Accident investigation --why, how, and after

B. Arunachalam,  Manager V.T,          Mines Group Vocational Training Society, Hospet

About the Author - B.Arunachalam, Age 66 years, Diploma from Chennai in 1962, FCC(R), served in limestone, iron ore and granite mines. worked in an MNC M/s Sesa goa ltd and super annuated in 2003, worked as a General  Manager in another group, Presently with Group V.T. Centre located at Hospet in Karnataka state India.   Email ID.      barunachalam43@gmail.com.       Sitemap     Factors affecting transportation

Accident is an unplanned welcome event which interrupts normal activity It is an unwelcome situation when every body gets tensed. Blame game starts .The normal activity is thrown out of gear. Tempers flare. Industrial trauma results in stoppage/slow down or too defensive attitude in performing the same or similar job. Depending upon the magnitude crisis develops. In case of loss of many lives this leads to a disaster to be managed. Crisis management and Disaster Management are post – facto scenarios and do not go in corrective measuresAccidents also lead to guilty conscience stage when we feel that had we  analyzed the risk this accident might not have happened.

 

Many a time we start thinking we could have avoided all this had we taken pro active measures. To get into a proactive stage it is not necessary that we should have come across such an eventAnalyzing each work situation and procedures, identifying the hazard, assessing the risk, training,  laying down safe operating procedures, are all required

 

Pro Active approach

Dissect all activities location wise/machine wise and Subject them to critical examination by putting basic questions. This would be needed to identify and eliminate the hazard or to modify the procedure.

When                                          Is it the proper time

Where                                          Is it the proper location or machine

What                                          Is it the correct thing to do

Who                                          Is it done by the proper person ,trained etc

Why                                          Is it necessary to do

How                                          Is it correctly done

 

Tabulate the results. They would, with unbiased state of mind and approach lead to answers to determine whether an activity is neededis it done correctly by the proper person, at the proper place and at the proper time.

 

Another area would be discussions with  Workmen inspectors. Thread bare unbiased discussions in the  pit safety committee can play quite a pivotal role in Hazard identification. Manager should not try to underplay or suppress any meaningful discussion. Points raised however minor they are need consideration.

Suggestion boxes unfortunately do not get suggestions at all.

 

Corrective methods

With all our proactive system in position still if an accident occurs we need to go in a cool frame of mind and find out ways to ensure that it does not recur. We should need to investigate without bias and creating fear. The purpose should be from a reactive for such an occurrence to  proactive for similar occurrences. Hence accident investigation is a tool to be used for improvement of situation and not to punish or create a fear complex.

 

The Purpose of investigation is

  • Exonerate individuals or management
  • Satisfy insurance requirements
  • Defend a position for legal argument
  • to assign responsibility

 

The key result should be to prevent a recurrence of the same accident. An accident investigation should not be with blame game. Management or managers should not use this for settling scores. Unions should not use this as an arm twisting advantage over the management or the vice versa. In fine the approach should be with open mind without bias and in the larger interests

 

Accidents can be broadly classified into

 

Minor accidents:

Such as paper cuts to fingers or dropping a box of materials

 

More serious accidents that cause injury or damage to equipment or property

 

Accidents that occur over an extended time frame such as hearing loss or an illness resulting from exposure to hazardous chemicals

 

Accidents have two things in common

They all have outcomes from the accident

 

They all have contributory factors that cause the accident

Outcomes of accidents

 

  • Negative aspects

 

    • Death & injury
    • Disease
    • Damage to equipment & property
    • Litigation costs
    • Lost productivity
  • Positive aspects

 

    • Accident investigation
    • Change to safety programs

 

Contributing factors

  • Environmental
    • Noise
    • Vapors, fumes, dust
    • Light
    • Heat

 

  • Design
    • Workplace layout
    • Design of tools & equipment

 

  • Systems & procedures
    • Lack of systems & procedures

                                Inappropriate systems &  procedures

  • Human behavior
    • Common to all accidents
    • Not limited to the person involved in the accident

 


We should need to decide the agency who can conduct the investigation. This would be Dependent on severity of the accident

    • Investigation team
      • Individuals involved
      • Supervisor
      • Safety supervisor
      • Upper management
      • Outside consultants

Purpose and Investigation strategy should be specified. This could be

  • Gather information & establish facts
  • Isolate essential contributory factors
  • Determine corrective actions

 

  • Implement corrective actions
  • Fact gathering
  •  

The investigating agency should be impartial & objective. It should

    • Compile procedures & rules for the area
    • Gather maintenance records on equipment involved
    • Isolate accident scene
    • Take photos & make diagrams
    • Do not discard or destroy anything
    • Time is of the essence
    • Obtain information regarding

 

      • Injured
      • Witnesses
      • Supervisors
      • Other personnel
      •  

To gain confidence and to get correct information Interviews should be conducted  separatelyMake it clear the object of the investigation is to avoid recurrence, not to blame. Individuals are concerned about ridicule, punishment, singling out or any humiliation and hence do not open out. It is therefore necessary to gain confidence with the individual. A defensive man may turn hostile defeating the purpose of enquiry altogether.. Then the exercise becomes an eyewash without meeting the basic need that is to prevent recurrence

Find out

      • What were you doing?
      • How do you think the accident occurred?
      • How were you trained for the job?
      • What is the safety procedure for this job?
      • Obtain facts not opinions.
      •  

Investigation team should

 

      • Tabulate the data collected from individuals and also scene of accident /incident.
      • Look out for corroboration and grey areas
      • Study them and reason out if necessary by reanalyzing
      • Evaluate all factors concerned
      • Isolate essential contributory factors along with an expert if necessary by asking the following question “Would the accident have happened if this particular factor was not present

Personal protective equipment is often shown as a cause of accident. Personal Protective Equipments (PPE) is the last line of defense. A helmet cannot save a head injury due fall of heavy object or shoes cannot prevent leg injury if a heavy objects falls down on leg while being lifted manually.

 

  • Determination of corrective actions by investigation team
      • Interpret& draw conclusion
      • Distinction between intermediate & underlying causes
      •  
  • Determine corrective actions.

 

      • Recommendations based on key contributory factors and underlying causes
  • Implement corrective actions

 

  • Such corrective action should be discussed in an open forum. It should have acceptance without reservation
  • Recommendation(s) must be communicated clearly
  • Strict time table established
  • Follow up conducted
  •  

Benefits of accident investigation

  • Preventing recurrence
  • Identifying out-moded procedures
  • Improvements to work environment
  • Increased productivity
  • Improvement of operational & safety procedures
  • Raises safety awareness level
  • Builds up confidence levels

 

Whenever we isolate a hazard either Pro active or reactive way and modify a procedure it is necessary to impart training it is necessary that all concerned are made aware of such changes and the necessity of such change. While we might have considered all aspects there could still be some hidden lacuna to surface out. It is therefore a must to monitor health of such changed scenario and further fine tune if need be .When an organization reacts swiftly and positively to accidents and injuries, its actions reaffirm its commitment to the safety and well-being of its employees and a confident system exists.

 

A pro -active organization prospers

Reactive organization survives  and

Inactive organization dooms      

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