Mechanics

This section will focus on the mechanics of the investigation process by examining the what, why, and how of a mishap event.

Everyone would probably be in full agreement that it is important to investigate mishaps that result in injury and/or property loss. However, this is not the case when taking into consideration the “near-miss” type of mishaps. That is, those occurrences that almost, or could have, resulted in injury or property damage, however, probably because of luck, did not. For example, suppose workers operating on a scaffold accidentally kick a tool that falls and hits the floor. There is no injury or no damage. except maybe to the tool itself. But what could have potentially happened if someone was walking by at that time or there were workers below? Under normal circumstances, will a potentially hazardous condition or work practice (no toe board and barricades) be identified and corrected?

Although the specific hierarchical numbers in Heinrich’s pyramid have never been scientifically validated, the concept is valid, in that, by allowing events to occur without intervention we can expect some serious outcome at some point of time. Or, alternatively, the more problems or issues we can identify and correct at the bottom of the pyramid (the workforce), the better the chance of mitigating or completely eliminating the reportable or serious mishaps. Hence, investigating near-miss (or the almost) is an effective and proactive means of identifying and correcting hazards.

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The main purpose of mishap investigation is PREVENTION. A means of meeting this objective is to:

a. Determine what happened and why; and

b. Take corrective action(s) to prevent recurrence.

Every mishap investigation must be taken on a case-by-case basis, and, obviously, some will be more involved than others. However, one thing the investigator has to be prepared for, and mechanisms should be in place, is to take immediate interim action when the preliminary investigation uncovers hazards that exist and have an immediate impact on other work practices or conditions within the immediate area or throughout the entire agency. The purpose is to alert others as soon as possible to prevent a similar occurrence. This may be as simple as an all-out, one-time inspection to stop a particular work practice or take certain effected equipment out of service until adequate corrective actions can be implemented.

Because of the compensability issue and statutory requirements for timely reporting of certain elements of the information, several reports may have to be completed and forwarded to SORM even though all segments of the investigation process may not have been completed. The investigation should be as expeditious as possible, however, not at the expense of thoroughness and accuracy. Any portions of the investigation that may require additional information or analyses should be followed through accordingly and any forms or reports that have in the meantime been submitted should be amended, if they are affected.

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It is extremely important that the investigator be objective and stick with fact-finding. These are not criminal investigations and tactics such as deception, threats, and shock-and-awe are not only unnecessary but can in the long run be counterproductive to the fundamental objective of preventions.

Normally, the investigation process and sequence of events can be summarized into the following steps.

1. INITIAL ACTION

1. If there is an injury, render assistance. Priority should be given to the injured employee’s condition.
    
2. Take any reasonable precaution(s) to remove or mitigate any threatening hazard.
    
3. Involve supervisors immediately if any hazardous conditions or work practices are noted.
    

2. SECURE THE SITE
This of course will depend a lot on the nature of the mishap and the location. The important point here is to preserve the scene for factual information and prevent any further injury or damage. Timing is extremely important. The sooner the information is collected and recorded, the less chance of losing details.

1. Keep unauthorized personnel out of the area until all facts of the mishap have been noted and recorded.
    
2. Document all observable information. When appropriate, use aids such as a camera, tape measure, and sketches. Examples of information to capture:
    
   1) The environment (weather conditions, liquid on floor, lighting, vapors, etc.);
    
   2) Equipment and tools in use (type of equipment, guarding, maintenance, noticeable defects, etc.);
    
   3) Material involved (size, shape, and weight);
    
   4) Safety equipment and devices or lack of (i.e. personal protective equipment); and
    
   5) Any unusual behavior or work practices.
   
   Note: The camera is a valuable tool for preserving factual information. Take as many pictures as necessary and from various angles. Try to catch something in the photo that is permanent in nature (i.e. poles, indented walls, etc.). This can provide the original orientation of the site in the event the information is challenged at a much later date. Using items such as furniture and office equipment as a reference is short-term, since these items can normally be rearranged. Also, when photographing an exhibit use a well-known object or item (i.e. coin or ruler) in the immediate background or alongside the exhibit to show comparative size.

3. IDENTIFY WITNESSES
In most cases, it may be difficult to conduct in-depth examination of key witnesses at the mishap site (we will discuss techniques later). Therefore, at the site:

1. Get the names and pertinent information of everyone involved in the mishap;
    
2. Get the names and pertinent information of anyone who actually witnessed the mishap; and
    
3. Get the names and pertinent information of peripheral witnesses. These are individuals that may not have been at the scene but:
    
   1) Someone who knows or heard something about the mishap; or
    
   2) Anyone with the technical knowledge or expertise about conditions that have or may have contributed to the mishap.

