Quality evaluation of official accident reports conducted by Labour Authorities in Andalusia (Spain)

Abstract

BACKGROUND:

A public accident investigation is carried out when the consequences of the incident are significant or the accident has occurred in unusual circumstances.

OBJECTIVE:

We evaluated the quality of the official accident investigations being conducted by Safety Specialists of the Labour Authorities in Andalusia.

METHODS:

To achieve this objective, we analysed 98 occupational accident investigations conducted by the Labour Authorities in Andalusia in the last quarter of 2014. Various phases in the accident investigation process were examined, such as the use of the Eurostat variables within European Statistics on Accidents at Work (ESAW), detection of causes, determination of preventive measures, cost analysis of the accidents, identification of noncompliance with legal requirements or the investigation method used.

RESULTS:

The results of this study show that 77% of the official occupational accident investigation reports analysed were conducted in accordance with all the quality criteria recommended in the literature.

CONCLUSIONS:

To enhance glogal learning, and optimize allocation of resources, we propose the development of a harmonized European model for the public investigation of occupational accidents. Further it would be advisable to create a common classification and coding system for the causes of accidents for all European Union Member States.

Keywords

Investigation occupational accidents causes preventive measures Eurostat variables legislation RIAAT model

1 Introduction

1.1 Official accident investigation reports

A public accident investigation is carried out when the consequences of the incident are significant or the accident has occurred in unusual circumstances [1]. As defined by Dechy et al. [2], the objective of a public accident investigation is to identify the probable causes of the accident in order to then define the necessary preventive measures intended to avoid repetition of similar events. In Europe, the Labour Authorities are in charge of enforcing the protection of workers at the workplace, as well as promoting the adaptation of Legislation to changing workplace needs [3].

In Spain, it is mandatory to notify the Labour Authorities of all occupational accidents requiring workers to be on leave for one or more days. The occupational accident reporting system in Spain complies with the European Statistics on Accidents at Work (ESAW) mandate [4], which was transposed to Spanish Law through Order TAS/2926/2002 [5]. Although some research is being carried out regarding the quality of data gathered within ESAW [6], ESAW does not include the causes of accidents this being the main objective of the accident investigation procedure.

Specifically, in Andalusia, an official investigation of an accident is carried out as determined by the Labour Inspectorate, the Judiciary, or the Labour Authorities. This official investigation must be conducted by a Safety Specialist of the Occupational Risk Prevention Centres (Centros de Prevención de Riesgos Laborales) attached to the Directorate-General for Occupational Health and Safety (Dirección General de Seguridad y Salud Laboral), which are the Labour Authorities in Andalusia, (hereinafter the Safety Specialist). Safety Specialists are civil servants with higher education in occupational risk prevention (university degree plus 800 credit hours of specialisation courses) and who receive regular training in accident investigation [7].

The above-mentioned occupational accident investigation is conducted in accordance with the responsibilities and role attributed to the Specialised Technical Body of the Labour Authorities pursuant to occupational risk prevention regulations. In particular, a Technical Manual is provided which establishes the accident investigation procedure to be carried out by the Safety Specialist of the Occupational Risk Prevention Centres.

In fact, this Technical Manual lays down the criteria whereby accidents may be subject to official accident investigation, namely, severe and fatal accidents and those involving more than four workers simultaneously, regardless of the severity, with the following exceptions:

In itinere accidents, those which involve commuting (investigated by specific authorities)

Non-traumatic diseases such as heart attacks or brain haemorrhages are not subject to official accident investigation by the Labour Authority.

However, in some cases accidents outside the scope of the Technical Manual are investigated based on a specific request issued by a Judicial Authority, for example when the accident involves under-age workers or when a criminal offence is suspected.

In fact, as established in Section 2, Article 9 of Act 31/1995, of 8 November on Occupational Risk Prevention [8], these accident investigations conducted by the Public Administration Safety Specialist are often considered by the Labour and Social Security Inspectorate, the Public Prosecutor’s Office and the Judiciary to be expert opinions, and the Administration thus considers the reports to be expert testimonies.

All of these aspects justify the need to evaluate the appropriateness of these investigation reports conducted by the Technicians of the Andalusian Labour Authority, both with regard to their formal characteristics and their fulfilment of the basic quality criteria established in the international scientific literature on health and safety [9, 10].

1.2 Literature review on quality criteria of safety investigations

1.2.1 Recording and notification of accidents at work

In relation to the quality criteria for the preparation of official accident investigation reports, several authors have proposed solutions to improve their implementation and results. In this respect, during the initial phase in which information pertaining to the circumstances of the accident is registered and coded, there is general agreement [11 –18] on the appropriateness of including ESAW coding as the main system of indicators at this stage, since it helps to understand the facts and basic causal factors of the accidents. In Spain, all accident reports submitted to the Labour Authority shall necessarily include ESAW variables, whereby the official investigations rely on registered and coded circumstances of the accident.

