents to OR-OSHA.

First things first...lay the groundwork

When a serious accident occurs in the workplace, everyone will be too busy dealing with the emergency at hand
to worry about putting together an investigation plan, so before the accident occurs... develop an effective
written incident/accident analysis plan that will:

■ Determine who should be notified of accident.

■ Establish who is authorized to notify outside agencies (fire, police, etc.)
■ Determine who is assigned to conduct investigations.
■ Conduct required training for accident investigators.
■ Determine who receives and acts on investigation reports.
■ Establish timetables for conducting the investigation and follow-up actions such as hazard correction.

The first step in an effective accident investigation procedure is to secure the accident scene as soon as possible
so you can begin collecting initial data. Sometimes, you may actually be able to begin the investigation, while the
victim is being assisted by emergency responders. In this case, make sure you do not interfere in any way with
them. The first responsibility is to make sure the victim is cared for. At this early point, you're primarily making
initial observations for later analysis.

Most of the time, your investigation will not begin until emergency response is completed. In this situation,
material evidence will most likely not be in its original location. Of course, this will make it more difficult for you
to determine the original location of evidence, but effective interviews will help you to construct the scene. In
either situation, you're not yet interested in what "caused" the accident, just gathering as much pertinent
information as possible for later analysis.

Why is it important to start the investigation as soon as possible? Of course, it's not to establish blame, but
rather to accurately determine the surface and root causes for the accident. The longer you wait to investigate,
the more unlikely you'll be able to fulfill this very important purpose. So, why does accuracy suffer over time?

Two things disappear after an accident occurs:

● Material evidence. Somehow, tools, equipment, and sometimes people just seem to move or disappear
from the scene. Understandably, the employer is anxious to "clean up" the accident scene so people can
get back to work. It's important that an effective procedure be developed to protect material evidence so
that it does not get moved, or disappears.

● Memory. Accidents are traumatic events. There are varying degrees of psychological trauma depending on
how "close" an individual is to the accident or victim. There may be physical trauma to the victim and
others whenever a serious accident occurs in the workplace. Everyone is affected somehow. As time passes
after an accident conversations with others and individual emotions distort what people believe they saw
and heard. After a while, the memory of everyone affected by the accident will be altered in some way.
This type of distortion can have nothing but negative effects on your success as an accident investigator.

With the above in mind, it becomes rather obvious why we must try to get information as soon as possible. But
what can we do to make sure evidence and memory do not disappear? Let's find out.
Secure the accident scene

Our first step in the accident investigation process is to physically

secure (close off) the accident scene to prevent material evidence
from being removed or relocated in any way. This is especially true
if the accident is a reportable (serious or fatal) injury that might
trigger an OR-OSHA accident investigation.

Remember, at the request of OR-OSHA, persons having direct authority must preserve and mark for
identification, materials, tools or equipment necessary to the proper investigation of an accident, so it's important
that material evidence does not "walk off" the scene.

Securing the accident scene isn't difficult, but it's critically important to do it quickly. You may use tape, cones,
even personnel to secure the accident scene. Securing the accident scene may not be rocket science, but it may
be extremely important in preventing the loss or misplacement of material evidence.

If required, report the accident

If your company is in the private sector, and a very serious injury or fatality accident occurs, you may be
required to report it to OR-OSHA. Let's take a look at the Standard for the specific requirements.

437-001-0052 Reporting an Occupational Fatality, Catastrophe, or Accident.

Employers shall inform the Administrator (or designee) of all fatalities or catastrophes within 8 hours,
and accidents or injuries resulting in a hospital admission with medical treatment other than first aid
within 24 hours after the employer receives notification.

A fatality is pretty much self-explanatory. A catastrophe is considered two or more fatalities or three or more
serious injuries. Think of an injury as serious if the victim is admitted to the hospital overnight for other than
observation. Once the employer has knowledge that any of the above conditions have been met, the eight and 24-
hour clock starts ticking.

Let's Review

1.What is the purpose of an accident investigation?

2. What's the most practical way to secure an accident scene?

3. What might be the result if the investigation is not initiated as soon as possible?

4. If a workplace fatality occurs, the affected employer must notify OR-OSHA within _____.

a. twenty-four hours
b. sixteen hours
c. eight hours
d. four hours

5. A catastrophe is considered ______or more fatalities or _____ or more serious injuries.

a. one, two
b. two, three
c. three, four
d. four, five

MODULE 2: DOCUMENTING THE ACCIDENT SCENE

Introduction

In this module we will take a look at strategies for documenting the accident scene. We'll emphasize the team
approach and discuss the advantages of using the various documentation methods including, personal
observation, photo/videotaping, taking statements, drawing sketches and reviewing records.

Why the team approach works best

Once the accident scene has been roped off, it's important to begin immediately to gather evidence from many
sources as possible during an investigation. One of the biggest challenges facing the investigator is to determine
what is relevant to what happened, how it happened, and why it happened. Identifying items that answer these
questions is the purpose of effective accident scene documentation.

As you'll learn, there are so many ways to document the scene that it may become quite difficult for one person
to effectively complete all actions. The most effective strategy is to document as much as possible, even if you
question relevancy. It's easy to discard clues or leads if they prove not useful to the investigation. It's not at all
easy to dig up material evidence well into the investigation. All items found at the scene should be considered
important and potentially relevant. Consequently, a team approach is probably the most efficient strategy when
conducting accident investigations when very serious injuries or fatalities are involved.

Sample Accident Investigator's Kit

Another important policy is to have a ready-and-waiting accident investigator's kit. You won't be able to fulfill this
purpose unless you come prepared so make sure an accident investigation kit (see example kit below) is available
for use.

● Camera - 35mm, Polaroid, panoramic

 ● Tape recorder
● Ground loop Impedance Tester
● Sound level meter
● Abney Level or clinometer
● Tape measure, 25 and 50 ft length
● Clipboard, paper, pencils, etc.
● Rain gear
● Rubber and caulked boots
● Plastic bags with ties
● Square, French curve template
● Personal Protective Equipment
❍ Eye protection

❍ Hand protection

❍ Clothing

❍ Respirators

❍ Hearing protection

● String
● Stakes
● Warning tape Employment Act or any standards issued by Oregon OSHA.

Methods to document the accident scene

Make personal observations. With clipboard in hand, take notes on personal observations.
Try to involve all the senses.

● What do you see? What equipment, tool, materials, machines, structures appear to be broken, damaged,
struck or otherwise involved in the event? Look for gouges, scratches, dents, smears. If vehicles are
involved, check for tracks and skid marks. Look for irregularities on surfaces. Are there any fluid spills,
stains, contaminated materials or debris?
● What about the environment? Were there any distractions, adverse conditions caused by weather? Record
the time of day, location, lighting conditions, etc. Note the terrain (flat, rough, etc.)
● What is the activity occurring around the accident scene?
● Who is there: Who is not? You'll need this information to take initial statements and interviews.
● Measure distances and positions of anything and everything you believe to be of any value to the
investigation.

Obtain initial statements. If you're fortunate there will be one or more eye-witnesses to the accident. Ask
them for an initial statement giving a description of the accident. Also try to obtain other information from the
witness including:

● Names of other possible witnesses for subsequent interviews.

● Names of company rescuers or emergency response service.
● Materials, equipment, articles that were moved or disturbed during the rescue. Employment Act or any
standards issued by Oregon OSHA.

Take photos of the accident scene. Make sure you start with distance shots, and move in closer as you take
the photos. Also make notes about the photos you took. Some important points to remember about taking photos
include:

● Take photos at different angles (from above, 360 deg. 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,
 containers.
● Take panoramic photos to help present the entire scene, top to bottom - side to side.
● Take notes on each photo. These will be included in the appendix of the report along with the photos.
Identify the type of photo, date, time, location, subject, weather conditions, measurements, etc.
● Place an item of known dimensions in the photo if hard-to-measure subjects are being photographed.
● Identification of person taking photo.
● You may indicate the locations photos were taken on sketches.
● Finally, do not use a digital camera as the photo may not be considered legally admissible. The digital
photo can be easily "touched up." Use a standard print camera.

