Accident/incident investigations supervisors

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. 

As the actuality of incident investigation practices is considered, one can t help but feel sorry for the supervisor. It is commonly said in the literature, as Ted Ferry did in Modem Accident Investigation and Analysis An Executive Guide, that the supervisor is closest to the action, that the mishap takes place in the supervisor s domain, and that initial responsibility for investigation is very often assigned to the supervisor (p. 9). 

When conducting the accident or incident investigation, try and use a neutral room rather than a manager s office. That will help set people at ease. Included in the investigation meeting should be the Individual or individuals involved in the incident, their supervisor, an HR representative, and a facilitator to lead the investigation. Others can be added as appropriate. 

Without participating in the detail of accident investigation, it is very difficult to appreciate the role of human behaviour in accident causation and hence to recommend or implement the most effective responses. Similarly, sole reliance on numbers of accidents/incidents in the organization as a guide to safety performance can be misleading, if the behavioural component is not understood. They do not show whether individual managers/supervisors are effectively dealing with prevention or if further action is required to prevent future accidents and losses. 

Observation They were teaching supervisors that a variation of Heinrich s premise—88 percent of accidents are caused principally by worker unsafe acts—was factual. Their number was 80 percent. Understandably, the supervisors responded to what they were taught and investigation reports were of little value. Safety professionals—ask yourselves— what is being taught to personnel who complete incident investigation reports ... 

In a minimal level investigation, the relevant supervisor will look into the circumstances of the accident/ incident and try to learn any lessons which will prevent future incidents... 

A low level investigation will involve a short investigation by the relevant supervisor or line manager into the circumstances and immediate underlying and root causes of the accident/incident, to try to prevent a recurrence and to learn any general lessons... 

Supervisors/forepersons will conduct an investigation of any accident/incident that results in death, injury, illness, or equipment damage. The supervisor will use the company s standard investigation form (see example. Figure 7.6). The completed accident investigation report will be submitted to the individual assigned responsibility for occupational safety and health. 

When an accident, incident, or fatality occurs, a myriad time-consuming and costly factors accompany it. Not just the cost of the investigation, but the loss of production, equipment damage, loss of productive worker, litigation, OSHA enforcement activities, loss of supervisor s time, and the list goes on and costs mount. 

All reported incidents (accidents and near accidents) are investigated immediately at this first level by the supervisor and safety representative. 

Obtaining the hest results from supervisors investigations of incidents that occur in the plant environment has been a goal of many safety professionals for many years, and the goal has often been quite elusive. In 1983, Plant Management became convinced of the merits of the accident causa-... 

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.). 

The results-oriented supervisor recognizes that the real value of investigation can only be achieved when his or her workers report every problem, incident, or accident that they know of. To promote conscientious reporting, it may be helpful to know... 

The source of the data was insurance claims files and records of plant owners, which cannot provide reliable accident causal data because they rarely include causal factors. Nor are accident investigation reports completed by supervisors adequate resources for causal data. When this author provided counsel to clients in the early stages of developing computer-based incident analysis systems, insurance claims reports and supervisors investigation reports were examined as possible sources for causal data. It was a rarity for insurance claims reports to include information from which causal factors could be selected. 

More specific typing is required. Injuries can usually be typed in a manner that matches the reports of the workers compensation carrier. Examples include lacerations, bruises, amputations, and burns. The tracking forms must also consider other metrics that could be central in identifying trends and determining causation. These usually include day, time, supervisor, process or machine-operated activity before accident, and many others. On this form, the data should actually be metrics used to track and compare incidents within the facility or company. Other contributing factors can be listed on the investigation form. 

Because accidents must be reported to supervisors immediately, all laboratories must post a list of emergency telephone numbers. Although generic accident report forms are available (Fig. 19.2), it is recommended that the winery develop its own forms to document accidents as well as those used by supervisors conducting accident investigations. Required information includes names and telephone numbers of the injured and witnesses, the date, time, and location of the incident, a description of the incident, the involved department(s), and the contract person and telephone number. 

The supervisor, foreman, or manager directly in charge of the area in which the event occurred should be the prime investigator. In some instances, the safety and health representative may have been appointed as the event investigator, but this should not free the immediate manager of his/her responsibilities to investigate the accident or near miss incident. 

Other accident analysis and investigation approaches that make explicit reference to supervision as a potential causal factor include AcciMaps (Svedung and Rasmussen, 2002), which diagrams company management and technical, operational, and management failure levels, and the Incident Cause Analysis Method (ICAM) (BHP Billiton, 2001), which addresses inadequate supervision and poor supervisor or worker ratio error modes. 

Supervisors must possess the knowledge and experience to provide hazard control guidance to those they lead. First-line supervisors occupy a key hazard control position in many organizations. This position of trust can require supervisors to conduct area inspections, provide job training, ensure timely incident reporting, and accomplish initial accident investigations. 

Objectives should be understood by all those directly involved. Use terms that have a clear meaning to all concerned supervisors and employees. Leave no doubt about what is to be accomplished. Example Determine the cause(s) of all accidents and incidents may be too abstract to be understood (and therefore accomplished) by those with responsibility. Be clear and speciflc Investigate all accidents and incidents at once to determine all contributing causes, and take corrective action within 24 hours of completing the investigation. ... 

Assist supervisors in investigating accidents and incidents such as property damage and near-misses. 

---