As health and safety professionals, many of us focus efforts on injury prevention, especially those of us who fall under Cal OSHA's requirement for a written Injury and Illness Prevention Program (T8 CCR Section 3203 GISO). Nationwide we are focusing our efforts on injury prevention in hopes of reducing OSHA 200 recordable injuries. A big part of injury prevention is accident investigation; the idea behind this being that we learn from our mistakes. Ideally we take corrective actions based on our findings to prevent similar occurrences. What do you do, however, if most of the corrective actions recommended by supervisors and Safety Committees are related to behaviors of the injured party? We have all heard the following statements: "He/she needs to pay more attention," "Supervisor needs to counsel the worker," and "Re-train employee." As safety professionals we must first start recognizing and replacing fault-finding injury reporting systems before we can be successful in preventing injuries.

Three methods have been identified to assist in determining the real "whys?" behind occupational injuries and illnesses. These include using injury reporting instruments that get to the root cause, tracking near misses, and observing critical behaviors.

How to Recognize Fault Finding Systems

There are a number of ways an organization can tell if they have a finger pointing system: one way is to look at completed investigative reports. If investigative reports tend to conclude a single reason for the accident, like "worker error," then the system is one that searches to find blame. If corrective actions too often state things like "counsel the worker" or "re-train employee" this may also indicate a fault-finding system. Perhaps your organization does not have such obvious signs, in this case a safety culture survey could be helpful in determining if the injury reporting system is perceived as fault-finding. You know you have a problem if there is low or no agreement with statements such as: "There is a strong communication network that ensures that significant stories, near accidents or accidents are shared within the organization;" "We have stories that make heroes out of people who were willing to bring up safety issues, even though the issue was unpopular;" "Supervisors give positive feedback for daily consistency in safety;" "In our company, near misses, incidents and accidents are opportunities to learn, not for blamefixing;" and "The stories that I hear about the way people were treated after an accident make me feel that management cares." 1

The City of Chula Vista and Sweetwater Authority identified the need to improve their injury reporting systems since their existing systems, by design or default, were fault-finding systems. Both of these organizations are actively striving to create positive safety cultures since discovering that this fault-finding system of accident investigation was interfering with the success of injury prevention efforts. Both agencies rely on Injury Reports to provide critical information to their Safety Committees who review injuries to identify and eliminate workplace hazards.

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