BOS 4601 Unit VIII Assessment

Which report writing tip do you feel is most important? Why?

Jeffrey Oakley offers several report-writing tips in his 2012 book, Accident Investigation Techniques and most would agree each of them stand on their own merit. Oakley states that job titles should be used as opposed to individual names, he likes to break facts into specific topic areas, and he purposes report authors insert graphics and tables into their reports so as to convey information more effectively (Oakley, 2012).

While these are all great tips and ideas I would put forth into my reports, I was impressed with Oakley’s ideas in terms of writing in a style that everyone can follow (Oakley, 2012). Most would agree that a well worded report should be something that all readers are able to understand. The style should be clear and concise so that everyone, from the entry-level custodian to the senior production engineers, are able to understand exactly what took place, what events led up to the accident happening, how the accident occurred, what happened following the accident, and what corrective steps are needed to ensure an accident similar to this never happens again.

The investigator who authors a report in such a manner as to impress everyone with their technical abilities and/or analytical prowess is only lessening the chances that everyone will be able to comprehend what casual factors precipitated the accident and how to implement corrective recommendations. The author should avoid writing in a style like he/she is describing a technical procedure (Oakley, 2012). Rather, explaining the procedures and recommendations in a way that everyone can understand will provide increased likelihood of those recommendations being implemented and followed.

Reference

Oakley, J. S. (2012). Accident investigation techniques: Basic theories, analytical methods, and applications (2nd ed.). Des Plaines, IL: American Society of Safety Professionals.

Why is it important to communicate lessons learned from an accident investigation to all levels of an organization? 

Oakley correctly points out that one of the biggest mistakes an organization can make is not learning from accidents and having the same situation happen again (Oakley, 2012). Ensuring the company has a lessons learned program in place ensures that an accident that occurred in one area or location of the organization is not repeated elsewhere. Most would agree that solving a near-miss issue in one bureau, but not communicating with others could lead to that same issue happening elsewhere within the company. Worse yet, the same issue that was successfully mitigated following a near-miss, could reoccur and cause injury or damage in another division if corrective recommendations are not shared (Oakley, 2012).

In today’s business, this communication is much easier and faster than in years past. Company management can utilize email, blogs, social media posts, newsletters, and even flash messages to work stations immediately to off-site locations (Oakley, 2012). It is paramount that companies share lessons learned and the resulting corrective actions to all members so as to prevent similar accidents from occurring and to be proactive in terms of sending a “Safety First” message to each and every employee. Communication is the key (Oakley, 2012).

Reference

Oakley, J. S. (2012). Accident investigation techniques: Basic theories, analytical methods, and applications (2nd ed.). Des Plaines, IL: American Society of Safety Professionals.

Identify the steps in an accident investigation follow-up. Which step do you feel is the most critical?

There are four (4) follow-up steps detailed in Jeffrey Oakley’s 2012 book, Accident Investigation Techniques and most would agree that each is necessary, prudent, and a productive product of a complete accident investigation (Oakley, 2012). With documentation being such an important aspect of the investigation process, it is important the investigator not only detail these steps in the final report, but those who accept the report do their part(s) to ensure these steps are implemented.

The first step in following up is checking to ensure that corrective action has been completed correctly (Oakley, 2012). Some organizations utilize a database to track these actions and noting when the correction was made ensures that it was completed.

The next step in this process is to make certain the purposed corrective action works to prevent accidents (Oakley, 2012). New procedures should be tested to make sure it is doing what was intended and prevents future accidents from happening.

Another follow-up step is ensuring that the corrective action is actually being used. It is one thing to write up a new procedure or policy and yet another thing to ensure employees and stakeholders are actually using or following it as designed (Oakley, 2012).

Finally, the fourth and arguably the most critical step in following-up is to be proactive. Most would agree with Oakley when he points out that a follow-up is an excellent opportunity to observe additional hazards in the field. Because any hazard has the potential to become an accident, they must be identified and corrected (Oakley, 2012). Keeping an open mind for potential secondary hazards is important as well. For example, telling workers they must wear full face protective masks before climbing down a long ladder into a tunnel may expose the very workers you are trying to protect to a new hazard because they cannot see clearly while descending the ladder. Agreeing with Oakley, an investigator must realize that the follow-up is the last line of defense in the accident investigation process; it must ensure the workplace is free of hazards and is safe (Oakley, 2012).

References

Oakley, J. S. (2012). Accident investigation techniques: Basic theories, analytical methods, and applications (2nd ed.). Des Plaines, IL: American Society of Safety Professionals.

What is accident trending? Why is trending so important for accident investigation to ensure hazard prevention?

