Accident/incident investigations reporting accidents

Written accident/incident investigation reporting system in place with follow-up... 

The source of the data—insurance claims files and records of plant owners — cannot provide reliable accident causal data. From personal experience, 1 can say that insurance claims reports rarely include causal data. And my studies of incident investigation reports completed by supervisors require the conclusion that they are not a reliable source for valid causal data. 

After one of my presentations, an attendee spoke to me about the poor quality of incident investigation reports that reached her desk. I had spoken of the need to emphasize systems causal factors and to get away from the excessive concentration shown in some of their investigation reports on what the worker had done in the accident process. She said that almost all of the investigation reports that came to her desk suggested a corrective action that would improve worker behavior, and stopped there. 

Acceptable risk levels cannot be maintained if systems are not adequately maintained. As this chapter was being written, incident investigation reports received by this author indicate that, because of severe expense reductions, maintenance has deteriorated—the result being serious injuries and fatalities. In the excerpt from Managing the Risks of Organizational Accidents (Reason, 1997) previously quoted, reference is made to maintenance failures as contributors to the... 

Work in steel plants is up to now loaded with a lot of different hazards workers have to cope with. A key variable of occupational safety is the perception of hazards as it was shown in Chap. 4. The study reported in this section was part of a greater investigation on hazard perception in different work settings (Ruppert et al., 1985). It entails extended interviews of employees as well as analyses of hazard descriptions, critical incidents, and reported accidents. 

Many companies use the form that documents the original discovery of a hazard to track the correction of the hazard. Inspection reports include notations about hazard correction alongside the information about the hazard. Employee reports of hazards and reports of accident/incident investigations also should provide space for notations about hazard correction. 

The employer investigates incidents that result in, or could result in, a catastrophic release of highly hazardous chemicals. An incident investigation is initiated as soon as possible, but before 48 hours following the incident. An incident investigation team is established to consist of one or more experts in the process involved, and accident investigation. The report prepared at the conclusion of the investigation includes at a minimum ... 

If the incident constitutes a reportable accident as defined in legislation the plant engineer will also ensure that the incident is immediately reported to the Factory Inspectorate. The Inspectorate will decide whether they wish to carry out an enquiry and, particularly if there has been loss of life, the accident site may be compulsorily isolated. Unless this is so, investigation by the insurer or a loss adjuster acting on his behalf may proceed. 

The accident investigation report is the major result of the investigation. In general, the format should be flexible and designed specifically to best explain the accident. The format may include the following sections (1) introduction, (2) process description (equipment and chemistry), (3) incident description, (4) investigation results, (5) discussion, (6) conclusions, and (7) layered recommendations. 

OSHA did not undertake an emergency revision of the PSM Standard in response to the labor unions petition. In October 1997, OSHA and EPA issued a joint chemical accident investigation report on the Napp Technologies incident. Among the recommendations was that OSHA and EPA review the lists of substances subject to the PSM Standard and RMP regulation (40 CFR 68) to determine whether reactive substances should be added. 

Notification of plant emergency personnel should be considered if a N-E-L is reached. A formal investigation must be conducted and an accident/incident report written. 

Incident and accident investigation reports and corrective actions taken... 

Accident/incident notification, investigation, and reporting requirements... 

Two articles by investigative reporters at the Wall Street Journal (WSJ) indicate the potential value of a more thorough approach to comparative analysis of performance indicators. The first, published shortly after the Macondo accident, found that for each 100 million hours worked offshore during the years between 2004 and 2009, U.S. operations incurred 4.84 worker fatalities, more than 4 times the European rate of 1.07 fatalities, and experienced 5 major losses of well control in 2007-2008, whereas 5 other major countries (Norway, United Kingdom, Australia, Canada, and the Netherlands), with about half as much drilling activities, reported no such incidents. ... 

Five of the 15 forms received require entry of codes for causal factors, incident types, and injury t)q)es. When computer analysis programs first became available, I had been an aggressive promoter of the entiy of causal factor codes for later analysis. That proved to be inappropriate because accurate causal data are often not included in supervisors investigation reports or in insurance claims reports. Now, I recommend that computer-based analysis systems not include provision for causal data entry. They serve analysis purposes quite well for types of accidents, injury types, parts of body injured, and identification data (location, age, job title, etc.). 

Monitor outstanding near-miss incident/accident investigation reports... 

Ron C. McKinnon, CSP, is an internationally experienced and acknowledged safety professional, author, motivator, and presenter. He has been extensively involved in safety research concerning the canse, effect, and control of accidental loss, near-miss incident reporting, accident investigation, and safety promotion. 

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