Unit NineAccident Investigations

Unit Nine Accident Investigations Although accident investigation is an after-the-fact approach to hazard identification, it is still an important part of this process. At times hazards exist, which no one seems to recognize until they result in an accident or incident. In complicated accidents it may take an investigation to actually determine what the cause of the accident was. This is especially true in cases where death results and few or no witnesses exist. An accident investigation is a fact-finding process and not a fault-finding, process with the purpose of affixing blame. The end of any result of an accident investigation should be to assure that the type of hazard or accident does not exist or occur in the future. Your company should have a formalized accident investigation procedure, which is followed by everyone. It should be spelled out in writing and end with a written report using as a foundation of yours standard company accident investigation form. It may be your workers compensation form or an equivalent from your insurance carrier. Accidents and even near misses should be investigated by your company if you are intent on identifying and preventing hazards in your workplace. Thousands of accidents occur throughout the United States every day. 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. Accident investigations should be conducted with accident prevention in mind. Investigations are NOT to place blame. An accident is any unplanned event that results in personal injury or in property damage. When the personal injury requires little or no treatment, it is minor. If it results in a fatality or in a permanent total, or temporary total (lost-time) disability, it is serious. Similarly, property damage may be minor or serious. Investigate all accidents regardless of the extent of injury or damage. Accidents are part o a broad group of events that adversely affect the completion of a task. These events are incidents. For simplicity the procedures discussed in later sections refer only to accidents. They are, however, also applicable to incidents. 1. Accident Prevention Accidents are usually complex. An accident may have 10 or more events that can be cause. A detailed analysis of an accident will normally reveal three cause levels: basic, indirect, and direct. At the lowest level, an accident results only when a person or object receives an amount of energy or hazardous material that cannot be absorbed safely. This energy or hazardous material is the DIRECT CAUSE of the accident. The direct cause is usually the result of one or more unsafe acts or unsafe conditions, or both. Unsafe acts and conditions are the indirect causes or symptoms. In turn, indirect causes are usually traceable to poor management policies, or to personal or environmental factors. These are the basic causes.In spite of their complexity, most accidents are preventable by eliminating one or more causes. Accident investigations determine not only what happened, but also how and why. The information gained from these investigations can prevent recurrence of similar or perhaps more disastrous accidents. Accident investigators are interested in each event as well as in the sequence of events that led to an accident. The accident type is also important to the investigator. The recurrence of accidents of a particular type or those with common causes shows areas needing special accident prevention emphasis. 2. Investigative Procedures The actual procedures used in a particular investigation depend on the nature and results of the accident. The agency having jurisdiction over the location determines the administrative procedures. In general, responsible officials will appoint an individual to be in charge of the investigation. An accident investigator should use most of the following steps:Define the scope of the investigation. Select the investigators. Assign specific tasks to each (preferably in writing).Present a preliminary briefing to the investigation team. Visit and inspect the accident site to get updated information. Interview each victim and witness. Also interview those who were present before the accident and those who arrived at the site shortly after the accident. Keep accurate records of each interview. Use a tape recorder if desired and if approved. Determine the following: What was not normal before the accident. Where the abnormality occurred. When if was first noted. How it occurred.Determine the following:Why the accident occurred. A likely sequence of events and probable causes (direct, indirect, basic).Alternative sequences. Determine the most likely sequence of events and the most probable causes. Conduct a post-investigation briefing. Prepare a summary report including the recommended actions to prevent a recurrence. Distribute the report according to applicable instructions. An investigation is not complete until all data are analyzed and a final report is completed. In practice, the investigative work, data analysis, and report preparation proceed simultaneously over much of the time spent on the investigation. 3. Fact-Finding Investigator collects evidence from many sources during an investigation, gets information from witnesses and observation as well as by reports, interviews witnesses as soon as possible after an accident, inspects the accident site before any changes occur, takes photographs and makes sketches of me accident scene, records all pertinent data on maps, and gets copies of all reports. Documents containing normal operating procedures flow diagrams, maintenance charts or reports of difficulties or abnormalities are particularly useful. Keep complete and accurate notes iin a bound notebook. Record pre-accident conditions, the accident sequence and post-accident conditions. In addition, document the location of victims, witnesses, machinery, energy sources, and hazardous materials.In some investigations, a particular physical or chemical law, principle, or property may explain a sequence of events. In addition, gather data during the investigation that may lend itself to analysis by these laws, principles, or properties. An appendix in the final report can include an extended discussion. 