Videotape the scene. The earlier you can begin videotaping, the better. Once company or
other emergency responders are attending to the victim, begin videotaping. The video
recorder will pick up details and conversations that can add much valuable information to
your investigation. Just remember...don't get in the way.

Some important points to remember when videotaping include:

● Have witness(es) accompany and describe what happened.

● If possible, reenact the event.
● Use a tripod when taping.
● To get the "lay of the land," stand back from a distance and zoom in to the scene.
● Scan slowly 360 degrees left and right to establish location.
● Narrate what is being taped, describe objects, size, direction, location, etc.
● If a vehicle was involved, tape direction of travel, going and coming. Employment Act or any standards
issued by Oregon OSHA.

Before you tape, make sure your video camera is operating properly, the battery is charged, and, oh yes...take
the cap off the lens ;-)

Sketch the accident scene. Sketches are very important because they compliment the information in photos,
and are good at indicating distances among the various elements of the accident scene which establishes
"position evidence." It is important to be as precise as possible when making sketches. The basic components of
the sketch are:

● Documentation. Date, time, location, identity of objects, victims, etc.

● Spatial relationships. Measurements.
● Location of photographs. Employment Act or any standards issued by Oregon OSHA.

Sketches are valuable because they reconstruct the accident in model form and are
best able to indicate movement through time. They also help establish testimony if it
becomes necessary to defend against a damage or injury claim. The sketch may also
help establish a claim against a supplier or manufacturer. You don't have to be a
professional illustrator to make a decent sketch, but you must be accurate in your
measurements. Take a look at the sketch below as a sample of a useful sketch.

Some sketching pointers:

■ Make sketches large; preferably 8" x 10".

 ■ Makes sketches clear. Include information pertinent to the investigation.
■ Include measurements. Establish precise fixed identifiable reference points.
■ Print legibly. All printing should be on the same plane.
■ Indicate directions, i.e., N,E,S,W.
■ Always tie measurements to a permanent point, e.g.. telephone pole, building.
■ Mark where people were standing.
■ Use sketches when interviewing people.
■ Show where photos were taken.
■ Upgrade the quality of the sketch. Turn it into a precise diagram.

The sketch below illustrates the Triangulation Method which makes it

possible to later pinpoint the exact location of an object. In this accident,
the victim contacted a high voltage line with a metal tree trimming pole.
The position of the victim's head is measured from three points. Notice the
small circles with horizontal lines through them. These circles indicate
where photos were taken. Also, North is indicated and all major objects
are identified.

Here's another sketch that helps to illustrate one of the major

advantages of sketching. It shows motion through time. In this sketch
you can see how the bulldozer rolled down the side of a hill.

Interview documents. That's right...you don't just review records, you "interview" them by asking questions. If
you ask...they will answer. Some records you might want to interview are:

■ Maintenance records - to determine the maintenance history of the tools, equipment or

machinery involved in the accident.
■ Training records - to determine the quantity and quality of the training received by the victim
and others.
■ Standard operating procedures - to determine what the formally established steps in the
procedures.
■ Safety policies, plans, rules - to determine their presence and adequacy.
■ Work schedules - to determine if the victim might have been fatigued or otherwise overworked.
■ Disciplinary records - if discipline is considered justified, to determine if disciplinary actions
have occurred previously.
■ Medical records - if permission granted, or otherwise allowed, to determine potential physical/
mental contributing factors.
■ EMT reports - to determine quality of response procedures.
■ OSHA Form 200 - (For years up to and including 2001) and 300 Log - to determine if similar
accidents have occurred previously. See OR-OSHA Recordkeeping Rules for more information.
 ■ OSHA Form 101, First Report of Injury - to collect additional information on accident events
and background. See OR-OSHA Recordkeeping Rules for more information.
■ Safety Committee Minutes - to determine the history of any discussion of related hazardous
conditions, unsafe behaviors or program elements.
■ Coroner's report - to determine direct cause of injury causing fatality.
■ Police report - to determine facts when criminal negligence is in question. Note: When criminal
negligence is suspected stop the investigation and coordinate all activities with legal advisors.

Final Words

Documenting the scene is important for so many reasons. Remember, the team approach works best because
accuracy in reconstructing the accident is the final criteria. I think you'll agree that given all the time and money
constraints, and complexity of the investigation process, two heads are better than one. Now let's take the quiz.

Let's Review

6. When documenting the scene, one of the biggest challenges facing the investigator is to:
Employment Act or any standards issued by Oregon OSHA. a. determine who is to blame
b. determine what is relevant
c. determine who is in charge
d. determine who is liable 7. The most effective documentation strategy is to: Employment Act or any
standards issued by Oregon OSHA. a. document material evidence
b. document obviously relevant material
c. document it, even if relevancy is in question
d. document evidence to establish relevancy

8. When making personal observations, the investigator should consider which of the following:
Employment Act or any standards issued by Oregon OSHA. a. What is not present
b. Condition of objects
c. What is present
d. All of the above
e. None of the above 9. Photos are better at documenting the scene for all the reasons below except:

a. Photos more effectively show motion through time.

b. Photos are better at displaying details.
c. Photos best show size relationships.
d. Photos are easier to produce.

10. What relevant information might be obtained by reviewing the OSHA Form 300 Log?

MODULE 3: CONDUCTING INTERVIEWS

Introduction

Once you have initially documented the accident scene, it becomes important to start digging for details through
the interview process. Conducting interviews is perhaps the most difficult part of an investigation. The purpose of
the accident investigation interview is to obtain an accurate and comprehensive picture of what happened by
obtaining all pertinent facts, interpretations, and opinions. Your job, as the interviewer is to construct a composite
story using the various accounts of the accident and other evidence. The effective interviewer will have a firm
understanding of the techniques for interviewing and the skills acquired through experience to apply those
techniques.
This module will help you understand the difference between an initial interview and an investigative interview,
how to set up an interview, and develop interview questions. The module will also discuss how to organize the
interview and participants to be able to obtain accurate information.

Preparing for the interview

You're first task is to determine who needs to be interviewed. Questions will need to designed around the
interviewee. Consequently, each interview will be a very unique experience. Interviews should occur as soon as
possible, but usually do not begin until things have settled down a bit. Some people you may want to consider for
an interview include:

■ The victim. To determine specific events leading up to and including the accident.
■ Co-workers. To establish what actual vs. appropriate procedures have been used.
■ Direct supervisor. To get background information on the victim. He or she can provide
procedural information about the task that was being performed.
■ Manager. Can be the main source for information on related systems.
■ Training department. To get information on quantity and quality of training the victim and
others have received.
■ Personnel department. To get information on the victim's and others' work history,
discipline, appraisals.
■ Maintenance personnel. To determine background on equipment/machinery maintenance.
■ Emergency responders. To learn what they saw when they arrived and during the response.
■ Medical personnel. To get medical information (as allowed by law.)
■ Coroner. Can be a valuable source to determine type/extent of fatal injuries.
■ Police. If they filed a report.
■ Other interested persons. Anyone interested in the accident may be a valuable source of
information.
■ The victim's spouse and family. They may have insight into the victims state of mind or
other work issues.

Employment Act or any standards issued by Oregon OSHA. Employment Act or any standards issued
by Oregon OSHA.

Cooperation not intimidation is the key to a successful accident investigation

interview. It's very counterproductive to give the impression in any way that can be
interpreted by the interviewee as trying to establish blame. The purpose of the accident
interview is to uncover additional information about the hazardous conditions, unsafe
work practices, and related system weaknesses that contributed to the accident.
Consequently, it's very important that effective techniques to establish a cooperative
atmosphere be used by the interviewer during the process.

What might be the results if a cooperative climate during the interview process is not established? Will the results
be what was intended, or something very different? What do you think. Complete the assignment.

