Accidents may be described as a loss. The loss is most troubling when it results an injury, but it could also involve the loss of product, process and equipment damage and thus it will also involve a financial loss. It is therefore important to understand the nature of accidents and try to prevent their occurrence.
In Ontario, the law only requires an accident investigation after a fatal or critical injury. This represents the minimal standard of the Occupational Health and Safety Act. However, an employer seeking to satisfy a due diligence mandate would not want to simply follow the minimum standard of law. In fact, an employer should seek to investigate all accidents. Indeed, even incidents that did not result in an actual accident, the near misses, should be actively investigated. After all the cause of a near miss is no different than the cause that resulted in an actual accident.
A workplace accident represents the failure of an organization’s management system to identify and control workplace hazards. Such failures must be studied and lessons learned if they are not to be repeated in the future. Thus the true role of accident investigation is to shine a light on what happened and, most importantly, why it happened. It is the understanding of the “why” of an accident that allows for a discussion of what can be done in the future to prevent the occurrence.
It is also important to understand what accident investigations are not. They must not become a “witch hunt”. An exercise in blaming the immediate cause, usually the injured worker, for not following the rules or not being careful in the carrying out of his or her work duties. It may very well be that a worker has not been sufficiently careful or followed appropriate work procedures; but the investigation must ask the all-important question of why. An understanding of why will lead to an understanding of the root cause of an accident and this is the whole point of accident investigation.
We can only fully address the why of an accident, if we understand the root cause of an accident. The point of doing accident investigation is to get to that root cause and then make changes based on that understanding.
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