While lifting a pallet with a forklift, the load slipped and fell onto the factory floor. Luckily there were no persons injured, although a co-worker was close to the accident scene observing and assisting in the lifting. The pallet and the product were damaged.
By Salla Lind-Kohvakka
Despite advances in safety and risk management, accidents and incidents happen. The outcome from an accident can vary greatly - sometimes almost identical chains of events can result in totally different outcomes.
This can lead to misunderstandings with regards to the indications minor incidents and near misses give us: instead of being single unfortunate events, they should be understood as something that can happen again, and often have the potential to cause more serious outcomes or losses.
For long, it has been understood that accidents need to be investigated, in order to prevent them from happening again. In the best case, we can identify some simple and effective improvements to ensure safe and disturbance-free work. Sometimes the corrective measures need to be targeted to multiple different issues. In any case, each accident should also be considered as a possibility to learn and improve safety and risk management.
When an accident happens in the workplace, an investigation may be required by national legislation. In order to ensure learning and that improvements are made, a thorough investigation is for minor cases, especially if it is obvious that they hold the potential for a major loss or accident. Sometimes, they can expose hidden risks and threats that require immediate actions.
Safety management can be divided into two categories: reactive and proactive.
It is important that the investigations are conducted systematically and with an open mind. As a result, investigation findings can be applied to improve safety in several locations or functions, instead of only addressing the actual accident scene.
Accidents have multiple causes and underlying contributors.
Accident investigation aims to answer the three main questions: what happened, why did it happen, and how do we prevent it from happening again in the future. These questions also direct the person conducting the investigation to remain objective, where the overall aim is not to identify whether someone is guilty.
Accidents have multiple causes and underlying contributors. Sticking to the most obvious ones will only tell a part of the story - it is important to look further and deeper. How would it change your mindset if you looked for explanations, instead of causes?
Many companies have a well-defined investigation process with good instructions in place. Still, it is common that accident investigations result in vague outcomes. Especially with minor cases with no or very little harm, it is quite common that the accident-preventive measures are extremely simple or focusing only on the most obvious cause.
This highlights the importance of avoiding hasty conclusions and simplifying the outcome of the investigation, for example “…to prevent this from happening again, let’s be more careful.” Although this is a commonly introduced improvement, it has very little or no efficiency in practice.
Instead of focusing (and relying) on human performance only, a better option is to list actions that are targeting both organisational and technical matters. In reference to the example, the outcome should be "...to prevent this from happening again, work practices and risk assessment need to be revised. Also, the adequacy of technical safety in the location has to be ensured, which means new security measures will need to be implemented."
A common issue is that the investigation focuses on merely documenting the case, instead of searching for a more coherent chain of events with causes and consequences. There can be many reasons for this; sometimes there may be lack of time to be allocated for a thorough investigation and reporting.
Also, accidents can be such rare events that no investigation routine has been established for those who conduct each investigation in practice. The overall aim of the investigation can also be unclear. These can lead to outcomes that will not provide much information for effective safety improvements.
The production line was often jammed with the materials on the conveyor. As removing the blockage according to the agreed safety instructions would cause remarkable delays in production (and impact daily KPI’s), it was an established practice to keep the line running and remove the blockage with a wrench or hammer.
This behaviour resulted in an accident, where an employee’s hand was trapped between the blockage and the conveyor, leading to injuries. The indirect losses, including production downtime following the accident, were significant.
In this imaginary example above, we could just report on the timeline and capture what happened, define some new work practices and install some safety devices, such as a shield or automatic stop when blockages occur. However, in order to ensure key learnings, there is an obvious need for analysing causes and consequences much deeper.
With this small description only, we can already see that there are some obvious deficiencies in work practices, safety culture and supervision, in addition to the defective technical safety issues and maintenance of the conveyor.
In the 1920’s, U.S. scientist H.W. Heinrich (1886-1962) made his famous approach to understand why accidents happen, and how they could be prevented. He came up with a pyramid model, which illustrates the relation between near-misses, less serious accidents and serious accidents. In this model, the peak of the pyramid represents the rarest cases, i.e. the serious accidents, and the number of cases increases the lower we go while the severity of these are reduced.
The point of the pyramid is to illustrate, that the most serious accidents are grounded in near misses, and the less serious accidents have a link to the serious ones. Thus, focusing and removing the near misses will have a reductive impact on the more serious accidents.
Over the years, this model has remained almost the same, and Heinrich’s theory has been proven to be valid in practice. After a century, this theory and the pyramid model still underline why gathering near misses and safety observations is so important – they are indicators for something that can cause much bigger loss next time, unless managed effectively.
Hazards and hazardous conditions should be identified and reported actively. This is a continuous process, that should take place every day. A good practice is that all employees identify hazards (including hazardous conditions) as a part of their everyday routines. This is a question of safety culture, combined with knowledge of the working conditions and tasks.
Accident investigation should aim to define the preventive measures holistically, so that improvements can be targeted to safety and risk management, as well as to technical details and work practices.
In order to help our clients to enhance their accident investigations, If has published a thorough training in our Learning Hub. The training gives a detailed overview to theories, practices and to some investigation models. The training is targeted especially for risk managers and occupational health and safety personnel. The training is useful for anyone interested in accident investigations and conducting them.
If you are an If client visit the Learning Hub to access this training course, and many more.