Effective Interviewing Techniques

What are effective ways to increase cooperation in the accident interview process? What communication
strategies might increase the likelihood of an adversarial relationship in the interview? As you conduct interviews,
gaining experience along the way, you'll further develop the "art" of interviewing by improving your ability to
apply these techniques.
 It's important to remember that you're conducting an accident investigation, not a
criminal investigation. These two interview processes may be similar, but each has a
unique purpose. Each process requires different techniques to assure they fulfill their
intended results. The last thing you want to do in an accident investigation is to come
down hard (be accusatory) on an interviewee. So Let's take a look at some effective
techniques that will assure you get to the facts...not find fault.

■ Keep the purpose of the investigation in mind: To determine the cause of the accident so that similar
accidents will not recur. Make sure the interviewee understands this.
■ Approach the investigation with an open mind. It will be obvious if you have preconceptions about the
individuals or the facts.
■ Go to the scene. Just because you are familiar with the location or the victim’s job, don't assume that
things are always the same. If you can't conduct a private interview at the location, find an office or
meeting room that the interviewee considers a "neutral" location.
■ Interview the people involved (victim, witnesses, people involved with the process, i.e., forklift driver,
mechanic).
■ Put the person at ease. Explain the purpose and your role. Sincerely express concern regarding the
accident and desire to prevent a similar occurrence.
■ Express to the individual that the information given is important. Be friendly, understanding, and open
minded. Be calm and unhurried.
■ Direct an eye witness to "explain what happened." Don't ask them to explain, because they may respond
with a simple "no," and that's that.
■ Let the individual talk. Ask background information, name, job, etc. first. Ask the witness to tell you what
happened; don't ask leading questions; don't interrupt; and don't make expressions (facial, verbal of
approval or disapproval).
■ Ask open ended questions to clarify particular areas or get specifics. Try to avoid yes and no answer (closed
ended) questions. Try to avoid asking "why" as these type of questions tend to make people respond
defensively. Example: Do not ask: "Why did you drive the forklift with under-inflated tires? Rather, ask:
What are forklift inspection procedures? What are forklift safety hazard reporting procedures?
■ Repeat the facts and sequence of events back to the person to avoid any misunderstandings.
■ Notes should be taken very carefully, and as casually as possible. Let the individual read them if desired.
Give the interviewee a copy of the notes you take.
■ Don't use a tape recorder unless you get permission. Tell the interviewee that the purpose of the recorder
is to insure accuracy. Offer to give the interviewee a copy of the tape.
■ Ask for their suggestions as to how the accident/incident could have been avoided.
■ Conclude the interview with a statement of appreciation for their contribution. Ask them to contact you if
they think of anything else. If possible, advise these people personally of the outcome of the investigation
before it becomes public knowledge.

Last Words

Understanding and applying the information above during the interview process will help assure you establish a
cooperative relationship so that you can obtain the facts. Intimidation and blaming will always result in an
ineffective interview process.

Let's Review

11. What is the purpose of the interview process. How do you best achieve that purpose?
12. All of the following are ineffective interview techniques except: Employment Act or any standards
issued by Oregon OSHA. Employment Act or any standards issued by Oregon OSHA. a. Ask "why-you" questions
b. Ask open-ended questions
c. Blow smoke in their face
d. Encourage fault-finding

13. Which of the following locations might be best for conducting the interview? Employment Act or any
standards issued by Oregon OSHA. Employment Act or any standards issued by Oregon OSHA. a. The scene of
the accident
b. Your office
c. The lunch room
d. At a restaurant

14. Why is it important to ask the interviewee to review your notes?

15. Why is it inappropriate to interview someone in the presence of others?

MODULE 4: ANALYZING THE ACCIDENT PROCESS

Introduction

This module introduces you to the very important process of event analysis. We'll review some theories of
accident causation and discuss the process of developing and analyzing the sequence of events occurring prior to,
during, and immediately after an accident.

Why accidents happen

Over the past century, safety professionals have tried to more effectively explain how and why accidents occur.
As you will see below, their explanations were at first rather simplistic. Theorists gradually realized that it was not
sufficient to explain away workplace accidents as simple cause-effect events. They developed new theories that
better explained the complicated interaction among conditions, behaviors and systems that result in an accident.
Let's take a look at some of these theories.

● Single Event Theory - "Common sense" leads us to this explanation. An accident is thought to be the
result of a single, one-time easily identifiable, unusual, unexpected occurrence that results in injury or
illness. Some still believe this explanation to be adequate. It's convenient to simply blame the victim when
an accident occurs. For instance, if a worker cuts her hand on a sharp edge of a work surface, her lack of
attentiveness may be explained as the cause of the accident. ALL responsibility for the accident is placed
squarely on the shoulders of the employees. An accident investigator who has adopted this explanation for
accidents will not produce quality investigation reports that result in long-term corrective actions.

● The Domino Theory - This explanation describes an accident as a series of related occurrences which lead
to a final event that results in injury or illness. Like dominoes, stacked in a row, the first domino falling sets
off a chain reaction of related events that result in an injury or illness. The accident investigator will
assume that by eliminating any one of those actions or events, the chain will be broken and future
accidents prevented. In the example above, the investigator may recommend removing the sharp edge of
the work surface (an engineering control) to prevent any future injuries. This explanation still ignores
important underlying system weaknesses or root causes for accidents.

● Multiple Cause Theory - This explanation takes us beyond the rather simplistic assumptions of the single
event and domino theories. Once again, accidents are not assumed to be simple events. They are the result
 of a series of random related or unrelated acts/events that somehow interact to cause the accident. Unlike
the domino theory, the investigator will realize that eliminating one of the events does not assure
prevention of future accidents. Removing the sharp edge of a work surface does not guarantee a similar
injury will be prevented at the same or other workstation. Many other factors may have contributed to an
injury. An accident investigation will not only recommend corrective actions to remove the sharp surface, it
will also address the underlying system weaknesses that caused it.

Sorting it all out...

We've collected a lot of factual data and it's strewn over the top of your desk. The task now is to turn that data
into useful information. We've got to somehow take this data and make some sense of it. It's important to know
that we are not just trying to take random facts to identify, or determine the presence of the conditions and
behaviors that caused the accident. More importantly, we're conducting a structured "analysis" to determine the
unique events that occurred prior to and including the injury event, and what kind of impact each event had on
the accident. Analysis defined

Webster defines analysis as the, "separation of an intellectual or substantial whole into its parts for individual
study."

When there is a workplace accident we need to separate or "break down" the accident process (the whole) into its
component parts (events) for study to determine how they relate to the whole. Since the accident, itself, is the
main event, its component "parts" may be thought of as the individual events leading up to and including the
main event or the accident. The accident investigator's challenge is to effectively assess and analyze each event
to determine if and how it contributed to the accident. To do this we need to make assumptions about what
causes accidents...why they happen.

Developing the sequence of events

Our challenge at this point in the investigation process is to accurately determine the sequence of events in
the accident process so that we can more effectively analyze the accident process. Once the steps in the
process are developed, we can then study each event to determine related:

● Hazardous conditions. Things and states that directly caused the accident.
● Unsafe behaviors. Actions taken/not taken that contributed to the accident.
● System weaknesses. Underlying inadequate or missing programs, plans, policies, processes, and
procedures that contributed to the accident.

We'll study these in the next module.

The final event in an unplanned process

When we understand that the accident is actually the final event in an unplanned process, we'll naturally want to
know what the initial event was. When the initial event occurs, it effects the actions of others, setting in motion a
potentially very complicated process eventually ending in an injury or illness. The trick is to take the information
gathered and arrange so that we can accurately determine what initial condition and/or action transformed the
planned work process into an unplanned accident process.

Remember, that in the multiple-cause approach to accident investigation, many events may occur, each
contributing to the final event. For instance, if a supervisor ignores an unsafe behavior because doing so is not
thought to be his or her responsibility, the failure to enforce behavior represents an event in the production
process that may contribute to or increase the probability of an accident.

