Post Accident Review - Part I - Hurtado & Associates

By Dean B. Wisecarver

There are plenty of ways to examine your operation to improve efficiencies and avoid errors. One of the most immediately obvious ways, but one most frequently not pursued, is to carefully examine the circumstances of things that actually do go wrong -- accidents. Accidents are red flags, indicators of things that are not quite right. Almost all accidents arise out of a series of events or situations, not just one and not just the most obvious. Every contributing event or situation is an opportunity to improve the way work gets done.

Learn from things that go wrong.

If your company does not do so already, it should require your on-site supervisors or crew leaders to thoroughly review any employee accident as soon as it occurs. I am not talking about gathering information to report the injury to your insurance company or to complete the Employers First Report of Injury forms. I am talking about digging into the details in a way that will help to identify the underlying causes of the accident and offer recommendations on what could be or should be done to prevent a recurrence. This is a process which can provide significant insight into how your company can revise and/or establish new work practices and procedures which will reduce the likelihood of future accidents and improve efficiency.

Review all accidents, including minor ones and close calls.

The post accident review process should follow every mishap or accident, not just unusual ones or particularly severe ones. Investigating (reviewing) even relatively small incidents, with an eye toward finding and correcting all the little things that contributed to each, will help your company control and avoid the big, serious accidents while improving operations and profitability. Ignoring "minor" injuries or accidents is to postpone correcting a problem until it causes serious damage.

Focus on the "process" not the person.

Post accident review is a problem solving activity. It is not a "witch hunt" to find someone to blame. If you or your supervisors are inclined to believe a given accident was caused by one individual's behavior or actions, ask yourself this question: "If I fire this person today, will this accident or one very similar to it ever happen again?" If the answer is "no" then perhaps you should terminate the individual. I suspect the vast majority of times the answer will be "yes, it could (and probably would) happen again, to somebody else." If it would happen again, what value is there in finding fault with one individual? We need to step back and look at how we do things, to correct them so somebody else does not get into the same situation or commit the same error. Post accident review is an analysis of facts to find opportunities to improve training, work practices, tools, and procedures which will help your organization avoid similar accidents and/or errors.

Simple documentation is fine.

The process need not be burdensome or create new paperwork. You probably already require supervisors to gather and report the basic information about what happened: who, where, when, and other details necessary to process a claim. The same reporting form could be expanded to give the supervisors a place to report recommendations to management about how to avoid similar accidents. Their assessments and conclusions are what you seek. How the supervisors report their findings and recommendations is completely up to you.

With a little training and encouragement, your supervisors can learn how to quickly examine the facts surrounding an accident and find several effective preventative approaches. Let's look more closely at how to analyze the details of a mishap to find the opportunities for improvements, who should do it initially and why, and what management (you) can do to support and sustain the process.

Who should do the review?

Once managers accept the idea that accidents should be reviewed to determine what the company can do to prevent future, similar accidents, the issue often becomes: Who should do the review? Who should be expected to sort through the facts and determine what changes are appropriate and necessary to prevent the same problems and results? Many managers I meet believe that only they, or managers in their Safety or Human Resources staff, have the objectivity, the analytical ability, and the broad-based interest in the company to review the facts and determine what is best for the company. Thus, if the reviews are done at all, high level managers tend to do them. While there is a certain logic to this approach, I believe much may be lost if top management always does the review.

I believe the supervisor on the site or in the area where the accident happened should be the person to do the review, at least initially. I certainly would not want the executive manager to abandon his/her close involvement and final review, but I believe the supervisor should have the first crack at assessing the circumstances of the accident and make pertinent recommendations to the executive. I believe there are several important benefits from this approach. The following paragraphs briefly outline the benefits.

Why the front line supervisor?

The supervisor retains authority and control. Generally, as an executive, you expect your first line site supervisors to assume responsibility for virtually everything that gets done or happens on a job site. You grant them the authority to make decisions about the work and to monitor and give direction to the workers to get the job done. When something goes wrong, you expect the supervisor to identify it and correct it. Probably dozens of little glitches arise in the course of a day's work that your supervisor handles within the scope of his/her authority and you may never even know about most of them. When you do know, you may well praise the supervisor for taking care of them and getting on with the job. If the "glitch" results in an injury to a worker, why should the supervisor's authority and responsibility change? He/she should still have the authority and responsibility to assess the situation and take corrective action. If you usurp this authority in such cases, the supervisor will immediately try to distance himself/herself from the situation, probably trying to blame the incident on the involved worker or someone else, ultimately a non-productive effort.

If you want front line supervisors to view themselves as "in control" and fully responsible for the actions and results accomplished by the crew, then they should retain the authority to try to solve all work-related problems, including injury accidents. Retaining this authority allows the supervisors to sustain their positions and stature in the eyes of the workers.

Supervisor develops skill in problem-solving. As an executive, you know you must rely on others to get things done. Even if you had all the knowledge to do so, you simply do not have time to solve all the problems that might come up throughout the company. At some point you will say to your supervisor, "You figure out what needs to be done, then tell me. I can't make all your decisions for you." This is a harsh way to admit a simple reality -- you have to give others the opportunity to solve problems and make decisions if they are to become effective doing so.

If you want supervisors to become good problem solvers, and if you want them to take personal responsibility for the safety of their workers (your workers) then it follows that they should have the authority to investigate (review) the facts of an accident involving their own crews and try to determine solutions. You may have to assess their results and coach them in ways that will help them improve, but that is no different than any other decision or problem situation that may arise. An injury to a supervised worker should not change the rules or the approach.

Supervisor retains the ability to be both honest and self-critical. Most of us know that judgment of ourselves is often more accurate and more critical than judgment from others. Furthermore, most of us can handle self-criticism much better than criticism from others. Self-assessment is a very important attribute for managers and supervisors if our goal is to do what is best for the success of the organization and not just for personal gain. If something goes wrong on the job and you rush in and take over from the supervisor, the supervisor's first reaction will almost always be defensive and self-preserving, not organizational. The supervisor will answer your questions about the accident with a careful eye on avoiding blame, which may result in less than accurate answers. Ironically, if that supervisor is given the direction and authority to assess the situation independently and is asked to offer meaningful solutions that truly will help the company, he/she will be much more likely to be honest and self-critical while trying to develop a positive result out of a negative incident. This ability to assess any problem without bias, and without covering up one's own mistakes, is an ability you would like to see in all your supervisors and managers.

Of course, top management definitely does have an important role in the post accident review process. Part 2 of this article, in the next issue, will address and define that role and offer some suggestions on fulfilling it effectively.