Supervisors accident investigation reports

Supervisors are required to submit accident investigation reports that answer the questions who, what, when, where and how ... 

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. 

Figure 19.2. An example of a supervisor s accident investigation report.

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. 

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. 

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.). 

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 ... 

It is commonly said in the literature, as Ted Ferry (1981) 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 (9). Ferry went on to say that being close to a situation may preclude a supervisor from taking an unbiased approach to causal factors that may reflect on his own performance or that of people to whom he reports (9). 

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. 

Implement processes or systems to report and track hazard correction actions Establish a timetable for implementing corrective hazard controls Prioritize hazards as identified by inspections, reporting, and accident investigations Require employees to report hazards using an established processes Provide quick feedback about the status of hazard correction activities Delegate responsibility for correcting hazards and documenting completion Permit supervisors and experienced employees to initiate hazard control actions... 

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. 

The routine investigation into accidents and near accidents is usually carried out by the first-line supervisor and safety representative, or in case of near accidents, by the persons directly involved. In Chapter 12, we discussed problems with the quality of the supervisors accident reports. The documentation in the reports focuses on the late phase of the sequence of events. There is often an arbitrary and incomplete documentation of deviations in the early phase of the sequence of events and of causal factors. This documentation thus suffers from problems of reliability and coverage. 

MAIM, the Merseyside Accident Information Model has many similarities to the Finnish accident-analysis model (Shannon and Davies, 1998). Both models are primarily designed for the purpose of recording and storing information from the supervisors first reports in a database. The Finnish model has also been implemented in accident-investigation forms, where the investigator is requested to record the information directly into the different boxes of the model. Experiences from such an application are mixed, since it requires investigators with high analytic skills. 

Efforts should be made to simplify the form for the registration of accidents and near accidents as far as possible. It is an important principle that the design of the form shall not create a barrier towards the reporting and investigation of accidents and near accidents. Some of the data are fed directly into the computer and need not show up on the form for the supervisor s first report. No specific form is needed for the in-depth investigations. Checklists should be developed to support the investigations. There are also other tools to be considered such as checklists and record sheets for use in workplace inspections, risk analyses and SHE audits. 

They should be closely involved in drawing-up the details of the experiments with the principal scientific investigator. They should ensure that they understand the work and follow strictly the safety guidelines and procedure required for the task they are performing, so as not to expose themselves or their colleagues. They should report any unsafe conditions of work to their supervisor and, in case of accident, report details of the conditions that resulted, or might have resulted, in exposure. 

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... 

All accidents will be investigated to determine causal factors and prevent future recurrences of similar accidents. A written report of investigation findings will be prepared by each injured employee s supervisor and submitted to management for... 

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