Similarly, during this initial information collection phase, the quality of official occupational accident investigation reports can be significantly increased in two ways, namely, by attaching an extensive and detailed description of the events [19] as well as by using a wide range of sources of information such as interviews, sketches, photographs, diagrams, etc. [20].

1.2.2 Investigation and analysis of accidents

In the next phase of the accident investigation and analysis, as stated by authors such as Van Waseenhove and Wybo (2002) [21] and Antao et al. (2008) [22], the initial analysis should identify the active failures associated with unsafe actions and unsafe conditions, and a subsequent in-depth analysis should identify the latent failures related to individual and job factors and conclude with the identification of the organisational and management aspects of the work [23]. It therefore coincides with Reason’s model (1997) [24] in that the three categories of errors should be able to explain the accident causality.

In the last two decades certain attempts to classify and code the causes have been made, such as those by Feyer and Williamson (1991) [25], Wiegmann and Shappell [26], Toole [27] or DOE [28]. The coding of causes developed in the WAIT (Work Accident Investigation Technique) method by Jacinto and Aspinwall [29, 30] is especially noteworthy. This method classifies and codes the three groups of factors that essentially contribute to accidents, that is, individual factors, workplace factors and organisational and management factors. Subsequently WAIT evolved to a new method and model for reporting accidents known as RIAAT (The Recording, Investigation and Analysis of Accidents at Work process), which imported and adapted the classification of causes proposed by the WAIT method [31]. In this regard, as stated by Carrillo-Castrillo and Onieva (2014) [32], a common coding system of the causes identified is needed in order to be able to compare the results obtained.

Together with the analysis of detected causes, the accident investigation report should be able to identify all legal noncompliance detected during investigation of the event [33]. This is because the official investigation of occupational accidents, as indicated by Saleh et al. [34] is becoming increasingly related to contentious aspects in the sense that in addition to the initial objective of identifying the causes of the accident, it now further aims to identify liability and enforce sanctions. Spanish provisions on legal noncompliance and infringements are contained in the Act on Offences and Penalties in the Social Order (LISOS) [35].

1.2.3 Plan of action

Likewise, as stated by Harms-Ringdahl [36], the data obtained during the investigation and analysis phase are essential for correcting and improving the risk assessments of the companies involved in the investigated accident. Therefore, the accuracy of risk assessments should be checked, as they will be revised in the course of accident investigation.

1.2.4 Organisational learning

Following the analysis of the causes detected, authors such as Jacinto and Aspinwall [29] or Weiwei et al. (2010) [37] agree that all accidents should lead to a proposal of preventive measures whose implementation should be followed up. In this sense, Hovden et al. [38] and Salguero-Caparros et al. [10] provide some of the few examples of studies which have identified a set of factors or indicators that potentially support processes to establish preventive measures.

1.2.5 Additional information

It is also acknowledged that all accident investigation reports should include data in order to analyse and establish the estimated costs involved. Proper and comprehensive prevention management at a corporate level should provide information on how much accidents cost, not only direct costs, which are more easily estimated, but also detailed information on hidden or indirect costs [39].

Naturally, accident analysis requires a method leading to a thorough diagnosis of the situation that has triggered the accident. Choosing the proper method [40] and applying it scientifically will structure the investigation process and improve identification of the causes, interpretation of the results and the validity of the recommendations [33].

It is essential that the investigation of the accident be carried out [41 –43] as soon as possible given the tendency to forget pertinent details, ‘reinvent’ facts or even to inappropriately influence others when discussing an incident before proper investigation.

1.3 Reference studies

In relation to the quality criteria described, few studies have analysed the context in which official occupational accident investigation reports are carried out by the Labour Authorities. Such studies used small samples and the following five are noted in particular:

A study entitled “Analysis of Occupational Accident Mortality in Spain” was introduced in 2002 [44]. This project was carried out by the INSHT (Spanish acronym for the National Institute of Occupational Health and Safety) which is the specialised technical scientific body of the Spanish Government in charge of analysing and studying health and safety conditions at work. This project aims to achieve an accurate understanding of occupational accident profiles and causes.

Jacinto and Aspinwall [11] conducted a study explaining the classification systems and the official recording and reporting procedures for occupational accidents in the EU.

Stoop and Roed-Larsen [45] conducted a literature review on the evolution of public safety investigation in the transport industry in Nordic countries (Denmark, Finland, Norway and Sweden).

Dechy et al. [2] conducted a study with two objectives: on the one hand to establish the current state of the art of accident investigation in Europe and, on the other, to promote the sharing of information among various Bodies and Authorities conducting official investigations.

HSE Investigation-Procedure [46]. This Procedure describes how investigations were carried out in work-related incidents that have resulted in death, physical injury, occupational disease or dangerous occurrences. The purpose of an investigation is to find out how and why an incident happened, and to take enforcement action, where appropriate, in accordance with the principles of HSE’s Enforcement Policy Statement.

