The Steps of an Accident Investigation

8/14/2017

Ethyl Mercaptan got out of her car and took in the view of the project site. She was here to help with an accident investigation. The other day there was a pretty bad incident where a worker was hit by a water truck that was spraying the roads as a dust control measure. She heard the initial scenario earlier this morning when she had a phone conversation with the site superintendent who frantically described the event. Some laborer listening to music on his smart phone didn’t see that he was walking into the path of the truck. There wasn’t much of a noise; just a two thuds and a scream – at least that’s how the workers described it.  That is, the worker, Eliot Rosewater getting hit, then hitting the ground. The scream came from either him or the driver of the water truck.  

At least, that’s how the preliminary report spelled it out. “Employee listening to music and not paying attention.” Without a doubt, the employee did have some fault, but Ethyl was wondering if this was an isolated case. In her eyes things didn’t add up. It seems that this employee, Eliot Rosewater, was assigned tasks throughout the workplace. Didn’t anyone say anything? Apparently, like most accident investigations, contrary to the initial assessment, most workplace accidents aren’t that clear-cut. Ethyl also knew that regardless of what the investigation turned up, placing the blame on one person is typically taking the easy way out and, more importantly, does not find the true cause of the accident and therefore, a similar event can happen again. Therefore, it was important to get to the bottom of things.

She walked up the stairs to the project trailer. Opening the door she was immediately greeted by the superintendent, Rush Limbaugh. After shaking hands and offering Ethyl a cup of coffee, they proceeded into Rush’s office. The door was shut and Rush began.

“Quite honestly, Ms. Mercaptan, I didn’t see the need for corporate to send you out here. Eliot did a stupid thing and he got a very expensive lesson. Unfortunately, this project will also get a black eye with this being a lost-time case. The doctor said that he’s expecting a full recovery, but still, here we are with a ‘stop work’ issued by our customer, so I guess you can help us calm things down and get us back up to speed.”

Ethyl nodded and put down her coffee. “I have received some information through my questionnaire that was sent out anonymously.” Rush looked a little ticked off as it appeared that Ethyl started work behind his back. Ethyl raised her right hand as if to say, “I understand your concern.”

“Information gathering is a very important step in an accident investigation.” From what I have received, it seems that there are quite a number of folks that did not know that using smart phones is not allowed. As a matter of fact, as I was driving through the worksite, I noticed a few people talking on their cell phones.”

Rush jumped in. “talking on one’s cell phone is one thing but listening to music is completely different.”

“They are both considered distracted behaviors as they take away focus for the task-at-hand. From what I am getting, it seems that workers are not fully aware of the potential hazards associated with cell phones. Without a doubt, I would have thought that listening to music would be obvious, but if it was never addressed…..” Ethyl trailed off. “Let me ask you something. Did we ever complete the investigation report?”   

Rush looked at Ethyl and retorted, “That’s why you’re here Ethyl, to help us with the investigation.”     

“Accident investigations need to be conducted ASAP Rush.” Ethyl continued. “This is because facts can get lost if they aren’t captured as soon as possible.  Also, as time goes on, people’s recall ability deteriorates or they start to recreate the event so as to ensure they are not left at fault. Another important point is that there needs to be complete confidence and cooperation. Otherwise, people will just say what they think we want to hear and then we will never get the real facts.  However – and this is BIG however, Rush – workers have got to understand that our primary purpose of going through an investigation is to find out why it happened and how we can prevent another similar occurrence from happening.” 

Ethyl was about to continue when Mika Brzezinski walked into the trailer. Rush explained that Mika was a student intern who was tasked with conducting the preliminary investigation. The two women shook hands.

“Mika, can you tell me how many people you interviewed? Any conflicting statements? And most importantly, do you feel you got to the root cause of the event?”

That was quite an earful for Mika.  Ethyl was able to see the panic in Mika’s eyes. After all, it was evident that performing a real-life accident investigation was something new to the intern and without a doubt, she looked lost.

Ethyl turned to Rush.  “I’ll tell you what Rush, why don’t you let Mika and I go over a few things together and we’ll get you something real soon?”

Rush smiled, realizing that Ethyl’s years of experience would be helpful, not just to the investigation but to help tutor his intern. “Alright, Ethyl, feel free to use my office. I’ll get out of your hair and get together with our mechanic. Give me a holler if you need anything.”

Once alone, Ethyl explained to Mika that the investigator’s role is to gather and organize information in an effort to uncover the truth behind the incident. Because details aren’t always clearly defined, and because witnesses can perceive things differently, the investigator should have enough experience and competency to perform the process .This means the investigator needs to understand when he/she needs additional subject matter expertise. And that means pushing one’s ego aside.

The information-gathering process involves questioning witnesses and asking them to complete and sign statements about what they saw. These findings need to be documented, even if a worker says that he or she didn’t see the incident, because that information will be helpful if stories change down the road. The purpose of questioning is not to determine who deserves any blame; it’s to collect as much information as possible about exactly what took place.

As the investigator looks over what he or she has been able to collect, it’s important to identify any gaps in the information and attempt to fill those gaps through additional investigation. Of course it is most important to share information with the crew as this provides powerful motivation to encourage workers to make the right choices in the future.

Ethyl’s final thoughts centered on implementing the recommendations and make any necessary changes to processes and procedures for the purpose of ensuring that there won’t be a repeat of the incident. Part of making that change is regular follow-up to ensure that the correct steps are being taken. That way, the time and energy that have been invested into the accident investigation will have been worthwhile.

If people are good only because they fear punishment, and hope for reward, then we are a sorry lot indeed

Albert Einstein