Each event in the unplanned accident process describes a unique:

● Actor. An individual or object that directly influenced the flow of the sequence of events. An actor may
participate in the process or merely observe the process. An actor initiates a change by performing or
failing to perform an action.
● Action. Something that is done by an actor. Actions may or may not be observable. An action may
describe something that is done or not done. Failure to act should be thought of as an act in itself.
It's important to understand that when describing events, first indicate the actor, then tell what the actor does.
Remember, the actor is the "doer," not the person or object being acted upon or otherwise having something
done to them. For instance, take a look at the statement below:

"Bob unhooked the lifeline from the harness."

In this example, "Bob" is the actor and "unhooking" is the action. First we describe the actor...Bob. Then we
describe the action...unhooking. The lifeline and harness, although "objects" are not actors because they are not
performing an action. Rather, something is being done to them. Also note that the statement is written in active
tense.

Paint a word picture

It's important that the sequence of events clearly describe what occurred so that someone unfamiliar with an
accident is able to "see it happen" as they read. If an event is hard to understand, it may be that the description
is too vague or general. The solution to this problem is to increase the detail by:

1. Determine if anything else was said/done before or after the event you are currently assessing.
2. Separate actors. Remember, an actor may be a person or a thing accomplishing a given action. If an event
includes actions by more than one actor, break the event down into two events.

To get a good idea what the sequence of events looks like, review the example below that was prepared for an
actual fatality investigation conducted by Oregon OR-OSHA a few years ago.

Sequence of Events 1. Employee #1 returned to work at 12:30 PM after lunch to continue laying
irrigation pipes. 2. At approximately 12:45 PM employee #1 began dumping accumulated sand from
an irrigation mainline pipe. 3. Employee #1 oriented the pipe vertically and it contacted a high
voltage power line directly over the work area. 4. Employee #2 heard a ‘zap’ and turned to see the
mainline pipe falling and employee #1 falling into an irrigation ditch. 5. Employee #2 ran to
employee #1 and pulled him from the irrigation ditch, laid him on his back and ran about 600 ft to
his truck and placed a call for help on his mobile phone. 6. Employee #2 than ran back to find
employee #1 had fallen back into the ditch. 7. Employee #2 jumped back into the ditch and held
employee #1 out of the water until help arrived. 8. Two other ranch employees arrived and assisted
employee #2 in getting employee #1 out of the ditch. 9. Approximately one minute later, paramedics
arrived and began to administer CPR on employee #1. They also used a heart defibrillation machine
in an attempt to stabilize employee #1’s heart beat. 10. At approximately 1:10 PM an ambulance
arrived and transported employee #1 to the hospital where he was pronounced dead at 1:30 PM.

This example is rather brief and there may be other related events that indirectly contributed to the accident.
However, it does give you sufficient descriptive detail to paint a mental picture of the actors and acts that
occurred immediately prior to and including the accident.

Last Words

Now that we have the sequence of events, we can begin the "analysis" by examining each event for potential
causes of the accident. We'll be covering causation, control strategies and system improvements in future
modules. But right now, it's time to take the quiz, so let's go.

Let's Review

16. (Fill in the blanks) _______________ determines presence/absence. ____________ breaks down
the whole into parts to see how they each relate to the whole.

a. Evaluation, Analysis
b. Analysis, Assessment
c. Identification, Analysis
 d. Analysis, Evaluation

17. You observe a coworker using a fixed circular saw that is missing a guard. Describe the hazardous
condition and related unsafe behavior.

18. Which theory below states, "An accident is the result of a series related events: Eliminate any one
event, and you prevent a future accident"?

a. Single event theory

b. Domino theory
c. Multiple cause theory
d. System weakness theory

19. (Fill in the blanks) In the event statement, "Robert uses a wrench to pound a nail," ________ is the
actor and ________ is the action.

a. Wrench, pound a nail

b. Nail, used a wrench
c. Robert, pound a nail
d. Robert, used a wrench

20. How does the investigator increase the detail of the an event that is vague or too general?

MODULE 5: DETERMINING SURFACE AND ROOT CAUSES

Introduction

Did you know that most accidents in the workplace result from unsafe work behaviors? According to the latest
research, they represent the direct cause for about 95% of all workplace accidents. Hazardous conditions
represent the direct cause for only about 3% of workplace accidents. "Acts of God" account for the remaining 2%.
All these statistics imply that management system weaknesses account for fully 98% of all workplace accidents.
To effectively fulfill our responsibilities as an accident investigator, we must not close the investigation until these
root causes have been identified.

It's a common struggle trying to overcome long-held perceptions about safety and how accidents occur.
Management perceptions and subsequent actions reflect both traditional and progressive approaches. Let's take a
look at old and new thinking.

Old Theory - Worker Error

Old thinking about the causes of accidents assumes that the worker makes a choice to work in an unsafe manner.
It implies that there are no outside forces acting upon the worker influencing his actions and that there are
simple reasons for the accident. Old thinking also considers accidents as solely resulting from worker error: A lack
of "common sense." The employee is the locus of "the problem." To prevent accidents, the employee must work
more safely. This thinking results in blaming and short-term fixes: Inefficient, ineffective, and in the long run
more expensive to implement and maintain.

New Theory - Systems Approach

The systems approach takes into account the dynamics of systems that interact within the overall safety
program. It concludes that accidents are considered defects in the system. People are only one part of a complex
system composed of many complicated processes (more than we realize). Accidents are the result of multiple
causes or defects in the system. It becomes the investigator's job to uncover the root causes (defects) in the
system. Fixing the system, not the employee, is the heart of the investigation. To prevent accidents, the system
must work more safely. This thinking results in long-term fixes: Less expensive to implement and maintain.
Time to analyze for cause

We've gathered information and used it to develop an accurate sequence of events. We've got a good mental
picture of what happened. Now it's time to conduct an analysis of each event to determine causes. This module
will introduce us to the following concepts:

● Injury analysis
● Event analysis
● Systems analysis
● Direct cause of injury
● Surface cause of the accident
● Root cause of the accident

Three levels of cause analysis

As mentioned earlier in the course, accidents are processes that culminate in an injury or illness. An accident may
be the result of many factors (simultaneous, interconnected, crosslinked events) that have interacted in some
dynamic way. In an effective accident investigation, the investigator will conduct three levels of cause analysis:

Injury analysis. At this level of analysis, we do not attempt to determine what caused the accident,
but rather we focus on trying to determine how harmful energy transfer caused the injury.
Remember, the outcome of the accident process is an injury.

Event Analysis. Here we determine the surface cause(s) for the accident: Those hazardous
conditions and unsafe behaviors described throughout all events that dynamically interact to produce
the injury. All hazardous conditions and unsafe behaviors are clues pointing to possible system
weaknesses. This level of investigation is also called "special cause" analysis because the analyst can
point to a specific thing or behavior.

Systems analysis. At this level we're analyzing the root causes contributing to the accident. We can
usually trace surface causes to inadequate safety policies, programs, plans, processes, or procedures.
Root causes always pre-exist surface causes and may function through poor component design to
allow, promote, encourage, or even require systems that result in hazardous conditions and unsafe
behaviors. This level of investigation is also called "common cause" analysis because we point to a
system component that may contribute to common conditions and behaviors throughout the
company.

The direct cause of injury

Whenever an injury occurs, a harmful level of energy is somehow transferred to our body. We should describe
the nature of that energy transfer and refer to it as the direct cause of the injury. Here are the various forms of
energy that can be harmful:

1. ACOUSTIC ENERGY - Excessive noise and vibration.

2. CHEMICAL ENERGY - Corrosive, toxic, flammable, or reactive substances. Involves a release of

energy ranging from "not violent" to "explosive" and "capable of detonation".

