Effective workplace accident investigations uncover underlying cause, correct deficiencies and prevent recurrence
When a workplace accident occurs — whether by an unidentified hazard, an insufficient control measure or an insubordinate worker — a thorough investigation must be conducted. This involves more than just finding out the events that led to the accident. Employers should also determine the underlying cause, correct deficiencies in hazard control and prevent recurrence. Accident investigations are also helpful for gathering evidence to prove due diligence in case of prosecution.
There are four main parts of an accident investigation — the initial emergency response, compliance with reporting requirements, collection and analysis of information, and implementation of corrective actions.
Emergency response
The first step in an accident investigation is to ensure the safety of people by providing first aid and emergency assistance, if needed, and ensuring the stability of property by turning off or isolating any hazardous energy.
After an accident, it is also important to preserve clues and evidence by setting up a secure area for authorized personnel, maintaining crowd control and securing the accident scene. When dealing with a critical injury or a fatality, employers are required by law to secure the accident scene — except for the purposes of saving life, maintaining essential public services or preventing unnecessary damage to equipment and property — until permission to release the scene is given by a Ministry of Labour inspector.
Reporting
Immediately after an accident, employers may have to notify occupational health and safety (OHS) government regulators, especially if there is a fatality, disabling or critical injury. The type of notice and time frames differ depending on the kind of accident, severity of the injury and jurisdiction. But employers should assign someone with the responsibility to provide notice of the accident to these external parties and to generate and maintain a record of notification.
Collection and analysis
In collecting and reviewing relevant evidence, the three types of evidence are testimonial, documentary and physical.
Employers should select an accident investigation team to take testimonial evidence from witnesses at the scene. Effective interviews require detailed inquiry, patience and preparation and should focus on the prevention of future accidents, not fault finding. That means open questions, listening, letting the person tell the story, confirming understanding of answers and recording questions and answers. The team conducting the interviews should not ask leading questions, interrupt, intimidate, act suspicious or surprised, or assume they know what the answers will be.
Interview anyone with information relevant to the accident, including people directly involved, others at the workplace and external people such as equipment manufacturers and suppliers or expert witnesses. As the investigation progresses, it may be necessary to re-interview original witnesses and additional witnesses.
The accident investigation team should also collect and review applicable company OHS policies, programs and procedures, training records and licenses and employee HR records. It should also gather prior inspection and investigation records, hazard reports, minutes from joint health and safety committees, maintenance records, correspondence, notices and orders from any regulatory authority. Assess the relevant documentation for consistencies and inconsistencies, and look for norms and deviations. Finally, review the applicable OHS statute, regulations, codes or guidelines that pertain to the accident to assess compliance or non-compliance with the applicable legislation.
Physical evidence may need to be collected as part of the accident investigation and sometimes testing or monitoring may be required. When physical evidence is collected, keep an inventory as well as a description of the physical evidence (what it is and who used it), record the date and time gathered, who gathered the evidence and by what means, the type of testing done and by what means, and who can verify authenticity of the item.
When all of the testimonial, documentary and physical evidence has been collected, documented and reviewed, it is extremely important to analyse the information to determine the sequence of events leading up to the accident and contributory factors. Without having a firm factual understanding of the sequence of events, it is impossible to determine the contributing factors and, in turn, develop effective recommendations to prevent recurrences.
Recommendations
One of the final steps in the accident investigation process is to develop recommendations based on analysis of the evidence. Identify the health and safety issue or hazard, provide supporting documentation for the recommendation (rationale from analysis) and identify the action plan for fixing the health and safety issue or the controls for the hazard. Recommendations should aim to prevent the same accident from reoccurring and improve the overall occupational health and safety management system.
The written accident investigation report should include an executive summary, a description of the accident, the facts, who was involved, the scope of work and instructions, the equipment and tools involved, applicable company policies, programs and procedures, the training and experience of workers and supervisors, cause-analysis assessments, conclusions and recommendations.
The report should be dated and signed and protected by solicitor and client privilege. Senior management should review the written report and decide on the next action, considering resources required, the schedule for implementation and the responsibility and ability of individuals to deliver required actions.
The investigation is not complete until the loop is closed on the non-conformances and deficiencies that caused the accident. Continue to measure the effectiveness of the controls implemented and make changes where needed.
Norm Keith is a Toronto-based partner and head of the OHS practice at Gowling Lafleur Henderson. Cathy Chandler is a Toronto-based OHS consultant with Gowlings. For more information, visit www.gowlings.com.