4. CONDUCTING INTERVIEWS
Conducting and documenting the information from interviews requires some prior mental and physical preparation if it is to be effective. Here are some tips.

1. Conduct the interview as soon as possible. As time lapses, it is only human nature to corroborate with others the sequence of events and mentally reconstruct and fill in the blanks where facts were not actually available.
    
2. In order to obtain an effective statement, make sure you understand, as much as possible, everything involved in the case at the time the interview is conducted. Thoroughly review all information available. Organize your thoughts. What information do you want the statement to include? Identify the issues that need to be addressed during the interview process and have a list of questions ready to be asked regarding each issue.
    
3. When site interviews are not possible, interview witnesses one at a time and in a private, comfortable location, preferably in an office, conference room, or anywhere there will be no distraction. The interview should be professional, however, in an informal atmosphere.
    
4. Interview the injured party last.
    
5. Look for facts. It only makes sense to expect people to be totally cooperative, honest, and candid with their information if they are convinced that the investigation is, in fact, intended to find the cause and prevent recurrence.
         Guides for drafting questions
    
6. Most individuals interviewed are not expert witnesses; therefore, ask open-ended questions. These are questions that require an answer other than yes or no. For example:
    
   1) Ask open-ended questions such as, “Can you tell us what you saw yesterday?”
    
   2) Avoid leading questions such as, “Was the forklift operating at an unsafe speed?” These types of questions ask for opinions and can appear accusatory.
    
   3) Try not to interrupt the witness. Take notes and ask your questions when he/she is finished.
    
   4) Restate the information to be sure you understood correctly.
    
   5) Probably one of the most important inputs to an investigation process is to ask the injured or witness for his/her idea on ways to prevent the mishap from recurring.

5. ANALYSES
This is the heart of the investigation process. This is the segment of the process where all the facts and ancillary information are consolidated into the sequences of events that led to the mishap and ultimately the root cause(s). Root causes are those human errors, conditions, and/or equipment/material failures that, if eliminated, would have prevented the occurrence or at least reduced its consequences. Also, it is important to remember that most mishaps occur due to the synergistic effect of multiple causes. It is rare, if at all, that a mishap would have a single cause.

There are a variety of theories and techniques on determining mishap causation. Terminologies and techniques will vary; however, in the final analysis, a common understanding seems to be that mishap causes can be viewed as a series of multi-layered action points, where each layer will feed or influence the next layer in succession such as depicted by the following triangle.

The layers can be explained as follows.

1. Basic causes
   This is the every-day mode of operandi in the workforce reflecting the adequacy or effectiveness of the implementation and enforcement of day-to-day policies and procedures.
    
2. Indirect causes
   This is the next successive layer that reflects the results of the first layer. For example, inconsistent or arbitrary application of policies and procedures will result or lead to what are commonly termed unsafe acts and unsafe conditions or, a more contemporary term, at-risk behavior.
    
3. Direct causes
   This is the final action, condition, or agent that caused the injury or damage. For example:
    
   1) A slip injury due to liquid on the floor; or
    
   2) A lifting injury due to incorrect lifting techniques.

From a sequence of events point of view:
 

The two paths can be read as follows:

As evident in the diagram, at the hub of this sequence of events is management. In a majority, if not all, of mishaps reported, one can generally trace the basic or root cause(s) to management.

The challenge then is for the investigator to diagram out the mishap scenario and actually work backward (sequence of events) or downward (cause triangle) in order to determine the basic or root cause(s).

MSN search of "Accident Investigation and Analysis"
http://search.msn.com/results.asp?RS=CHECKED&FORM=MSNH&v=1 &q=Accident+Investigation+and+Analysis

Indiana University of Pennsylvania, Dept. of Safety Science -- Prinicples of Occupational Safety: Accident Investigation and Analysis
http://www.coned.iup.edu/SafetyScience/OCCSafety/os2_week3.htm

SafetyInfo, PowerPoint Presentation Library -- Accident Investigation
http://www.safetyinfo.com/safetyinfo/html/aa-guest-info/powerpoint/accident-investigation.ppt

There are several other commonly used, scientific, problem-solving models that can serve as additional useful tools in the investigation process. Probably the two most familiar and commonly used are the Fault Tree Analysis ...

http://www.faulttree.org/
http://reliability.sandia.gov/Reliability/Fault_Tree_Analysis/fault_tree_analysis.html
http://www.relexsoftware.com/resources/faulttree.asp
http://www.iee.org/Policy/Areas/Health/hsb26c.cfm

and the “Ishikawa fishbone diagram.”

http://www.pathmaker.com/resources/leaders/ishikawa.asp
http://mielsvr2.ecs.umass.edu/virtual_econ/module2/Cause_effect.htm
http://www.pathmaker.com/resources/tools/cause.asp