Accident trending is one of the latest advancements in the accident investigation process (Oakley, 2012). It is the process of using a database to analyze accident trends and find out which programs, areas, tasks, and jobs are having the most accidents. It is also used for finding out why these accidents are happening. When used, this trending information is referred to as proactive trending and it can be utilized to act as an indicator of where is accident might happen next (Oakley, 2012).

While some companies use this information to create colorful looking charts and graphs, the real idea is to use the information to not only track what has happened, but what can happen again should corrective measures not be implemented. This trending, when used properly, can be used to show how many accidents can be expected, what days of the week they might occur on, and they can even filter by gender, age group, or department among other parameters. It is important to use this tool for proactive actions in the prevention of accidents and correcting weaknesses in safety programs (Oakley, 2012).

Reference

Oakley, J. S. (2012). Accident investigation techniques: Basic theories, analytical methods, and applications (2nd ed.). Des Plaines, IL: American Society of Safety Professionals.

What are the differences between accident forms and accident reports? How should you determine which one to use?

The three types of accident investigation reports are logs, forms, and investigative reports (Oakley, 2012). Each should convey the basic facts of the investigation, casual factors, and what corrective actions should be implemented following completion. There are different types of each; there are medical logs, accidents logs, OSHA logs, forms containing certain parts or aspects of an investigation such as an evidence form, and reports that some or all facets of an investigation that need to be supplemented by other reports (Oakley, 2012).

Accident forms generally contain two types of information; facts and analysis. They can range from very basic and simple to several pages long and complex (Oakley, 2012). A form can be an excellent opportunity to record evidence and the basic facts surrounding an accident. Organizations often create their own forms customized to what types of issues that company deals with on a reoccurring basis.

Accident reports should be completed for accidents that involve injury or death, property damage, and even near-misses that have the potential for serious damage or injury (Oakley, 2012). The report should include casual factors, sequence, a description of what occurred (and why), facts, and corrective actions. These are professional documents used not only to chronicle what happened, but also to prevent this type of incident from happening again. They should include an introduction, methodology, sequence of events, facts & analysis, casual factors, corrective actions, conclusions and summary (Oakley, 2012).

When completed correctly, the reader should have an understanding of what happened, who was injured & how, what was damaged & extent of damage, how & why it happened, why is should not have happened, and what can be done to prevent this from ever happening again.

Discuss ways that accident causation theories can be used proactively to prevent accidents. Provide examples that illustrate your points

Because accidents usually have more than one cause, the multiple causation theory expanded upon the domino theory and the unsafe acts / unsafe conditions concept. Discovering all of the causal factors that relate to an accident in the key to fixing the condition(s) that caused the accident and prevent future accidents (Oakley, 2012). As accident investigation causation theories advance, it is said they can be used to proactively prevent future events by establishing regulatory actions on a broad scale by groups such as OSHA, EPA, FAA, and others. The standards these organizations implement have starting points for companies to recognize potential hazards and reduce injuries in the workplace (Oakley, 2012).

The most widely known management approach to accident causation is the Management Oversite and Risk Tree (MORT) system (Oakley, 2012). MORT links causes from the employee/worker level all the way up through the management levels of a company. While the system is widely used, it is not normally utilized for actual accident investigations. As such, the investigations still need to be completed at the local level, but the information gleaned can be uploaded into the system for wider ranging risk management.

Oakley points out that several accident theories have come and gone over the years as businesses evolve and some theories have changed shape to adapt to today’s workplace, but the goals have stayed constant; reducing future accidents by examining those of today and yesterday. These accident causation theories guide investigators to finding potential hazards and deter future accidents after analyzing past events.

Henrich’s Domino theory, for example, states that factors leading to an accident are similar to dominoes standing on edge. The moment the first domino falls, it hits the next and so on (Oakley, 2012). The basic understanding is that we can utilize theory like this to aid in an investigation of the Little General Store Propane Explosion for example. One domino being a malfunctioning valve falling into another domino being the location of the tank being too close to the store. When the investigator is able to determine the triggering factor(s), employees and management can implement change to prevent the same type of thing from happening again. Accidents can then be prevented by finding hazards and initiating corrective actions before an accident or near-miss can take place (Oregon OSHA, nd).

References

Oakley, J. S. (2012). Accident investigation techniques: Basic theories, analytical methods, and applications (2nd ed.). Des Plaines, IL: American Society of Safety Professionals.

Oregon Occupational Safety & Health Administration. (n.d.). Conducting an accident investigation. Retrieved from: https://osha.oregon.gov/pubs/Pages/index.aspx