3. ELECTRICAL ENERGY - Low voltage (below 440 volts) and high voltage (above 440 volts).

4. KINETIC (IMPACT) ENERGY - Energy from "things in motion" and "impact," and are associated with
the collision of objects in relative motion to each other. Includes impact between moving objects,
moving object against a stationary object, falling objects, flying objects, and flying particles. Also
involves movement resulting from hazards of high pressure pneumatic, hydraulic systems.

5. MECHANICAL ENERGY - Cut, crush, bend, shear, pinch, wrap, pull, and puncture. Such hazards are
associated with components that move in circular, transverse (single direction), or reciprocating
motion.

6. POTENTIAL (STORED) ENERGY - Involves "stored energy." Includes objects that are under
pressure, tension, or compression; or objects that attract or repulse one another. Susceptible to
 sudden unexpected movement. Includes gravity - potential falling objects, potential falls of persons.
Includes forces transferred biomechanically to the human body during lifting.

7. RADIANT ENERGY HAZARDS - Relatively short wavelength energy forms within the
electromagnetic spectrum. Includes infra-red, visible, microwave, ultra-violet, x-ray, and ionizing
radiation.

8. THERMAL ENERGY - Excessive heat, extreme cold, sources of flame ignition, flame propagation,
and heat related explosions.

Let's take a look at some examples describing the direct cause of injury:

● If a harsh acid splashes on our face, we may suffer a chemical burn because our skin has been exposed to
a chemical form of energy that destroys tissue. In this instance, the direct cause of the injury is harmful
a chemical reaction. The related surface cause might be the acid (condition) or working without proper face
protection (unsafe behavior).

● If our workload is too strenuous, force requirements on our body may cause a muscle strain. Here, the
direct cause of injury is a harmful level of kinetic energy (energy resulting from motion), causing injury
muscle tissue. A related surface cause of the accident might be fatigue (hazardous condition) or improper
lifting techniques (unsafe behavior).

The important point to remember here is that the "direct cause of injury" is not the same as the surface cause of
the accident. To summarize:

● The direct cause of injury is the harmful transfer of energy. The direct result is injury.

● The surface cause of the accident describes a condition or behavior. The result of the condition and/or
behavior is the direct cause of injury...a harmful transfer of energy.

The surface causes of accidents

The surfaces causes of accidents are those specific hazardous conditions and
unsafe employee/manager behaviors that have directly caused or contributed in
some way to the accident.

Hazardous conditions:

● are basically things or objects that cause injury or illness

● may also be thought to be defects in a process
● may exist at any level of the organization

Hazardous conditions may exist in any of the following categories:

● Materials ● Environment
● Machinery ● Workstations
● Equipment ● Facilities
● Tools ● People
● Chemicals ● Workload
 It's important to know that most hazardous conditions in the workplace are the result
of specific unsafe behaviors that produced them.

Unsafe behaviors:

● are actions we take or don't take that increase risk of injury or illness.
● may also be thought to be errors in a process
● may occur at any level of the organization.

Some example of unsafe employee/manager behaviors include:

● Failing to comply with rules ● Allowing unsafe behaviors

● Using unsafe methods ● Failing to train
● Taking shortcuts ● Failing to supervise
● Horseplay ● Failing to correct
● Failing to report injuries ● Scheduling too much work
● Failing to report hazards ● Ignoring worker stress

Event Analysis

In the last module we learned that each event in our sequence will include descriptions of actors and their
actions that may have contributed to the accident.

Our next step is to examine each event to determine the hazardous conditions and unsafe or
inappropriate behaviors representing the surface causes for the incident or accident:

1. the actor represents a hazardous condition, and

2. action that represents an unsafe or inappropriate behavior.

What techniques can we use to help us do the event analysis? Let's take a look at one technique that I have
found efficient in conducting an event analysis.

I've modified the commonly used "fishbone diagram," used successfully by many as a general problem solving
tool, to help conduct an event analysis.

1. Get a sheet of paper.

2. At the top of the sheet write "Accident Analysis". Doing this reminds you that you're breaking down the
process into a number of events.
3. At the left side of the sheet, centered, write "The Injury".
4. Extend a horizontal line out from the right of the box.
5. Describe the injury event on the horizontal line.
6. Identify and circle the actors and actions described in the event statement.
7. Start asking why questions about the actor and actions to uncover any hazardous conditions or unsafe
behaviors.
8. Draw lines either angling up or down from the circled actors and actions and write the answers to your
questions.
9. Repeat these steps with each of the new level of answers.
The diagram you produce using this procedure should look something like this. Each level of questioning will get
you closer to the root cause(s) that allowed the hazardous condition or unsafe behavior.

System Analysis to determine the root causes of accidents

Once you start identifying inadequate policies, programs, plans, processes, and
procedures in the diagram above...you're getting to the real root causes! The
root causes for accidents are the underlying safety system weaknesses that
have somehow contributed to the existence of hazardous conditions and unsafe
behaviors that represent surfaces causes of accidents. These weaknesses can
take two forms:

● Design root causes. Inadequate planning and design of the system. The
development of formal (written) safety management system policies, plans,
processes, procedures is very important to make sure appropriate
conditions, activities, behaviors, and practices occur.
● Implementation root causes. Inadequate implementation of the system.
Failure to effectively carry out the safety management system is critical to
the success of the system. You can develop a wonderfully designed system,
yet if it's not implemented correctly, it won't work.

It's important to understand that root causes always pre-exist surface causes. Indeed, inadequately designed and
implemented system components have the potential to feed and nurture hazardous conditions and unsafe
behaviors. If root causes are left unchecked, surface causes will flourish!

Examples of safety management system functions

Safety systems: System components:

Systems are developed to: ● Policies

● Programs
● Promote Commitment/leadership ● Plans
● Increase employee involvement ● Processes
● Establish accountability ● Procedures
● Identify and control hazards ● Budgets
● Investigate incidents/accidents ● Reports
● Educate and train ● Rules
● Evaluate the safety program
 The biggest challenge to effective accident investigation is to transition from event analysis
to systems analysis.

The role of safety engineers and safety coordinators

Safety "engineers" closely analyze all the surface cause categories and attempt to:

● eliminate the harmful energy,

● reduce the harmful energy transfer, or
● reduce exposure to harmful energy transfer.

They do this by designing safety features directly into tools, machinery, equipment, facilities, etc. Safety
coordinators work with safety engineers to eliminate or reduce exposure to hazards through effectively
improving safety system components. Because systems design work common throughout the workplace,
eliminating any single root cause may simultaneously eliminate many hazardous conditions and unsafe behaviors.

Since root causes reside within safety management systems, upper management -- those who formulate
systems, are most likely going to be involved in making the necessary improvements. When analyzing for system
weaknesses, it may be beneficial to coordinate closely with those who will be responsible for implementing
system improvements.

Last Words

One last important point to make is that most accident processes are far more complex than we might originally
think. Some experts believe at least 10 or more factors come together to cause a serious injury. Other experts
state that, on average, 27 factors directly and indirectly contribute to serious accidents.

Only by thoroughly conducting all three levels of analysis can we design system improvements that effectively
eliminate hazardous conditions and unsafe behaviors at all levels of the organization. The accident investigation
can not serve as a proactive safety process unless system improvements effectively prevent future accidents.

Let's Review

21. All of the following are examples of surface causes except:

a. Tools
b. Procedures
c. Machinery
d. People

22. All of the following are examples of root causes except:

a. Policies
b. Conditions
c. Plans
d. Processes

23. (Fill in the blank) Surface causes describe hazardous _________ and unsafe ____________. Root
causes describe inadequate ___________.
a. Systems, behaviors, conditions
b. Behaviors, activities, policies
c. Conditions, behaviors, systems
d. Conditions, systems, accountability

24. If similar accidents occur repeatedly, what weaknesses in the analysis

process is most likely the cause?

a. It focuses on placing blame

b. It focuses only on root causes
c. It determines only surface causes
d. It focuses on both surface and root causes

25. If discipline occurs immediately after an accident occurs, what basic process
flaw exists?

a. Blame is based on fact, not feeling

b. The process places blame before considering safety program weaknesses
c. The process determines system flaws before considering personal liability
d. The process neglects to place initial blame.