4. Interviews In general, experienced personnel should conduct interviews. If possible, the team assigned to this task should include an individual with a legal background. After interviewing all witnesses, the team should analyze each witness statement. They there may be inconsistencies in witnesses statements, investigators should assemble the available testimony into a logical order. Analyze this information along with data fro the accident site.Not all people react in the same manner to a particular stimulus. For example, a witness within close proximity to the accident may have an entirely different story from one who saw it at a distance. Some witnesses may also change their stories after they have discussed it with others. The reason for the change may be additional clues. A witness who has had a traumatic experience may not be able to recall the details of the accident. A witness who has a vested interest in the results of the investigation may offer biased testimony. Finally, eyesight, hearing, reaction time, and the general condition of each witness may affect his or her powers of observation. A witness may omit entire sequences because of a failure to observe them or because their importance was not realized.5. Report of Investigation As noted earlier, an accident investigation is not complete until a report is prepared and submitted to proper authorities. Special report forms are available in many cases. Other instances may require a more extended report. Such reports are often very elaborate and may include a cover page, tile page, abstract, table of contents, commentary or narrative discussion of probable causes, and a section on conclusions and recommendations. Accident investigation should be an integral part of your written safety and health program. It should be a formal procedure. A successful accident investigation determines not only what happened, but also finds how and why the accident occurred. Investigations are an effort to prevent a similar or perhaps more disastrous sequence of events. You can then use the resulting information and recommendations to prevent future accidents. Keeping records is also very important to recognizing and reducing hazards. A review of accident and injury records over a period of time can help pinpoint the cause of some accidents. If a certain worker shows up several times on the record as being injured, it may indicate that the person is physically unsuited for the job, is not properly trained, or needs better supervision. If one or two occupations experience a high percentage of the accidents in a workplace, they should be carefully analyzed and counter measures should be taken to eliminate the cause. If there are multiple accidents involving one machine or process, it is possible that work procedures must be changed or that maintenance is needed. Records that show many accidents during a short period of time would suggest an environmental problem. Once the hazards have been identified then the information and sources must be analyzed to determine their origin and the potential to remove or mitigate their effects upon the workplace. Analysis of hazards forces us to take a serious look at them. Words and expressionsReading Material Cooperation between Insurance and Prevention Work injures are an unwelcome byproduct of economic activity. In part, they are random events, but they are all, to some extent, under the control of workers and employers. But they are all, to some extent, under the control of workers and employers. Employers can reduce the number of workplace injuries and illnesses by investing in safer technologies, providing workers with personal safety protective equipment, training workers and their supervisors; workers can avoid accidents by following safe work practices and by taking greater care on the job. Both parties incur costs when an accident occurs. Workers costs include potential loss of income and medical expenses associated with treatment and rehabilitation as well as intangibles, such as pain and suffering and disability that reduce the ability to enjoy life. Employers costs include interruptions in production and damage to capital equipment and physical plant. Since accident prevention also entails costs to employers and employees, pubic policy should encourage employers and employees to optimize the allocation of the combined costs of accidents and accident prevention that are incurred by both workers and employers. It is possible to spend either too much or too little on accident prevention. Investment in accident prevention is socially efficient when total costs are minimized, that is when one additional dollar spent on prevention reduces accident costs by exactly one dollar. When the majority of the economic costs of the preventable occupational health and safety burden are borne by parties external to the firm, firms will not have a clear understanding of actual costs of under-investment in workplace health and safety. Insurance instruments can clarify the precise economic costs incurred by firms. Regulation and enforcement can raise the firm-level costs of under-investment in occupational health and safety. And information and consultation services provided b prevention authorities can increase firm-level recognition of effective OHS policies and practices.There are at least three ways to the rule of occupational health and safety. The first way, classically identified as occupational health and safety regulation, involves the promulgation of rules prescribing or proscribing specific policies and practices by employers, which are enforced through onsite inspections and monetary penalties for infractions. Direct rule attempts to change employer behavior by prescribing specific practices. Regulatory sanctions have the effect of raising the level of “efficient health and safety investment by the firm to the expected value of the sanction. In so doing, regulation introduces costs. There are two costs that must be considered by the efficient regulator: the administration costs of regulation and the cost of regulatory error. The evidence for the effectiveness of regulatory inspection and enforcement in occupational.The second way emphasizes the role of economic incentive that reward or punish employers on the basis of safety and health outcomes rather than behaviors. This way is embodied in experience ration. At the company level, experience-rated workers compensation insurance premiums present a choice at the company level between investments in accident prevention and investments in disability management. Higher spending on diability management will generally mean lower spending on accident prevention. Third way, termed internal responsibility, is