Peter Knaack

Accident Investigations:

The need to investigate a hazardous occurrence remains a definite legal requirement in most jurisdictions in Canada.

Many organizations fail to appreciate their legal obligations to investigate hazardous occurrences in an expeditious fashion and the related responsibility to inform the regulator and internal health and safety resources within a few hours of such an event.

Despite the cost to an organization in terms of lost production, additional labour inputs and the like, the completion of a detailed investigation in the wake of a hazardous occurrence by a team of proficient investigators can bear a variety of significant organizational benefits.

Timing:

The investigation of hazardous occurrences can often be derailed by the actions of responsible managers and supervisors who more often than not remain squarely focused upon their production related responsibilities to the detriment of any subsequent hazardous occurrence investigation. Hence corporate health and safety policy must clearly emphasize the fact that responsible managers bear a primary responsibility to ensure that the need for an investigation is communicated and that the scene of the event remains secured and isolated from any potential interferences.

Part of the necessary action required to secure a scene, is the need to localize witnesses and to keep them apart from one another or any other individuals such as coworkers, family members or supervisors until they can be successfully interviewed. The fact that a hazardous occurrence has just taken place must also be communicated to corporate health and safety resources including especially members of joint health and safety committees.

In many jurisdictions there also exist definite legal responsibilities to report hazardous occurrences to the regulator. This is especially the case with fatalities, high severity events, events that target specific parts of the body such as the head, eyes or limbs and hazardous occurrences with the potential to result in mass casualties. Most jurisdictions in Canada require notification of a significant event within 24 hours or less.

Seriousness:

Unfortunately many organizations do not regard the investigation of incidents, those events that generally do not result in injury, property losses or environmental damage, as an operational priority. Incidents are generally considered to be of little importance and certainly not serious enough to warrant the expenditure of corporate resources to investigate.

The challenges associated with ignoring near accidents remains the fact that the conditions present during an incident are in most cases identical to those present during a "full blown" accident. Hazardous occurrences with fortunate outcomes represent a significant opportunity to preempt the accident cycle if they are acted upon through the completion of a proper investigation. By localizing the causes of a near accident investigators can quickly resolve a situation before it can result in injury or other serious losses. Hence the real false economy in many corporate health and safety programs lies in the low priority assigned to investigate incidents over accidents.

The costs associated with investigating a near accident are also significantly lower than those that accompany the need to investigate an accident. In many cases near accidents can be investigated by a smaller number of investigators or a team lead by the responsible manager. Depending on the severity of an actual accident it may prove necessary to involve a variety of expensive outside resources including professional hazardous occurrence investigators to spearhead an investigation into a high severity hazardous occurrence.

A 65 year old Ottawa area backhoe operator, Ulderico Iannucci, tried in vain to jump out the back window of his machine before it plunged off a 50-metre escarpment behind Parliament Hill in 2005.

Iannucci had been compacting trash behind the Parliament Buildings on Friday, August 19, 2005 with the rear scoop of his backhoe when the machine suddenly engaged. Witnesses said the backhoe hurtled through a chain link construction fence toward a stone and wrought-iron retaining wall at the top of the steep escarpment above the Ottawa River. Investigators believe that the accident happened when the machine inadvertently slipped into gear and veered toward the cliff.

A 31-year-old employee of Mancuso Chemicals Ltd., Charles Condez, was tragically killed while he and a colleague poured two 500-kilogram bags of formaldehyde powder into a mixture of phenol and water at about 11:20 on Friday, November 22nd, 2002.

An unusual chemical reaction ensued at the company’s Progress Street location and Condez was splashed with the resultant toxic mixture which rapidly led to his death. For nearly 100 hours, the chemical worker's highly contaminated body came into contact with co-workers, firefighters, emergency paramedical personnel as well as hospital workers.

On November 26, 2002 local firefighters supported by the Hamilton Regional Police and a private Hazardous Materials Emergency Services provider equipped with protective suits and self-contained breathing apparatus were called to the Greater Niagara General Hospital morgue to decontaminate a body that had become so toxic that doctors could not safely conduct an autopsy.

Charles Condez was a trainee at the time of his death.

Legal Requirements:

Two basic legal requirements exist for employers with regard to workplace accidents. In the case of injury especially those that require medical intervention beyond first aid, employers must proactively report workplace accidents to their respective provincial or territorial worker's compensation authority within three days using a specially designed fax, email or telephone form. In the case that an accident meets specific criteria set buy the authority having jurisdiction, employers generally also face an additional reporting requirement.

Once an event meets any of the reporting criteria identified in statute or regulation employers bear an additional responsibility to report any such event to their authority having health and safety jurisdiction. Even accidents that are investigated by a law enforcement agency such as the RCMP or a municipal police force may also require an additional investigation if the occurrence involved an employee engaged in work on behalf of an employer.