Module 6: DEVELOPING RECOMMENDATIONS

Introduction

An accident investigation is generally thought to be a reactive safety process because it

is initiated only after an accident has occurred. However, if we propose recommendations
that include effective control strategies and system improvements, we transform the
investigation into a valuable proactive process that ensures similar accidents do not
recur. In this module we'll explore tips and tactics for making effective recommendations
that "sell" safety improvements.

Do it right!

Some employers may assign the responsibility for making recommendations to safety
directors or maintenance supervisors. However, you, as the accident investigator, may
be required to take on this very important responsibility. Consequently, it's a good idea
to know where to start, and how to write strong proposals. One tip up front: If you find
the responsibility is yours, be sure to get the help of experts if you're unsure how to
proceed. Consultants in OR-OSHA or your workers' compensation insurer can be a great
source for help.

What is an effective recommendation

To make sure recommendations are effective, we need to address effective control

strategies that will eliminate or reduce the specific surface causes of the accident. We
must also propose system improvements to missing or inadequate safety system
components that contributed to the accident. Let's continue this discussion by taking a
look at control strategies.

The Hierarchy of Controls

Hazard control strategies may be quite effective in eliminating hazards or reducing

exposure. Effective corrective actions will include one or more of the following hazard
control strategies:
 1. Engineering controls. Sometimes the cause of an accident
is corrected most effectively by removing or reducing the
hazard, itself. This may be done in a number of ways, including:

● Redesign the hazard out. Example - Fabricate a mesh

guard to protect against exposure to moving parts.
● Replace the unsafe item with a safe item. Example -
Replace a poor quality grinder stone with a high quality
grinder stone.
● Enclose the hazard. Example - Place a hood over a source
of noisy printer.
● Substitute an unsafe item with different item. Example -
Substitute a toxic chemical with a non-toxic chemical.

Engineering out the hazard is our top priority

Why is this control strategy our top priority? Engineering controls remove the hazard
itself. We're somehow changing a thing/condition in the workplace. It has the potential to
completely remove a hazard, and as we all know...we can't be exposed to a hazard if it
does not exist. No hazard...no exposure...no accident.

It's important to note that the intent of OR-OSHA law is that the employer attempts to
engineer the hazard out if feasible. For instance, if a machine is producing a noise level
of 120 decibels, OR-OSHA expects the employer to first attempt to reduce the noise level
to acceptable levels using an engineering control such as enclosure.
2. Management controls. Safety managers employ these
control strategies to eliminate or reduce the frequency and
duration of exposure to hazards. This is accomplished
through:

● Manage work practices. Effective design and

implementation of safe work procedures and practices.
● Manage work schedules. These strategies include job
rotation, breaks, shift work, etc.

As you might have guessed, these control strategies are less

effective in the long term than engineering controls because
they do not remove the hazards, themselves. Rather, they
attempt to reduce exposure to hazards by controlling human
behavior - attempting to change "things we do or don't do."
As long as employees "behave" or comply with the changed
procedures or schedules, management controls work.
However, it's "normal" for us to want to work in the most
efficient manner. Sometimes safe work procedures are not
perceived as most efficient...so we may not use them.
Managers must diligently oversee and maintain management
control strategies or those controls may become ineffective.

"Any system that depends on

human reliability is inherently
unreliable."

A. Block, Murphy's Law - Book

Two
 3. Personal protective equipment (PPE). Some jobs
require PPE by law. This control strategy is used in
conjunction with the other control strategies. It should not be
used to replace them. When engineering and/or
administrative controls don't adequately eliminate or reduce
the hazard(s)of a task, PPE may be needed in addition to
those strategies. PPE places a barrier between workers and
the hazard. Remember, PPE does not eliminate or reduce the
hazard itself, it merely sets up a barrier between you and the
hazard. And, to be successful, it is highly dependent on safe
behaviors.

The Hierarchy of Controls, when used separately or in combination, may be quite

effective in eliminating or greatly reducing the probability of a similar accident recurring.
However, to make sure long term risk reduction is achieved throughout the entire
company, system improvements must be made.

Recommend system improvements

Missing or inadequate safety system components represent root causes for workplace
accidents. Surface causes represent symptoms indicating system weaknesses.
Therefore, every effort should be made to improve system components to ensure long
term workplace safety. As we learned in the last module, the most successful accident
investigator is actually a systems analyst: Not an easy task.

Making system improvements might include some of the following:

● Including "safety" in a mission statement.

● Improving safety policy so that it clearly establishes responsibility and
accountability.
● Changing a work process so that checklists are used that include safety checks.
● Revising purchasing policy to include safety considerations as well as cost.
● Changing the safety inspection process to include all supervisors and employees.

A little about behavior-based safety (BBS)

All of the proposals above represent "antecedents" or "activators" to behavior that serve
to initiate appropriate behaviors. These changes in expectations must be clearly
communicated to everyone through effective education and training to ensure behavioral
changes are understood. Behavior-based safety, a type of formal observation process, is
successful when the data gathering process is clearly understood by observer and
observed, and the data collected is analyzed only to fix the system, not blame. Behavior-
based safety is not usually successful if the process is, in any way, tied to discipline. The
only consequences that work in BBS are positive consequences for making observations
and being observed demonstrating safety leadership.

It's important to understand that once improvements have been designed and
implemented, they then should be tied to accountability. Only effective consequences will
ensure the changed behaviors are sustained long term. Remember, antecedents are
likely to fail without effective consequences. We do what we do because of
consequences...not antecedents. In other words...we do what we do, not because we're
told to do it...but because we're going to (1) get something good, or (2) avoid something
bad.

Bottom-line, behavior-based safety is another useful analysis tool that can be quite
successful, when carefully designed, in helping the employer improve the safety
management system.

Garbage In -- Garbage Out (GIGO)

When managers do not respond to a recommendation, it may be that they do not have
enough useful information to make a sound judgment or take action. The GIGO principle
-- "If you put garbage in, you'll get garbage out" -- that is commonly applied to
data entry and computer programming, applies equally well to the process of making
effective recommendations: Useful information must be presented to management so
they are able to make correct decisions.

Proactive recommendations

To speed up the process and to improve the approval rate, we must learn to anticipate
the concerns and questions that supervisors have when deciding what actions to take.
The more pertinent the information included in the recommendation, the greater the
likelihood for approval. To make sure you do provide good information, ask some
important proactive questions.

Answer Six Key Questions

Answer the following six questions to help develop and justify

recommendations.

1. Pinpoint the problem - What exactly is the problem?

What are the specific hazardous conditions and unsafe work practices that caused the
problem? What are system components - the inadequate or missing policies, processes,
rules that allowed the conditions and practices to exist?

2. What is the history of the problem

Have similar accidents occurred previously? If so, probability for similar accidents is
highly likely to certain. What are previous direct and indirect costs for similar accidents?
How have similar accidents affected production and morale?

3. Pinpoint the specific solution - What are the solutions that would correct the
problem?

What are the specific engineering, administrative and PPE controls that, when applied,
will eliminate or at least reduce exposure to the hazardous conditions? What are the
specific system improvements needed to ensure a long term fix?

4. Who is the decision maker?

Who is the person that can approve, authorize, and act on the corrective measures?
What are the possible objections that he/she might have? What are the arguments that
will be most effective in overcoming objections?

5. Why is that person doing safety?

It's important to know what is motivating the decision-maker. Is the manager doing
safety to:

● Fulfill the legal obligation? You may need to emphasize possible penalties if
corrections are not made.

● Fulfill the fiscal obligation? You may want to emphasize the costs/benefits.

● Fulfill the moral obligation? You may want to emphasize improved morale,
public relations.

6. What will be the cost/benefits if the recommendation is approved and the

 predictable cost/benefits if not?

