It’s important to do an objective accident investigation for several reasons. We want to prevent the same thing from happening again. Everyone is curious and wants to know why it happened. Your insurance premiums could go up. You may need to pay the claim. Litigation can ensue, and you want to know the real truth.
You, the contractor, are the best one to investigate, says Frank Keres of Construction Risk Associates, Lake Bluff, IL. Keres gave a presentation on this topic at the Construction Safety Council conference last year (2014). You have more control over the situation. You have more knowledge of the people and your operations. And you have the financial interest. Your investigation is the most cost-effective. Insurance companies send adjusters, not investigators. Their job is to “adjust.”
Most theories of root cause are two-fold: A) the event actually happened; and B) the corporate culture allowed it to happen. This article will not address the corporate culture. It clouds the investigations and is contrary to the methodology. Save it for later.
When you approach an accident investigation, it’s vital to keep an open mind. Forget what you have heard or what you might think caused the accident. Lose your preconceptions; they are misconceptions. You should brainstorm to ensure that all possible causes are included, not just those that you are sure are involved.
Do not look for fault. That is subjective and for lawyers. Don’t look for what went wrong; just look for what happened. Do not try to shift blame. The cause could very well lie within your company.
Keres says you must not take on certain roles. You are not the safety person; you are an investigator. Forget OSHA. Most accidents are not OSHA violations. You are not a lawyer, and you are not stupid. You are not afraid to open your mind.
Three “Cs” are needed for a successful investigation, says Keres. One is control. All information comes to YOU. You have the authority over the investigation and the power to tell others what to do. Secondly, cooperation with others is necessary. You will need to interact with others, such as insurance reps and lawyers. Finally, you must have good communication with those you control and cooperate.
Keres recommends that contractors put together a written policy on accident investigations. This is different from a procedure for accident reporting, which most companies have. Establish the three “Cs” for your company. Maybe you want to delegate someone to be in charge of accident investigations.
At the Site
Before you or anyone else begins to investigate the accident, make sure the site is safe. If you’re not at the site when the accident happens, select the one person to take control until you get there. All employees who are witnesses should be taken offsite. Separate them. Leave everything just the way it is. No one should move anything or touch anything.
Select one person onsite to relay communications through the main office—someone to man the telephone. Select another person, usually the key onsite rep, to be with you and do whatever you ask. Tell this person to listen; you do not care what this person thinks or has heard from others. Get a camera or video camera and use it. Take notes.
To find the root cause, Keres says you should:
- Observe.
- Ask one question.
- Get one answer.
- Eliminate your first questions.
In your observation, start with a wide perspective. Look from outside the site. Be a wide angle lens, says Keres. Who knows what you might see? You might have questions such as, “What is that crane? What is the stage of the project?”
Write your questions down. Don’t ask anyone. Let your senses tell you the answers. Continue observing as you get to the actual site of the occurrence. Note where things are and what is on the ground and what is up above. Look for things that are out of place. For example, observe a hammer on the ground when the accident was above. Whose hammer is that? Could it have been the injured person’s hammer? Write down your questions.
Observe everything. Look closely. Work your way to the accident location. Look at the whole area. At the actual location, observe further and focus. Where did the person “start” and where did he end up? Look for personal items: tools, harness, lunch box. Is equipment still running? What equipment is there, and what is its condition? Whatever you see should be photographed.
As you observe, question everything you see. How did that get there? Why is that in that condition? Why is that in that position? If the accident involves a person, where did that person fall, slip, or trip? Where was the person before, and how did he or she get there?
Keres says if your mind is open and you are observing everything, you will have questions. Only answer the questions that the observed facts support. You still will have questions with no answers. For the unanswered questions, go back and observe, or look at your pictures. Doing it twice is nice, says Keres. Doing the observation twice will answer most of the unanswered questions.
Do not make assumptions based on your experience and education. Do not suppose that if something should have happened that it did. You can apply science. Examples are the path of falling objects, the weather conditions, etc. You have realistic knowledge. For example, a cable at the site should not have a new splice. Side brackets on a scaffold cannot support heavy loads, or certain combinations of materials can cause fumes, for example.
Use your objective knowledge to answer the remaining questions. Be a scientist or engineer. Never apply the thought process that uses the concepts of “normally this would happen,” “this is supposed to happen,” or “typically that should occur.” Only apply the proven rules that are factually supported.
Keres recommends asking yourself what you don’t see. If a worker fell, where is his or her harness? What if you happened to be at the site before, and a shaft was covered? If it is not covered after the accident, where is the cover? Find it. Your knowledge must be that of facts, not based on what should have been the case.
By now the evidence should provide the root cause or present only a limited number of possibilities. Collect any materials or items and put them in a secure place. Mark them as not to be touched without your authority.
You should know by now if you’re in trouble. You can now take statements from witnesses. Before taking a statement, go over with the employee his location before, during, and after the incident. If the employee is an eyewitness, have him or her tell you exactly and only what he saw. Do not overlook to ask what the employee heard. Get the timing recorded correctly. Prepare the statement and have the employee sign it. Tell the witness not to talk to anyone about this until you allow him or her to.
If you still have some unanswered questions, go to factual documents. Was an employee on prescription medications? Check with union benefits. Was he or she late for work? Check doctor’s reports, bruises, marks, etc. These are physical facts.
You should now have recorded the facts that were causal to the accident. Take these facts and any evidence into your possession. You may want to give the originals and evidence to your legal counsel to hold.
Keres says it’s a good idea to practice doing accident investigations. “Seriously, this is a great idea and a way to develop your skills as an investigator,” he says. Beware of using forms for investigations. They can stop you from using your brain—and they can hurt you in a lawsuit.
