Conducting an Accident Investigation

In industrial businesses like scrap recycling, the potential for accidents is ever-present.
  Equipment, scrap material, weather, oil, and human error are just a few of the factors involved.
  In general industry, for every serious accident, there are 10 minor injuries, 30 incidents of property damage, and 600 near misses, according to Richard Ziebell, product development manager for J.J. Keller & Assocs. Inc. (Neenah, Wis.), which produces safety and compliance products. As these statistics show, the problem of occupational accidents demands serious attention.
   Naturally, the best approach to addressing workplace accidents is to prevent them through aggressive employee safety programs and training. Remember: An ounce of preventive measures is worth much more than a ton of workers’ comp payments.
   But accidents will happen, as the saying goes. And when they do, your best approach is to conduct an accident investigation, which will help you understand the factors that caused the accident—or near miss—and enable you to take steps to prevent a similar incident from reoccurring.

First Things First
  Before you can conduct an accident investigation, you have to take a tip from the Boy Scout credo: Be prepared.
  For starters, have an accident investigation kit in your plant that includes such items as:
• a camera (with fresh film);
• yellow barricade tape;
• a flashlight (with fresh batteries);
• graph paper and pencils for quick sketches;
• warning signs;
• tape measures;
• rubber gloves;
• sample containers with labels; and
• accident report and witness statement forms along with sample interview questions.
   Aside from these supplies, you should have internal accident investigation procedures in place, as well as the phone number of an outside investigator so you don’t waste valuable time searching for one following an accident.
   Plus, under certain circumstances you are required to notify either federal OSHA or your state workplace safety agency when an occupational accident occurs. Be sure you know what rules apply to your situation.
   When an accident happens, of course, the first step is to “make sure all of the injured people are taken care of,” says Bob Toth, human resources manager for Annaco Inc. (Akron, Ohio). Keep in mind, however, that your accident investigation should begin as soon as possible.
   Following an accident, employees should be trained to:
• remain calm and proceed with caution;
• refrain from moving anything at or near the accident scene unless instructed to do so;
• return to their workstations, if necessary, to clear the area for rescue personnel and the investigation;
• take precautions regarding bloodborne pathogens if spilled blood is present;
• follow the lead of the accident investigator; and
• make themselves available to the investigator if they can serve as witnesses to the events of the accident or the conditions prior to the accident.

The Outside Investigator
As for who conducts the investigation, the answer is: It depends.
  Cases involving near misses, property damage, and minor injuries can generally be investigated internally. One option is to call on the supervisor covering the work area in which the accident occurred. Some companies hand all investigation responsibilities to their in-house safety or personnel director. Others use more than one internal investigator to provide a set of mutual checks and balances.
   At Annaco, at least three members of its safety committee independently go through what Toth calls “a long and arduous report.” Then the different reports come to him for review to note discrepancies and ask further questions, if needed.
Sam Hummelstein, president of Hummelstein Iron & Metal Inc. (Jonesboro, Ark.), gathers different perspectives from supervisors, members of the safety team, and employees from different departments. Why employees from other departments? As he explains, “Sometimes you can get so used to looking at trees that you don’t really see them any more.”
Though you may prefer to conduct all accident investigations internally, that’s not always advisable, according to Joseph Kinney, president of the National Safe Workplace Institute (Charlotte, N.C.). In his view, any industrial incident that results in serious or multiple injuries or a fatality should be handled by an outside independent investigator. “If you have a serious accident and don’t bring in an outside investigator, you’re being foolish for there will be an investigation by OSHA and there can be a lawsuit,” he states.
   One reason to bring in an expert is that “85 percent of accidents involve the human factor of behavior,” and your in-house investigators may not have the expertise to look for and understand such factors, Kinney says. Also, an outside investigator can provide objective evidence that can help you in court, whereas an in-house investigation can be inadequate and perceived as unreliable or self-serving.
   And though hiring an external investigator isn’t free, cost shouldn’t be a consideration when it comes to serious accident investigations. As Kinney notes, insurance research reveals that a serious accident in which four or more people are injured will cost at least $100,000, a typical lawsuit will start at $1 million, while a good outside investigator can cost less than $10,000.

How to Interview
After an accident, there are three groups to be interviewed—the victim or victims (if possible), eyewitnesses (if any), and people who may not have seen the accident but who may have some insight into the state of mind of the victim in the minutes, hours, or days leading up to the accident. This latter group can include coworkers, friends, or family members.
   Since memory tends to fade, interviews should be conducted and documented as soon as possible after the incident. Mike Mattia, ISRI’s director of risk management, also suggests talking with key interviewees, including the victim, more than once. This approach can help verify the facts in a case or point out discrepancies. “If an employee is covering his tracks, then contradictions are likely to appear,” Mattia notes. “And if he’s questioned more than once, he may, after a period of time, just want to get it off his conscience and say what really happened.”
   When conducting interviews, the investigator shouldn’t be looking to cast blame, only to find out what happened, Ziebell says.
   Sunday Vogler, vice president/loss control for CNA Commercial Insurance (Chicago), agrees. “All too often, we see employee carelessness listed as the cause,” she says. “But the real causes might be underlying managerial ones, such as lack of adequate supervision or training, or, for that matter, lack of progressive discipline. We’ve often heard managers say, ‘I told him over and over not to do such and such.’ But what should have happened is that the worker be given progressive warnings, sanctions, or even termination. Losing a job is better than losing a limb or a life.”
   Along these lines, witnesses should be asked open-ended rather than suggestive or leading questions. “You don’t ask an employee if he saw oil on the floor, for the oil may or may not have been a hazard in that situation or a cause of that particular accident,” Ziebell says. “Ask instead if the employee saw anything unusual.”
   Interviews should, whenever possible, take place in a quiet room away from other employees. This is especially true if the accident scene was turbulent or traumatic.

