THE IMPORTANCE OF THOROUGH ACCIDENT INVESTIGATION

BY ALEX CHAN, FIOSH, RSP, RSO, CHSC

An accident is an undesirable and unplanned event that results in a personal injury. Firefighting is an honorable and very risky profession in which firefighters put their well-being on the line to protect the public. Any firefighter accident that occurs when responding to an emergency can result in injury or even death. Firefighters’ training, standard operating procedures (SOPs) and guidelines (SOGs), and personal protective equipment (PPE) are all designed to minimize the risk of firefighter injury. If firefighters properly use their PPE (their frontline protection system) and operate according to the established SOGs/SOPs, theoretically, they should be well protected.

However, as human beings, we make mistakes-inappropriate actions or decisions. If we don’t learn from them, we can’t avoid repeating them. We may be injured under similar circumstances again, possibly paying the ultimate price! We definitely need to learn from the results of past actions and decisions. We should not let such opportunities to learn slip by, even if we are too busy or too exhausted.

Example. A firefighter reports to his captain that while exiting the apparatus at an emergency scene, he lost his footing and injured his ankle. Let’s change the situation a little. The firefighter was responding to a multilevel alarm, and the on-scene situation was very desperate. Every firefighter was anxious to do his job to control the fire and save the trapped civilians. As the truck approached the scene, but before it stopped, the firefighters, eager to carry out their mission, disembarked from the truck in full gear. But one member lost his footing and fell into the street. Remember that the truck was still in motion. What are the possible consequences of this scenario? How would this affect the on-scene operation, the public’s safety, the firefighter’s family, and the other members on the same truck-particularly the driver?

All accidents result from inadequacies in an organization. Unless we diligently look for them, more serious, even fatal, accidents may just be waiting to happen. Conducting thorough accident investigations is one way to uncover these shortcomings. Such an investigation includes establishing not only the immediate cause of the accident but also the systemic failures in the organization that led up to it. With a thorough investigation, we can see what needs to change in our individual and organizational practices so we can more effectively prevent workplace injuries.

All accidents have more than one cause and may be traced to inadequate practices at various organizational levels. Note that although many of these practices may have been implemented with good intentions, they were not carefully thought out or implemented with adequate coordination and communication. Thus, they are a potential threat to the health and safety of everyone in the organization, including the chief.

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Always remember that an accident investigation is not intended to assign blame. The inquiry’s purpose is to find out the cause of the accident so that the whole organization can find practical ways to improve related shortcomings to avoid a future incident.

AN ACCIDENT INVESTIGATION

Incident and loss. Discovering all the factors that played a role in an accident in an orderly fashion is like peeling an onion. Our investigation starts from the moment of the firefighter’s injury and proceeds from there to identify some possible causes. For example, let’s look at an incident at which a firefighter cut his hand when breaking the windows during a house fire. The breaking of the window at the house fire is the incident, the situation in which the accident occurred. The injury that resulted from contacting an object or a substance that the body is not able to withstand is the loss, the actual accident.

Immediate cause. The fire and the broken glass are conditions a firefighter regularly encounters throughout his career. One condition exists on its own; the other results from firefighting activities. By themselves they will not cause harm unless one comes in contact with them. The firefighter’s actions bring him in contact with the condition that caused the injury-i.e., the broken glass (when he broke the glass, when he leaned out of the window, or when he was trying to place something nearby for his work). Is this the only possible cause of this accident? No, it is just the immediate cause-the last link in a chain of actions leading to the final result, the injury. These factors are the cause of the injury-how the firefighter injured himself.

Accident hypotheses. Firefighters are required to use personal protective equipment (PPE). In the above example, the firefighter should not have been injured if he had been wearing the required PPE. Now think: Where was the firefighter injured? His hands. How do we protect our hands? Gloves. Did the firefighter wear his gloves? If so, in what condition were his gloves? Although there are many possible situations that can illustrate our point, let’s limit our discussion to two hypothetical situations.

Situation 1. The firefighter wore a pair of loosely fitted gloves and was not used to the material in them. Why? These were the only gloves available at the time. The properly fitting gloves he had been issued were still drying from a previous incident, and his replacement gloves had not arrived at the time of the incident.

Situation 2. The firefighter wore a pair of worn or partially worn gloves at the incident because the replacement pair he had ordered had not arrived when he responded to the call.