What are the estimated costs and benefits of taking corrective action, as contrasted with
the possible costs and harm that might occur if the hazardous conditions and unsafe
work practices remain? What are the employer obligations under administrative law?
What is the "message" sent to the workforce as a result of action or inaction?

The maintenance supervisor may be able to help you determine these estimates. Also,
detail the costs associated with any training that might be required.

A simple cost-benefit analysis

A simple cost-benefit analysis assumes that there is a reasonable expectation that a disabling injury
is likely in the foreseeable future (five years) when employees are exposed (place themselves within
a danger zone) to a workplace hazard. The object is to contrast the relatively high cost/low benefit
if the hazard is not eliminated, with the low cost/high benefit if the hazard is eliminated.

The analysis answers the following questions:

● What are the potential costs to the company if the hazard is not eliminated?

● What are the potential costs to the company if the hazard is eliminated?

● How soon will the corrective action pay for itself?

● What is our return on investment (ROI) if corrective actions are taken?

Example: If, during a safety inspection, you notice that an elevated platform area in a warehouse
does not have a proper guardrail. You note that several workers work on the platform each day, and
a well-used walkway passes directly under the platform. To construct a cost-benefit analysis for this
situation you would answer the above questions as follows:

Average direct dollar costs for different types of accidents

To be effective, recommendations should be supported by a bottom-line cost/benefit analysis that

contrasts the relative high costs of accidents against the much lower costs associated with corrective
actions. Doing a cost benefit analysis is even more important when recommending corrective actions
before an accident occurs.

According to the National Safety Council, which considers all industries nationally, the estimated
2000 average direct and indirect costs of a lost time injury is about $28,000, and a fatality averages
$980,000. In Oregon, the direct costs to close a serious injury claim is around $10,500 and $300,000
to close a fatality claim.

Indirect costs, according to the NSC figures above average 1.6x direct costs. However, it's important
to understand that indirect costs may amount to much more than this multiple with any single claim.
Indirect costs can be as much as 2x to 50x direct costs...or more. Two things to remember in when
estimating indirect costs:

● The lower the direct cost, the higher the ratio between the direct and indirect costs.
For instance, if someone suffers only minor injury requiring a few hundred dollars to close the
claim, the indirect/direct costs ratio may be much higher than the NSC average.

● Capital intensive operations, where large sums have been invested in facilities, realize
higher and average indirect/direct cost ratios. For example, if someone is seriously or fatally
injured on a oil-drilling rig, resulting in operations shutting down for a day or so, many
thousands of dollars in lost production will result. In high capital intensive work processes, the
expected ratio between direct and indirect costs may be 5x to 50x.

● Labor intensive operations, where more investment is made in labor than capital assets,
realize lower indirect/direct cost ratios. Someone may suffer a serious injury, but operations
 are not as likely to be significantly impacted. In labor intensive operations the expected ratio
between direct and indirect costs may be 2x to 10x.

You can use these figures to demonstrate the benefits of taking corrective action.

What are the estimated costs to the company if the hazard is eliminated?

Costs: $1,500 needed to purchase and repair guardrail.

How soon will the corrective action pay for itself?

If a disabling injury occurs within the next 5 years, using National Safety Council figures we can
estimate a direct/indirect cost to the company of approximately $28,000. Given the cost to purchase
and repair the guard rail of $1,500. The corrective action will pay for itself in just 3.3 months ($1,500/
($28,000/60 months)).

What is our return on investment (ROI) if corrective actions are taken? The ROI over the five
year period will be $25,500 or 1,800 percent!

Last Words

Finally, it's important to provide alternatives to make it more likely that corrective actions will be
taken. Your options might follow the logic below:

● First option -- If we had all the money we needed, what could we do? Eliminate the hazard
with primarily engineering controls. Additional administrative controls if required.

● Second option -- If we have limited funds, what would we do. Eliminate the hazard with using
work practice and/or administrative controls. Engineering controls if required.

● Third option -- If we don't have any money, what can we do? Reduce exposure to the hazard
with work practice/administrative controls and/or PPE.

It's important to remember that your employer should first try to engineer out the hazard if feasible
before using administrative controls or PPE. Of course, some tasks require the use of PPE in
accordance with Material Safety Data Sheet (MSDS) requirements.

Let's Review

26. (Fill in the blank) When making recommendations, we need to propose corrective actions
____ system improvements.

a. instead of
b. or
c. rather than
d. and

27. Engineering controls include all of the following except:

a. Substitution
b. Enclosure
c. Rescheduling
d. Redesign
28. Which control strategy is most effective in eliminating hazards?

a. Engineering Controls
b. Management Controls
c. PPE Control
d. Personnel Controls

29. All of the following are safety management system improvements except:

a. Writing a new safety policy.

b. Establishing a proactive incentive program.
c. Placing a guard on a table saw.
d. Revising an accident investigation form.

30. How does the "GIGO" principle apply to safety system improvements?

MODULE 7: WRITING THE REPORT

Introduction

Now that you have accurately assessed and analyzed the facts related to the accident, you must
report your findings to those who have authority, accountability, and can take action (We call this the
"A Person"). In this module, we'll cover the procedure for effectively reporting the facts. Perception
is reality...

Never forget that your primary objective, as an accident investigator, is to uncover the causal factors
that contributed to the accident. It's not your job to place blame. Your challenge is to be as objective
and accurate as possible.

Your findings, and how you present them, will shape perceptions and subsequent corrective actions.
If your report arrives at conclusions such as..."Bob should have used common sense," or "Bobbie
forgot to use PPE," how effective will it be? Of course, it won't be affective at all. If your report
concludes with statements such as this, it will be virtually impossible to take corrective actions that
permanently eliminate the causes. It's likely that similar accidents will repeatedly occur. Bottom line:
If the accident investigation doesn't fix the system, it's most likely been a waste of time and effort.

So the challenge is to report your findings in a well-thought-out

manner so that management will more likely adopt
recommendations for improving its safety processes, thus solving
problems long-term.

The Accident Report Form

The primary reason accident investigations fail to help eliminate similar accidents, is that report
forms are poorly designed. In many cases the form design actually makes it possible to identify and
correct only surface causes: root causes are often ignored. Let's take a look at one format that is
designed to give emphasis to root causes. You can also take a look at sample below. This is a report
format similar to that used by OR-OSHA accident investigators in conducting workplace accident
investigations:

Section I. Background

This section contains background information that answers questions about who the victim is, and
the time, date, location of the accident, as well as other necessary details. Most forms do quite well
detailing background information.

Section II. Description of the accident

This section presents a descriptive narrative of the events leading up to, including and immediately
after the accident. It's important that the narrative paint a vivid "word picture" so that someone
unfamiliar with the accident can clearly see what happened. The format you choose is important. You
may want to eliminate or keep event numbers. See the example below.

Section II: Description of the Accident Event -3. Employee #1 returned to work at
12:30 PM after lunch to continue laying irrigation pipes. Event -2. At approximately
12:45 PM employee #1 began dumping accumulated sand from an irrigation mainline
pipe. Event -1. Employee #1 oriented the pipe vertically and it contacted a high voltage
power line directly over the work area. Event 0. Employee #2 heard a ‘zap’ and turned
to see the mainline pipe falling and employee #1 falling into an irrigation ditch.
Event +1. Employee #2 ran to employee #1 and pulled him from the irrigation ditch,
laid him on his back and ran about 600 ft to his truck and placed a call for help on his
mobile phone.
Event +2. Employee #2 than ran back to find employee #1 had fallen back into the
ditch.
Event +3. Employee #2 jumped back into the ditch and held employee #1 out of the
water until help arrived. Event +4. Two other ranch employees arrived and assisted
employee #2 in getting employee #1 out of the ditch. Event +5. Approximately one
minute later, paramedics arrived and began to administer CPR on employee #1. They
also used a heart defibrillation machine in an attempt to stabilize employee #1’s heart
beat. Event +6. At approximately 1:10 PM an ambulance arrived and transported
employee #1 to the hospital where he was pronounced dead at 1:30 PM.