The Six Big Questions
Just as in police investigations, accident investigations are largely based on information gleaned from the six basic questions of who, what, when, where, why, and how? While these questions target different facts, they often overlap.
   Who? This question seeks to identify not only the injured employee, but also those who may have contributed to or witnessed the accident, as well as those with information that could help explain the accident or the injured employee’s behavior.
   What? This covers the question: What happened? Perhaps an employee slipped on oily ground, had his foot crushed in machinery, or fell off a loading dock while driving a forklift. The goal is to describe the events and employee actions (or inactions) that played themselves out to create the accident. “You have to get specific,” Toth says. “What task was the employee doing? Sorting scrap metal? Was he shearing structural plate, milling a shaft, or stocking shelves? Fastening this bolt or cutting that rod? Having trouble fitting it into this machine?”
   When? A particular convergence of factors triggered an event at a particular time. When an accident happened can become a significant fact in an investigation, especially when an ongoing recreation of a scene has failed to reveal the cause of an accident.
   Mattia recalls one incident in which an employee drove a forklift around a corner and fell off the loading dock, badly injuring himself. “We went over and over what happened,” he says. “But when we nailed down the exact time of day, we found that the sun was hitting some siding, which produced a glare that momentarily confused the forklift driver. He didn’t realize what was happening, it happened so fast. When we pinpointed this, he recalled it. It’s not unusual for someone to forget details like that in the trauma of an accident.”
   Where? This question seeks to place the injured employee and others in their exact locations when the accident occurred.
   How? Here, you’re trying to identify the manner in which an action was done. After all, the way something is done can determine whether the result is positive or negative. We’ve all heard, for example, that when doing heavy lifting, we should lift with our legs, not our back.
   Why? This question seeks to explain the reasons or causes behind an accident.
   Immediate causes are those conditions that are obviously related to an accident. Sometimes, accidents can be traced directly to a specific action or inaction. A forklift operator crashed because he was driving too fast. A maintenance employee was injured because he didn’t follow proper lockout/tagout procedures. An employee threw his back out because he lifted with his back instead of his legs.
   Root causes, on the other hand, are the underlying conditions that make the immediate causes possible. In the above examples, for instance, perhaps the employees never received the proper training in forklift operation, lockout/tagout, and lifting.
   By looking no further than the immediate causes, it’s easy to lay the blame for many accidents on employees. However, deficiencies in company policy and procedure, faulty or poorly designed equipment, or lapses in company training programs are often at the root of accidents.
   These root causes, which are often masked by the immediate causes, point to company policy or procedures that should be addressed. When you get to the root causes, you can make changes to prevent the occurrence of the immediate causes.
   There could also be other contributing factors that might merit further probing. The employee who threw his back out, for example, could have suffered a back injury off-hours while playing basketball and exacerbated it while working. Other factors that could cause employees to have an accident include financial and emotional pressures, substance abuse, and on-the-job horseplay.
   As you can see, the why can be difficult to explain. “One of the fallacies in accident investigation is that it takes as its model a police investigation of two cars in an accident,” Mattia says. “That may give the mechanics and who was at fault, but it doesn’t tell you what led to the accident, especially with the view of preventing it again.”
   More often than not, he argues, an accident is caused by the vagaries of human nature. “Often we know there’s been a mistake, but we can’t really tell why,” he says. “We find ourselves asking, ‘Why did you do that? It doesn’t make sense.’ We think it’s common sense to be safe. But human nature doesn’t focus primarily on acting safely. It focuses on comfort, convenience, and pleasure. That’s what’s natural to us. Safety isn’t. It has to be trained.”
   As a final note, it’s important to note that many of these six basic questions can apply to more than just employees. They can also relate to the physical environment of the accident scene—the spills, skid marks, and equipment. For instance, electrical and mechanical switches or knobs, equipment with parts that may have failed, interfered with, or interrupted normal operations, the arrangement of scattered products, and the proximity of ladders or other tools can be key pieces of evidence based on their position at the accident scene.

Reaching Resolution
Once an accident investigation is completed, management should brief employees on the results. “Management has to regain the confidence of employees, to show that they really care,” Kinney says. “Employees need to know what happened, as well as the measures the company has taken to make sure it doesn’t happen again.”
   The same candor should extend to the courtroom if an accident case goes to trial. “This is where lawyers often go astray,” Kinney says. “Lawyers are concerned about the law, but juries usually take a common-sense approach. If the company did an internal investigation, especially a sloppy one, or none at all, the plaintiff’s lawyer will make it appear that the company doesn’t care about its employees.”
   But what if the outside investigation shows that the company was at fault?
Here, too, Kinney maintains that the truth is going to come out sooner or later, so you’ll have a better chance of winning a jury’s sympathy and minimizing damages by admitting your shortcomings. “Juries respond to a company who says something along the lines of, ‘We were under pressure, did too much overtime, and screwed up,’” he says.
   Though accident investigations may not always tell you what you want to hear, they’re your best step toward protecting your employees against certain accidents happening again. n

Editor’s note: For safety- and risk management-related resources, contact:
• National Safe Workplace Institute, 2201 Coronation Blvd., Suite 145, Charlotte, NC 28227; 704/841-1175 (fax, 704/ 841-3893); www.nsafewi.com; 
• National Safety Council, 1121 Spring Lake Drive, Itasca, IL 60143-3201; 630/285-1121 (fax, 630/285-1315); www. nsc.org; or
• J.J. Keller & Assocs. Inc., which produces accident-investigation resources and other “safety and compliance solutions.” (You can order these products through NASCO-OP, 800/321-3396.)