Employers may also bear a variety of other legal reporting responsibilities that derive from contractual obligations. For instance collective bargaining agreements often spell out additional reporting responsibilities vis-à-vis a union organization.

Such additional reporting responsibilities may also exist with regard to certain manufacturers who require notification where their equipment is implicated in an event. Similarly a variety of public and private regulators exist that need to be notified when specific classes of hazardous occurrence take place. One important example would be the failure of boilers and pressure vessels as well as accidents involving elevators both of which are regulated by specific provincial bodies such as the TSSA in Ontario.

The Benefits of Accident Investigations - Hazardous Occurrence Investigations are much more than just a Legal Requirement!

Aside from the obvious legal implications involved with the investigation of a hazardous occurrence, one of the key benefits of such an investigation for an organization is the development of a clearer understanding of the effectiveness of preexisting safety controls.

Safety controls and procedures represent an essential aspect of corporate health and safety policy. They also represent a significant investment of time, money and other important corporate resources. Hence a professionally conducted hazardous occurrence investigation has the potential to provide a clear determination of all of the driving causes of an accident or incident including especially a micro level review of the sequence of events.

Such an investigation can also yield a detailed picture of some of the more unfortunate organizational dynamics that either directly or indirectly influenced the development of a hazardous occurrence. Thus an analysis of a workplace accident or other mishap conducted at the macro level can yield significant insights into a number of crucial internal organizational factors for instance the impact of a functional or dysfunctional corporate culture on the overall traction of corporate safety systems.

Establish Direct Causes:

An investigation into a hazardous occurrence allows investigators to delve into the direct and indirect causes of such an event. Once investigators have been able to identify all of the causal factors it becomes possible for an organization's management team to implement the necessary corrective measures.

Determine Cost:

The total cost picture that accompanies a hazardous occurrence often remains unclear. If conducted properly, an investigation into a hazardous occurrence can uncover a clearer picture of what the event cost an organization both in terms of the human and the material costs. One of the most important cost drivers associated with a hazardous occurrence would be the resulting worker's compensation and medical inputs which due to the way some organizations are structured are not always made available to investigators in the wake of a hazardous occurrence. Calculating the cost of broken machinery and lost production time can be relatively straightforward. On the other hand developing clear calculations of the worker's compensation and medical costs can be much more challenging considering the timelines involved for a case to be resolved.

Identify Contributing Causes:

Hazardous occurrences typically involve a variety of causal factors including such factors that in themselves were mere enabling factors but not the actual direct cause of the event. A thorough investigation into a hazardous investigation will typically uncover a number of important secondary causal factors as well as a number of previously unrecognized hazards such as malfunctioning machine controls and poorly reasoned safety procedures. An example of a secondary or indirect causal factor can be the regular commission by staff of unsafe actions. More often than not more experienced workers engage in taking potentially hazardous shortcuts during the production process despite the obvious danger of doing so. In many cases when accidents begin to manifest themselves it is not the more experienced worker who is hurt by these departures from safe practices but the younger inexperienced workers trying to emulate the behaviours of their more seasoned colleagues.

Prevent Similar Occurrences:

Corrective measures implemented post accident or post incident are put into place by employers to ensure that any future recurrences can and will be prevented. Hazardous occurrence investigations are usually an excellent prevention tool as investigators typically will uncover a variety of previously unknown hazards in addition to providing a more fundamental understanding of an organization's existing hazard profile and the associated controls. As such the knowledge derived from a hazardous investigation can lead to targeted improvements being applied to existing health and safety systems and vicarious lessons being shared within an organization and between different organizations as part of some form of mutual aid arrangement.

Creates a Permanent Record:

Most jurisdictions in Canada require employers to investigate hazardous occurrences especially when they result in fatalities or where the severity of the occurrence was sufficient to result in time loss injuries. In addition to the reports generated to satisfy the requirements of provincial and territorial worker's compensation legislation, employers often must also generate a separate report for their requisite provincial or federal regulator such as a Ministry of Labour Inspector or a Labour Affairs Officer attached to Human Resources Skills Development Canada (HRSDC)

Promote Safety Awareness amongst Staff:

Accidents in the workplace can act as a wakeup call to both staff and management. In many cases a hazardous occurrence will take place at a point in time where corporate safety systems and cultures have become challenged by complacency. It becomes harder for supervisors and managers to justify existing health and safety procedures where "nothing ever seems to happen." As such most organizations will witness over time an up swell of accidents and injuries that appear to take place after a long period where no hazardous occurrences were noted. With this factor in mind it is essential that lessons learned through an investigation are quickly shared with staff to ensure that a heightened level of awareness results.

Peter M. Knaack, MA