Section III. Findings

The findings section describes the hazardous conditions, unsafe behaviors and system weaknesses
your investigation has uncovered. Each description of surface and root cause will also include
justification for the finding. The justification will explain how you came to your conclusion.

Some report forms used today "force" the investigator to list only surface causes for accidents.
Consequently, the investigator believes the job is done without ferreting out the root causes. Other
forms offer very little space to write findings. The form does not "report" the root causes uncovered
associated with each surface cause. It is not the object of this section to find fault or place blame.
Just state the facts: The hazardous conditions, unsafe procedures, inadequate or missing policies,
training, accountability, etc. Be sure to write complete descriptive sentences. Not short cryptic
phrases.

Sample primary surface cause finding statements

The findings describe the hazardous conditions and unsafe behaviors that directly caused injury. They
exist or occur immediately prior to the injury event.

● Hazardous condition: The bolts for the machine guard on the chipper were missing and the
grating cut open.

● Unsafe behaviors: The injured employee fed limbs into the unguarded chipper, exposing
himself to the hazardous condition.

Sample secondary surface cause finding statements

These findings describe those conditions and behaviors produced by individuals at some point prior to
the injury event. These conditions, activities, practices and behaviors can exist at any time, in any
place, and be produced by any person in the organization.

● Hazardous condition: Tools to repair the machine guard were broken and unusable.

● Unsafe behaviors: An employee (could not be determined who) failed to replace bolts on the
guard. An employee defeated the guard by cutting through the guard grating producing a large
hole. The injured employee had not been trained in chipper operation or machine guarding
principles.

Sample safety program implementation root cause finding statements

These findings describe management failures to implement programs, processes, plans, procedures
within the safety management system. These failures result in secondary surface causes; those
conditions and behaviors common to work groups or the entire organization.

● Inadequate process: Employees are not being properly rained in safe work procedures
around high voltage lines. None of the employees exposed to high voltage have been trained.
Supervisors are unfamiliar with rules and have not received training in this subject.

● Inappropriate behaviors: Supervisors are generally allowing unsafe work practices

associated with high voltage lines.

Sample safety program design root cause finding statements

These findings describe one or more inadequate safety management system policies, programs, and
processes in any of the seven element areas: commitment, accountability, involvement, identification/
control, incident/accident analysis, education/training, and evaluation. These "deep root causes"
result in inadequate implementation of the safety management system.

● Conditions: Safety training policy statement does not exist. Safety training plan does not
include policies and practices for employees working around high voltage line systems. The
safety training plan does not include supervisor or manager level training on this subject.

Section IV. Recommendations

If root causes are not addressed properly in Section III of the report, it is doubtful recommendations
in this section will include improving system inadequacies. Effective recommendations will describe
ways to eliminate or reduce both surface and root causes. They will also detail estimated investments
involved with implementing corrective actions and system improvements. Let's take a closer look at
effective recommendation writing.

Sample recommendations that correct primary surface causes

These recommendations describe how to correct those unique hazardous condition(s) and unsafe
behaviors that directly resulted in injury. These recommendations will impact only the unique
condition or behavior.

● To correct a condition. Repair and/or replace the machine guard. Benefit: This hazardous
condition is eliminated. Estimated investment: $200.00

● To correct a behavior. Educate and train the injured employee on hazard reporting procedures.
Benefit: The injured employee will understand and gain the skills necessary to prevent a similar
accident. Estimated investment: $30.00

Sample recommendations that correct secondary surface causes

These recommendations describe how to correct those common hazardous conditions and unsafe or
inappropriate behaviors that eventually "set up" or produced the unique conditions and behaviors of
the injury event. Correcting secondary surface causes is accomplished by improving the
implementation of the safety management system. These recommendations will have a general
positive impact throughout the work group or organization.

● Implement an effective education and training process covering machine guarding principles for
all maintenance and affected employees Benefit: Affected employees will understand and be
skilled in identifying and correcting machine guard hazards. Estimated investment: $500.00

● Implement improved employee orientation that includes education and training on hazard
reporting procedures. Benefit: New employees will understand and gain skills in appropriate
hazard reporting procedures. Estimated investment: $100

● Conduct supervisor/manager training on new policies. Management will better understand and
gain skills in their responsibilities in response to hazard reports. Estimated investment: $200.

Sample recommendations that correct implementation and design root causes

Solving implementation weaknesses is accomplished by improving system design. These

recommendations address improvements to written safety management system and specific program
policies and plans that correct inadequate implementation of processes and procedures.
Recommendations may include improvements in more than one of the seven safety management
system element areas discussed earlier. In most instances, safety committees and/or safety
coordinators will be involved in this process. Draft policies, plans, procedures are developed and
forwarded to upper management for approval.

● Review and improve the safety training plan to ensure it includes machine guarding, lockout/
tagout, and hazard reporting procedures. Benefit: Ensures the safety training plan addresses
affected employee responsibilities regarding machine guarding, and other related safety
programs. Estimated investment: $1500.00

● Develop company safety policy and safe work plan addressing work near high voltage lines.
Benefit: Ensures safe work policies and procedures regarding work around high voltage lines
are detailed and properly implemented. Estimated investment: $1,000

● Include supervisor/manager education and training in accountability principles and application.

Benefit: Ensures management is effectively educated and trained in their accountabilities to the
employer and employees, and how to administer corrective actions. Estimated investment:
$500

● Include supervisor/manager education and training in recognition principles and application.

Benefit: Ensures management is effectively educated and trained in methods to motivate
hazard reporting and discretionary behaviors such as suggesting and involvement. Estimated
investment: $500.

Section V. Summary

This section contains a brief review of the causes of the accident and recommendations for corrective
actions. In your review, it's important to include language that contrasts the costs of the accident
with the benefits derived from investing in corrective actions. Including bottom-line information will
ensure that your recommendation will be understood and appreciated by management.

Section VI. Review and Follow-Up Actions

This section describes the actions taken to repair equipment/machinery, conduct training, revise
policies, etc. It also describes the persons responsible for carrying out corrective actions and system
improvements.

Section VII. Attachment

This section describes contains all of the photos, sketches, interview notes, etc. material to the
investigation. Of course the more comprehensive the investigation, the more supporting
documentation will be included here. Last Words
There you have it...all there is to know about the accident analysis process, and how to report it.
Well, not quire all there is to know...but you've worked hard on these seven modules and now have
the basic understanding about effective accident investigation procedures. Only experience will
transform knowledge into expertise. Good luck in that effort. One last task before you're through. It's
time you take the module quiz.

Let's Review

31. What is the purpose of the accident report?

32. What, if anything, is incorrect or "wrong" about the following: "Finding -- Employee #1
demonstrated poor safety attitude by not properly wearing hearing protection.

33. In the finding above, what might be a root cause for the unsafe behavior?

34. Given your answer to the previous question, how might you rewrite the finding above?

35. Once the report is completed, who should receive it? Who receives it in your company?

ASSIGNMENTS

Important Tip! Writing drafts first, before submitting coursework, will help improve the quality of
your work. On a sheet of paper, write your first draft responses for the following assignments. When
finished, return to the online assignments page, enter your final coursework, and complete the
course evaluation and certificate information.

See Appendix B for help in answering the extended response assignments.

Assignment 1: List and briefly describe each of the steps in the accident
investigation procedure discussed in the course.

Assignment 2: Discuss your response to an interviewee who accuses you of

interviewing only to fix blame.

Assignment 3: Give examples of two surface causes for an accident. Describe a

possible root cause for each surface cause.

Congratulations! Now that you've drafted all of the assignments and quiz questions, go online to
the Final Assignments and Quiz page to enter your coursework. I'll normally respond to your
assignments within one workday with the good news that your certificate is on the way... or, I'll ask
you to redo one or more of the assignments. In either case, you'll hear from me shortly. As always, if
you have any questions or comments about the assignments, feel free to email me at larry.
fipps@state.or.us