Basic causes. The matter does not end here. Not yet-we have only proposed some possible basic causes of the accident that resulted in the injury. Basic causes relate to how the job is done (e.g., types of tools, how tools are specified for purchasing, how tools are used/maintained, officer leadership) and the personal factors (the physical and mental ability of the person as related to the task, health conditions, and his ability-knowledge, skills, and experience-for the task).

Root causes. These are what ultimately caused the accident and are the bigger picture behind the basic causes. Root causes, like the root system of a tree, branch out extensively throughout the organizational structure, affecting every division within the department. Without identifying these pieces of the puzzle and fitting them in where they belong, we can see only a part of the situation, which will not help eliminate accidents.

Equipment distribution factors. Going back to Situation 1, we hypothesize that the firefighter was never provided with the properly fitting gloves. We need to determine the following: Who is responsible for issuing the gloves? Why were the gloves not issued? Did that person know that it is his responsibility to issue or arrange the issuing of protective gear? What is the departmental policy regarding issuing PPE? Did the policy define the responsibility clearly? Were policies supporting the use and distribution of PPE in place? Were implemented policies and guidelines enforced? Were they enforced consistently and persistently?

Backup equipment factors.We hypothesize that the firefighter’s issued gloves were being dried when he was called out. What are the arrangements in the department to ensure that firefighters have spare equipment? Was there an adequate amount of spare equipment available? Had the department considered the amount of spare items and the sizes that optimally should be available? What is the condition of the available spare equipment?

Equipment procurement factors. We hypothesize that the firefighter was waiting for his replacement gloves. What procedures have been implemented to get replacement PPE? How complicated is it to get replacements, and how long does it take? Are firefighters required to inspect their PPE frequently and periodically to ensure they are in good working condition? Are firefighters aware of the importance of such inspection? Do standards exist that determine the condition of equipment under which they must be replaced?

Equipment quality control factors. Finally, we hypothesize that the firefighter was not used to the new replacement gloves. Did the department investigate the gloves’ quality and the construction materials used when buying them? What standards exist regarding breaking in new PPE? Had the firefighter discussed the concern with the department and tried to find a way to address the matter?

In Situation 2, we hypothesize that the firefighter’s gloves were worn out and he was waiting for his replacement pair when he was called to respond. Is the replacement equipment request process unusually lengthy? Was the quartermaster out of stock? What resources does the quartermaster have to meet equipment replacement requests efficiently-e.g., inventory control, a stockkeeper, and means of delivery to customers?

THE DOMINO THEORY OF ACCIDENTS

From the example above, it is apparent that an accident, no matter how minor it may seem, can provide us with very critical, valuable information that helps identify the inadequacies in our organization. Once the shortcomings are identified, we can correct them before a serious accident occurs. If we do not investigate an accident thoroughly and determine its root causes, we will be wasting our resources and be unable to prevent future occurrences. Pioneers in health and safety and loss control management call this the Domino Theory of Accidents.

Thorough accident investigation requires dedication, commitment, and self-discipline. Some may question the need to investigate (especially if the injury is minor) when they have just returned from a call in the middle of the night totally exhausted. Although the exhaustion is understandable, everyone should bear in mind that, if we are not able to find out the causes, especially those “hidden behind the scenes,” we will be unable to eliminate accidents. No one knows who might next fall victim to inadequate, unsafe practices. In different circumstances, this minor accident could have been fatal if the firefighter had cut his artery and he was working on the 30th floor of a high-rise building.

Senior management should review accidents to identify the root causes and rectify them promptly. They need not scrutinize every accident reported but should review accident reports at least biweekly, if not weekly. The health and safety section, if the department has one, could be assigned this review task. The health and safety section should be empowered to conduct thorough impartial investigations and report its findings and recommendations to senior management. When an investigation identifies potential flaws in the organization’s system, they should be reported to senior management, which should then intervene to rectify the flaws.

ALEX CHAN is an occupational health and safety consultant for the Toronto Fire Services in Ontario, Canada. An occupational health and safety practitioner for 23 years, he has served a commercial airline, a construction company, and the City of Toronto Water and Wastewater Services, leading investigations into serious workplace accidents and incidents. He is a fellow of the Institution of Occupational Safety and Health and a registered safety practitioner in the United Kingdom, a certified health and safety consultant and a member of the Canadian Society of Safety Engineering, a professional member of the American Society of Safety Engineers, and a member of the Hong Kong Occupational Safety and Health Association.

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