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 that 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. For example look at the descriptive surface cause and a root cause statements below.
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.
Knowledge Check Choose the best answer for the question.
8-4. What is the most common failure found in accident reports?
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