Why do they occur? Are they inevitable?
- By Stephen V. Magyar, Jr., MBA, CSP
- Jul 01, 2006
accident is an unwanted event that is never scheduled or planned. Many
factors contribute to accidents' occurrence; significant losses and
even bodily injury can result following each incident. These basic
facts are well understood, yet accidents continue to occur, property
damage accumulates, work schedules remain interrupted, and injuries
reduce personal income.
Are accidents inevitable? Do they occur as a natural consequence of a daily routine? Can they be avoided?
All accidents are caused. They are the result of human error, and
they involve unsafe behavior or an unsafe condition, or a combination
of both. Process improvement opportunities are always identified
following an accident, and prompt corrective measures are scheduled.
Unfortunately, the inherent ability of the environment or behavior that
initially caused the accident is seldom addressed in its entirety.
Thus, we wait for the next accident in order to identify the next
required corrective action. Hindsight has future value, but only after
the accident occurs. The opposite of hindsight is foresight. With
foresight, you identify accident potentials; with hindsight, you
investigate accidents. Let us consider the value of each.
The Process of Hindsight: Accident Investigation
Discovering "what happened" and "why" are the objectives of an
accident investigation. To ensure standardization in fact gathering,
checklists are often used. Supervisor and employee work together to
identify causes and remedial actions. The process requires a
Everyone involved should know that an accident investigation is not
a "fault finding" or "finger pointing" expedition. Meaningful
involvement is essential. Employees can provide valuable suggestions
when they are regarded as "full partners" in the investigation process.
There are generally five major elements in a good investigation:
specifics, procedures, conditions, unsafe elements (acts and/or
behavior), and corrective action. How, when, where, and why did the
accident occur? What procedures were being followed and why? What
conditions existed when the accident occurred? What was the primary
cause of the accident? What should be done to prevent similar
occurrences? Remember: All accidents are caused and could have been
prevented by the identification and removal of one or more of the
contributing factors. All possible factors must be discussed and
identified. Participants in the investigation should agree with the
"Employee tripped and fell while en route to the parking lot" does
not provide sufficient details. "Employee should be more careful" is
not adequate corrective action. "Repaired the defective equipment" does
not identify the root cause of the failure. "Additional training will
be provided" does not explain why the unsafe behavior occurred. Anyone
reading an accident investigation report should be able to visualize
exactly how the accident happened and should know the corrective action
needed to prevent recurrence is adequate.
Hindsight is effective only when each accident, regardless of
disposition, is treated as a matter of real importance. Reporting must
be encouraged, and investigation must be prompt. Supervisor and
employee must work as a team to identify accident causes and corrective
actions needed to prevent similar incidents.
The Process of Foresight: Identification of Potentials
Each accident results from a breakdown in the safety system.
Employee behavior/procedures and/or the condition of
equipment/environment are always involved. The ability to monitor and
evaluate these elements on a continuous basis can identify work
practices and conditions that have the ability to produce accidents.
Employee involvement is critical to the foresight approach. Most
injuries involve shop employees who "do the work." Their work practices
and attitudes determine the level of safety that exists in the shop.
It is not possible to provide continuous monitoring during a work
shift. A representative sample of work routines is usually enough,
provided the data collected is quantified and reviewed with
supervisors. Behavioral trends must be determined; equipment
abuse/misuse must be identified; random adjustments in work procedures
must be discovered; and work flow must be evaluated. Whenever the
potential to cause an accident/injury is apparent, corrective action
must be implemented.
"Foresight Programs" must be a joint effort (supervisor and
employee) with objectives that are pre-determined. Audit teams must be
developed, and observations of work practices in designated areas must
be scheduled. Typically, an audit might involve a supervisor and
employee visiting a work area other than their own to observe work
habits/routines. The actual process would be:
- Select the workstation or operation to be observed before
beginning the audit. Concentrate on a single worker or operation. (The
"big picture look" often produces very little meaningful information.)
- Observe the work habits/procedures/equipment being used to perform work. Determine how accidents/injuries can occur.
- Identify any behavioral changes that occur during the audit.
- Evaluate housekeeping conditions and equipment in the work area.
Is anything "out of place"? Is unnecessary material or equipment
located in the work area?
- Discuss work routine with the worker. Do not "coach" the worker.
Ask questions such as, "Why are you using (a particular method)?" "Do
you think there is a better method?" "Have you ever had an accident?"
The worker should identify unsafe practices and/or potential accident
causes without assistance. Unsafe behavior should not be criticized.
- 6. Summarize your observations and provide corrective action not
indicated by the worker. The worker should take the initiative in
correcting unsafe work practices and should accept responsibility for
Information collected should be combined with data from other audits
to establish trends and to identify accident potentials that are
inherent within the work process. Accident source reports should be
developed and reviewed with supervision. Appropriate corrective action
should be implemented. All workers should know that these "get
acquainted audits" are being conducted to evaluate safety practices and
to provide improvements that will "make work easier and safer" for all
Foresight is an effective means of preventing accidents when workers
embrace the concept, regular audits are conducted, and corrective
action is provided. Participation must be encouraged and supported by
top management. Considerable benefits, including "before-the-fact"
accident prevention, can be derived from a well-run program.
Hindsight vs. Foresight
Hindsight determines why accidents occurred; it does not
prevent them. Foresight identifies potential accident conditions and
provides corrective action before the incident occurs. It is the
difference between being proactive and reactive in your safety
philosophy. Both methods require employee involvement and an investment
of time. The foresight approach does not involve equipment and/or
property damage, injury costs, unscheduled production downtime, or
product quality issues.
While there is no guarantee that accidents will not continue to
occur when the foresight approach is adopted, there is a "comfortable
feeling" about the value of accident prevention efforts.
- Earnest, R.E., "Making Safety a Basic Value," Professional Safety, August 2000, pp. 33-38.
- E.I. DuPont de Nemours & Company, "Safety Training Observation Program," Wilmington, Delaware, 2005.
- National Safety Council, "Accident Prevention Manual for Industrial Operations, 7th Edition," Chicago, Illinois, 1974.
This column appeared in the July 2006 issue of Occupational Health & Safety.
This article originally appeared in the July 2006 issue of Occupational Health & Safety.