For severe or life threatening injuries to employees of The Ohio State University, call 9-1-1 (campus phone) or 614-292-2525 (cell phone) immediately. Also, promptly contact Environmental Health and Safety (EHS) at 614-292-1284 to report the injury.
For minor occupational injuries, the supervisor should direct the employee to Employee Health Services, located at 2100 Cramblett Hall, 614-293-8146.
For all injuries, the supervisor shall:
- Ensure that a Ohio State Employee Accident Report is completed and submitted to Employee Health Services; and
- Investigate the incident to determine a root cause and, as appropriate, implement measures to prevent recurrence. Note: For assistance or if you have questions, contact Environmental Health and Safety.
What is the purpose of accident/incident investigation?
Intent is prevention and correction (i.e., identify the root cause(s), not to assign blame).
Definitions
- ACCIDENT: an undesired event that results in personal injury or property damage
- INCIDENT: an unplanned, undesired event that adversely affects completion of a task
- NEAR MISS: incidents where no property was damaged and no personal injury sustained, but where, given a slight shift in time or position, damage and/or injury easily could have occurred
When should you conduct an investigation?
All incidents whether a near miss or an actual injury-related event should be investigated. Near miss reporting and investigation enable identification and control of hazards before they cause a more serious incident. Accident and incident investigations are tools for uncovering hazards that were either missed during earlier job hazard analyses or have managed to slip away from the controls planned for them. To be useful, an investigation needs to be done with the aim of discovering every contributing factor to the accident or incident to “fail-safe” the condition and/or activity to prevent reoccurrence. While all accidents should be investigated, including accidents involving property damage only, the extent of the investigation shall be reflective of the seriousness of the accident. When an accident results in a fatality or hospitalization of employees, promptly contact Environmental Health and Safety. In these situations (except to the extent necessary to protect employees and the public), evidence at the scene of an accident shall be left untouched until the site has been inspected by health and safety officials.
Who should investigate?
The usual investigator for incidents is the supervisor in charge of the involved area and/or activity. The supervisor should be accountable for accidents in his/her area, should know the situation and the people involved best, has a personal interest in cause identification, and can take immediate corrective action. The injured or impacted employee should be involved because the individual can clarify any uncertainties by providing details about what happened and why it occurred. Employee involvement in investigations will provide additional expertise and insight and, in the eyes of the workers, will lend credibility to the results. Employee involvement can enhance employee knowledge of potential hazards, and the experience can make employees advocates of the importance of safety, thus strengthening the safety culture of the organization.
EHS will assist with investigation of accidents involving fatalities, serious injuries, or extensive property damage. Upon request, EHS will provide assistance investigating any accident, incident, or near miss. EHS will review the investigation findings and recommendations.
The investigation report should answer six key questions
Six key questions should be answered: who, what, when, where, why, and how. Facts should be distinguished from opinion, and both should be presented carefully and clearly. The report should include thorough interviews with everyone with any knowledge of the incident. A good investigation is likely to reveal several contributing factors, and it probably will recommend several preventive actions.
Avoid the trap of laying sole blame on the injured employee. Even if an injured worker openly blames himself/herself for making a mistake or not following a prescribed process, the accident investigator should not be satisfied that all contributing causes have been identified. The error made by the employee may not be the most important contributing cause. The employee who has not followed prescribed procedures may have been encouraged directly or indirectly by a supervisor or expected workload to “cut corners.” The prescribed procedures may not be practical or even safe in the eyes of the employee. Sometimes where elaborate and difficult procedures are required, engineering redesign might be a better answer. In such cases, management error – not employee error – may be the most important contributing cause.
All supervisors and others who investigate accidents or incidents should be held accountable for describing causes carefully and clearly. Investigation reports should not include catch-phrases, such as “Employee did not plan job properly.” While such a statement may suggest an underlying problem with this worker, it is not conducive to identifying all possible causes, preventions, and controls. Certainly, it is too late to plan a job when the employee is about to do it. Further, it is unlikely that safe work will always result when each employee is expected to plan procedures alone.
Implications of accident investigations
Recommended preventive actions should make it very difficult, if not impossible, for the incident to recur. The investigative report should list all the ways to fail-safe the condition or activity. Considerations of cost or engineering should not enter at this stage. The primary purpose of accident investigations is to prevent future occurrences. Beyond this immediate purpose, the information obtained through the investigation should be used to update and revise controls used to reduce hazards to employees. For example, the Job Safety Analysis should be revised and employees retrained to the extent that it fully reflects the recommendations made by an accident or incident investigation report. Implications from the root causes of the accident need to be analyzed for their impact on all other operations and procedures.
References
- Occupational Safety and Health Administration Fact Sheets: Accident/Incident Investigations.
- Occupational Safety and Health Administration: Accident/Incident Investigation Tools and Tips.