Out Loud Blog

While accident investigation is a basic function of EHS management, it is by no means routine or predictable. If not managed appropriately, the investigation process can produce tunnel vision as the investigator searches for the accident cause – and too often produces a singular finding when the real cause is more complex.

To conduct a successful accident investigation, investigators must look beyond what meets the eye in the form of the immediate cause and instead examine the root cause(s) of an accident, which often is more multifaceted than a single cause.

The Multiple Factor Theory

Investigators can avoid the pitfall of tunnel vision by employing the Multiple Cause Theory, popularized by V.L. Grose. This theory holds the belief that accidents are rarely, if ever, caused by a single event. Rather, multiple factors work together and culminate into a singular accident event.

These factors can vary but are typically divided into four groups: man, machine, media and management.

Man

Despite the fact that the human factor is sometimes overlooked, it is a vital consideration during accident investigation. More often than not, people are a composite component in the creation of an accident.

Factors such as worker age, experience, skill level, education, fatigue level and attitude, as well as many other human factors, can influence the development of an accident.

Machine

The majority of accidents experienced in industry involve exterior forces such as mechanized equipment, vehicles, stationary industrial equipment and a plethora of other types of equipment that feature moving parts or the ability to produce energy. The machine factor is integral to any accident investigation.

Media

Media includes the method and/or atmosphere in which the accident took place. It is important to consider the atmospheric conditions (weather, environment, pollution, etc.) as they often play a role in accidents. Equally important is the method in which the accident came about — this provides valuable causal insight.

Management

Company or organization management represents a commonly overlooked accident factor. The lack of management buy-in to company safety programs is a systemic problem that likely will lead to accidents. Company/organization policies, organization structure, mission statements and production objectives should include EHS endeavors. The absence of EHS in these elements is a definite consideration to be made during an accident investigation.

Although not all of the aforementioned factors will always come into play during accident investigations, it is likely that several will. Be sure to include them in your protocol. After all, while most EHS managers understand that accident investigations are not implemented to place blame, properly executed investigations are vital to the health and well-being of an organization’s work force.

EHS Today guest blogger Jason Townsell was named the 2010 Future Leader in EHS. He works as an assistant safety manager/trainer for LA World Airports (LAWA) Airport Development Group.

One of my OSHA instructors once said, “A safety program has to have four basic components. First of all, you have to actually have a plan in place. If you don’t have a safety plan, the following three are meaningless. Secondly, it needs to be in writing. Because we all know if it’s not written down, it didn’t happen. Thirdly, the program needs to be clearly communicated to your employees. They need to know what the program actually entails. And finally, employers need to continuously monitor the effectiveness of the safety plan.”

This process came in handy when my younger brother recently asked me to help lay sod in his front yard. Of course I was more than happy to help out my little brother by providing my time, truck, physical exertion and limited knowledge of the sod process. And yes, I’m definitely collecting those IOU checks for the future. I’m kidding … but seriously, they come in handy.

In any case, we had the plan: Remove the old grass and replace it with the dark green, thick, healthy stuff. We put it in writing: the measurements (square footage) of the yard, how much sod we’d need, what tools and products we’d need and the expense, which always seems to be far more than the original estimation. Next, we communicated the plan: We headed to the nursery and asked the garden “expert” what the steps and actions we needed to take in order to make this mission a successful one.

Eight hours and a pair of ruined shoes later, the job was complete. Now it’s up to my brother to monitor, manicure and make all this work pay off.

Going the Distance

In my experience, you can approach workers on a construction site and ask if their company has a safety program – let’s use a fall protection program as an example. Most likely, the workers will respond with an emphatic “yes.” When asked what the fall protection plan is, most of them can give you the watered down, standard answers. For example, they might say, “When working from 6 feet or more above a lower level, a personal fall arrest system is required. Checking the harness and lanyard before every use is also required.” Some can even give you the amount of weight an anchor must be able to support.

All these are very good things. Can I get an “air hi-five” for that? But ask them what the procedure is once someone has fallen and is hanging by the yo-yo or lanyard and you get a blank stare, a shrug of the shoulders and a disappointing “I don’t know.”

I ask you this: What’s the use of having an IIPP, SOPs or a safety program at all if you’re not actually using it, communicating and training your employees on it, or revising and making necessary changes to the program? Why invest in an emergency action plan if your employees don’t know what to do when an emergency actually happens?

Let’s assume that you have a written safety program in place. Now what? Well, how about holding regular safety meetings (tailgates, tool box topics, etc.) on job-specific safety hazards. In those meetings, you could ask your employees to physically show you how to lift an extension ladder, place it correctly against the wall (4-to-1 ratio, 36 inches above landing) and how to safely climb the ladder (three points of contact). You could give a quiz on the safety topic, preventing the ever popular “pencil whipping.” Consider developing an incentive or bonus program to encourage safe work practices.

In the end, sometimes it’s just a matter of supervisors, superintendents and safety professionals getting out on the jobsite and hanging out with the workers. Ask the workers questions and request their suggestions. Always remember that a truly effective safety program is a fluid process.

Whatever you find most effective for your company and employees, make it happen – like my brother’s new front yard. All that planning, work, time and effort is pointless if you don’t follow up, monitor and make necessary changes to your safety program.

Guest blogger Aaron J. Morrow is a safety consultant, an OSHA 500 trainer, a Cal/OSHA 5109 trainer and a construction risk insurance specialist.