Although both models have some unique characteristics and their application can be quite involved, the concept of both is the same and can be useful in providing a structured approach to the investigation process. Like in the model described above, the word why plays an important role in these two models. To illustrate, using the fishbone diagram:
 

Although techniques and specific terminology can and will vary, for our purposes, most major categories of causes (direct causes) can first be summarized as supervision, procedures, material, and equipment. Then, after labeling all major cause(s), ask the question, “Why does this situation exist?” After answering the “whys” at the major level, proceed to ask the same question at the sub-level etc., etc. As long as one gets a reasonably viable answer to each level of why, continue to a further sub-level. Otherwise, if the process is stopped too soon, it is possible to be addressing the symptoms (indirect causes) of a problem and not the root cause (basic cause).

The application of these models is not always as clear-cut as indicated. For our purpose of investigating and reporting state agency mishaps, we can borrow and rearrange the theoretical concepts and produce a more user-friendly model, such as:

In most real-world mishaps, there will be a problem or deficiency in one or a combination of the major categories listed on the left of the model that will lead to an act, practice, or condition resulting in a mishap. As noted before, traditional thinking often refers to these as unsafe acts or unsafe conditions. However, when one performs an in-depth examination of all the circumstances surrounding a mishap, many of the acts, actions, and conditions that took place at the time may not have been viewed as unsafe. The dynamics of the situation or insidious change can obsolete established work norms, policies, and procedures. Therefore, a practical approach to root cause analysis via the theoretical models identified is to examine in detail the categories through a systematic approach, such as:

Procedure

1. Was a procedure available for this specific act, practice, or condition? If not, should there be one? The point here is that faulting someone when a policy or procedure does not exist, or they do exist but are inadequate, can be counterproductive to the moral of the organization and its culture.
    
2. If a governing policy or procedure was available, was it properly followed? If not, why not?
    
   1) Didn’t know. If a sound viable policy or procedure did exist, but was not followed because of the lack of skill or knowledge, then education and training is an appropriate solution.
    
   2) Didn’t want to. If the employee knew about an applicable policy or procedure and was trained accordingly but performed otherwise, then this was an individual choice where documented counseling and disciplinary action may be the most appropriate course of action.

Supervision
Was supervision adequate? This can mean anything from an inadequate span of control to bad role modeling. Based on principles of management, the supervisor is ultimately responsible for everything within his/her area of responsibility. However, at times it is possible for supervision to be less than adequate for various reasons. For example:

1. Understaffed or over-tasked
   In order to get the job done and on time, the supervisor may be forced into a position of establishing mission priorities at the expense of caution and safety.
    
2. Role modeling
   Usually this is a derivative of the type, style, and leadership skills of the supervisor. Most supervisors are motivated to do a good job; however, all too often first-level supervisors are placed in that position without any formal training, especially in behavior science, and lack the necessary skills of working with and through people. New supervisors, especially, have a tendency to view accepted leadership as a friendly peer-to-peer relation rather than demonstrated leadership through action(s) and consistent and fair application of established policies and procedures.
    
3. Buy-in
   Failure to take ownership of the safety program within their area of responsibility. This is probably the most common deficiency of any safety program. Traditionally, a common management fallacy has been that safety should be condoned and is the domain and the responsibility of the safety staff. This ignores the fundamental principle that safety is sound management and, as an integral part of management, should be incorporated and enforced through every policy and procedure.

6. EQUIPMENT/MATERIAL
Because of the various state agency missions and nature of exposures, this category is unlimited in depth and scope and attempting to list specifics is not reasonable. However, a broad area can be covered through use of a series of questions.

1. Was the appropriate material/equipment used?
    
2. Was the material/equipment properly maintained?
    
3. Was the material/equipment properly used?
    
4. Was personal protective equipment (PPE):
    
   1) Required?
    
   2) Available?
    
   3) Used?
    
5. Was the work area or work process a factor?

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This part of the investigation process should flow directly from the analysis and identification of root causes and applicable corrective action(s). Normally, corrective actions can be lumped into three major categories:

1. Engineering
This is a broad, all-encompassing category that can range from totally mechanizing an operation (minimizing human involvement) to a re-design of a work station. This is probably the most expensive solution in terms of required resources. However, it is also the most permanent or effective solution.

2. Administrative
The next and most common corrective action(s) is to address and implement where necessary adequate policies, procedures, education, and training and to ensure adequate and quality supervision.

3. Personal Protective Equipment (PPE)
From time-to-time there will be occasions where viable corrective actions are not readily available to eliminate the hazard, but a given task or work practice still has to be performed. In this case, the focus should be on protecting the employee or resource, such as protective clothing, face shields, etc.

Workers' compensation fraud

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