The Accident Report Form
Section III. Findings
The findings section describes the hazardous conditions, unsafe behaviors and the system weaknesses your analysis has uncovered. Each description of a surface or root cause will also include justification for the finding. The justification will explain how you came to your conclusion.
Unfortunately, the most common failure found in accident reports is they address only surface causes. Consequently, similar accidents recur. These report forms may have a format that "forces" the investigator to list only surface causes for accidents. The form does not "report" the system weaknesses associated with each surface cause. Consequently, the investigator believes the job is done without ferreting out the system weaknesses representing the root causes.
Other forms may actually require the investigator to indicate the status of employee negligence. Now, how can the accident investigator assure an interviewee or any other employee that the purpose of the analysis process is to "fix the system - not the blame," when the report form shouts "negligent"?
To complete this section, just state the facts: The hazardous conditions, unsafe behaviors, practices, and inadequate or missing programs, policies, plans, processes and procedures that produced them. Be sure to write complete descriptive sentences. Not short cryptic phrases.
Sample surface cause statements
Hazardous condition: A high voltage power line was located directly over the work area.
Unsafe behaviors/activities: Employee #1 was working with equipment within 10 feet of high voltage power lines without spotter or taking other precautions. Employee #1 received training from another employee who did not have sufficient knowledge of safety procedures.
Sample root cause statements
Inadequate process: The process of training employee #1 and #2 around high voltage lines does not include safe work procedures.
Inadequate training plan Safety training plan does not include procedures for employees working around high voltage line.
Missing Policy. Policies regarding safe working procedures and practices related to work around high voltage lines do not exist.
Section IV. Recommendations
If root causes are not addressed properly in Section III of the report, it is doubtful recommendations in this section will include improving system inadequacies. Effective recommendations will describe ways to eliminate or reduce both surface and root causes. They will also detail estimated costs involved with implementing corrective actions. Let's take a closer look at effective recommendation writing.
Sample Recommendation that Corrects the Surface Cause
Conduct immediate training for all affected employees, and their supervisors, who are exposed to the high voltage line. Document all training. Estimated costs: $500.00
Sample Recommendations that Correct the Root Cause
Develop and implement policy directing supervisors to conduct safety training, including demonstration, to all employees under their control. Estimated costs: $1500.00
Develop company safety training plan for employees and supervisors that includes safe work procedures and responsibilities while working near high voltage lines. Estimated costs: $1,000
Develop and implement an executive level safety and health education plan. Estimated costs: $500
Section V. Summary
This section contains a brief review of the causes of the accident and recommendations for corrective actions. In your review, it's important to include language that contrasts the costs of the accident with the benefits derived from investing in corrective actions. Including bottom-line information will ensure that your recommendation will be understood and appreciated by management. Remember, it's never appropriate for the accident investigator to recommend disciplinary action. Disciplinary action should be considered only by managers and only after very careful consideration of all of the facts. By the way, if system weaknesses that contributed to the accident are identified, discipline is likely unnecessary.
Open document: The accident investigation report should be considered an open document until all recommendations have been addressed.
Knowledge Check Choose the best answer for the question.
2-10. Which of the following is not appropriate in an accident investigation report?
You forgot to answer the question!