designed to improve safety and health conditions through workers empowerment and involves three principal elements: 1) workers right to refuse unsafe work, 2) workers rights to information on nature of workplace hazards and 3) joint labor-management safety and health committees. The emphasis on the free exchange of high quality information gives expression to a key provision in economic theory; efficient decision-making within firms requires an understanding of the economic costs and benefits of different courses of action, including the costs of doing nothing compared to the costs of effective methods of removing a risk or hazard. The premise behind the economic theory of experience-rated insurance is that it provides more precise information to individual firms concerning the economic cost of occupational injury and illness than ways to levying insurance premiums based on collective experience of all employers in an economic sector or a national labor market. Unfortunately, it is very frequently the case that insurance premiums schedule only a fraction of the true direct and indirect cost of workplace injury and illness. The majority of the economic costs of occupational injury and illness are externalized. As a result of the broad failure to “internalize the full costs of occupational injury and illness at the firm-level, the conventional guidance of economic theory, that the firm will invest in health and safety up to a threshold less than or equal to the firms costs arising from occupational injury and illness can be expected to yield a response which is not sufficient to mitigate the true costs of occupational injury and illness. In theory, providers of insurance have some incentives to improve loss management practices among holder of insurance policies. Improved loss management practices among insurance policy holders should reduce the range of error in risk assessment on the part of insurance providers. There are many examples of insurance providers delivering loss management services: automobile driver education, home or commercial propertys fire protection practice, workplace health and safety practice. While some have argued that the profit motive provides private insurance carriers with an incentive to control losses and provide insured parties with safety management service, others have suggested that loss management services are provided by insurers to create a premium service brand identity in competitive markets. Whatever the actual case, there is broad consensus that private insurance carriers will only provide loss management services up to the point where an additional dollar spent on loss control is equal to the additional dollar of losses saved. Public insurance providers, such as the single-payer monopoly workers compensation agencies, may be more likely to embrace a dual mandate; both to operate an efficient and fiscally sound insurance program and to expend resources or invest capital to reduce the future burden of preventable morbidity in workplace. The latter objective is a social objective, and is external to the function of insurance. Insurance providers in private markets are not in the business of reducing or eliminating property and personal economic losses due to accidents or injuries. Private market insurance is specifically in the business of selling insurance policies at prices which cover the economic risks borne by the insurance policies. Private market insurance is, then, indifferent to the scale of societal economic loss arising from accidents and injuries. Given the high proportion of true costs of occupational injury and disease that are borne by parties external to the firm, there is a stronger theoretical justification for the intervention of prevention authorities to influence the decision-making of employers. As reviewed in this presentation, there are three types of instruments available to prevention authorities to influence firms: regulation, inspection and enforcement, insurance incentives and information and consultation (including the sponsorship of research investment).In a great many jurisdictions, especially those jurisdictions with publicly mandated single-payer insurance authorities, we have seen substantial experimentation by the insurance function as a direct funder of prevention activities. Much of this experimentation has been at a modest scale of financial commitment. A promising area for future program innovation may be for insurance funds to act as providers of capital for firm-level or sector level investments in technology which improves the future health of workers. Capital is scarce, and there is intense competition within enterprises for access to these scarce resources. Insurers have large capital reserves, of which a substantial share is invested (risked) in investment markers. Investment managers may well benefit from comparing capital investments to reduce the future economic burden of occupational injury and disease. Peter Dorman, a thoughtful commentator on the economic principles underlying occupational health and safety, has offered this additional observation: expenditures by firms on improvements in working conditions are investments in strict economic sense-they are costs borne in an earlier period in order to reap benefits in later ones. But investments must be financed. For large enterprises this may not be a problem, since they may have sufficient internal finance to meet all reasonable OSH needs. Smaller firms, however, must often turn to external source of funding. The cost and availability of finance is crucially dependent on the degree of collateralization-the ability of borrowers to put up assets as security behind their pledge to repay. Typically, the loans of which investments are made are made are collateralized by the assets the investments purchase or produce, such as equipment, materials, patents and stocks of finished or semi-finished goods. This does not work, in every case, for OSH investments, however, because the asset may well be the workforce itself, and workers cannot be offered as collateral. All investments in human capital, including investments in occupational health and safety, are subject to adverse reverse discrimination in financial markets. Policies that move in the direction of more aggressive prevention expenditures by insurance agencies will encounter resistance. Some of this resistance arises simply from the conservative orientation of most organization of most organ