1.4 Scope of the present research

This led us to carry out the present study, in which we analysed a sample of 98 official occupational accident investigation reports conducted by Safety Specialists of the Labour Authority in Andalusia. The study aimed to evaluate the quality of the occupational accident investigation reports issued by Safety Specialists of the Labour Authority and to identify the main deficiencies in their preparation, in accordance with the various quality criteria disclosed. Therefore, we analysed the collection and recording of information, identification of causes, breaches of legislation, verification of risk assessment, establishment of preventive measures, method of investigation and the time required.

2 Material and method

2.1 Reference to the investigation method

Official occupational accident reports in Spain, are prepared in accordance with a standardised method approved by the Spanish Institute for Occupational Health and Safety [47]. The method used in all official accident investigations is Fault Tree Analysis (FTA), which is internationally recognised in scientific literature [19 , 48].

In 2004, the Labour Authorities in Andalusia adopted a common coding system to identify the causes in official accident investigations which was promoted by the National Institute of Occupational Health and Safety [49].

The study presented here is based on the results of official investigations of occupational accidents performed by Technical experts of the Labour Authority in Andalusia. Since the minimum number of accidents for statistical analysis is 100 [50], to conduct this study, 98 cases which had been previously investigated by Safety Specialists of the Labour Authority were analysed. Such cases covered official occupational accident investigation reports submitted by Safety Specialists from the Occupational Risk Prevention Centres in Andalusia in the period from October to December 2014 involving employees working in this area. It should be clarified that the number of accidents included in this study is not a sample of the actual number accidents reported during this period in Andalusia, but a sample of the accidents investigated by the Labour Authority.

The analysis of this sample was conducted in accordance with the five phases defined in the RIAAT method [51] in addition to other variables that have been validated in the quality criteria referred to in the introduction.

RIAAT (The Recording, Investigation and Analysis of Accidents at Work process) was chosen as the reference method to conduct this study given its holistic approach to analyse the accident investigation process as a whole, which contributes to improve prevention efficacy [31]. Likewise, RIAAT is something more than a method; it is a complete “process” for analysis of occupational accidents and has its own embedded methodology: WAIT [52]. These two methods are based on the theoretical model of “organisational accidents” proposed by Reason (1997) [24]. Furthermore, they include a broad set of variables proposed by the European Commission, [4, 53].

2.2 Sample distribution

The 98 official investigation reports submitted in the last quarter of 2014, provided by the Directorate General on Occupational Health and Safety, were classified as shown in Table 1, by the OHS organisation of the company where the victim was working, the business industry and the level of severity of the accident.

Table 1
Distribution of reports analysed

Variable Category No. of reports (%)

Organisation Mode . Internal OHS advisors 80 (81.6%)

. External OHS advisors 18 (18.4%)

Business sector . Manufacturing 29 (29.6%)

. Construction 19 (19.4%)

. Services 27 (27.6%)

. Agriculture 23 (23.4%)

Accident severity . Severe 82 (83.7%)

. Very severe 2 (2%)

Total . Fatal 14 (14.3%)

98 (100%)

Variable	Category	No. of reports (%)
Organisation Mode	. Internal OHS advisors	80 (81.6%)
	. External OHS advisors	18 (18.4%)
Business sector	. Manufacturing	29 (29.6%)
	. Construction	19 (19.4%)
	. Services	27 (27.6%)
	. Agriculture	23 (23.4%)
Accident severity	. Severe	82 (83.7%)
	. Very severe	2 (2%)
Total	. Fatal	14 (14.3%)
		98 (100%)

As the accidents analysed are selected without any criteria, there is no bias on selection. In Andalusia each year around four hundred accidents are investigated, most of them comply with the previously discussed criteria: investigating fatal and serious accidents or those which affect more than 4 workers provided they are not commuting accidents or related to non-traumatic diseases.

In Spain, in terms of severity, accidents can be classified as slight, severe or fatal. Medical criteria are applied by the physicians of the Mutual Insurance System of Occupational Injuries and Illnesses (which belongs to the Public Social Security scheme) to classify the accident depending on the severity of the injuries and expected period of recovery [54].

According to accidents reported in Andalusia [55], during 2014 there were 70,775 occupational accidents that implied a sick leave lasting at least one working day, of which 98.8% were rated as slight, a total of 786 accidents were classified as serious (1.1%) and a total of 75, fatal accidents (0.1%). It should be stressed that the aim of the study is not to analyse the distribution of causes in the accidents reported but to analyse the quality of the official investigations. Hence, due to criteria used by the Labour Authority when considering an accident for official investigation, whereby fatal and serious accidents are prioritised, slight accidents will be under-represented in any sample of investigated accidents.

2.3 Analysis design

To conduct the analysis of the sample considered, a total of 42 variables for each official occupational accident investigation report were examined (see Tables 2–6). These variables were extracted from a literature review and related to the quality criteria established. These quality criteria were classified and structured in Tables 2–6 according to the five phases defined in the RIAAT model [31]: Phase 1 (Recording), Phase 2 (Investigation & Analysis), Phase 3 (Plan of action), Phase 4 (Organisational Learning), Phase 5 (Additional information).

Table 2
Variables for statistical analysis of accident investigations. Recording

Variable Assessment of Variable Author

1. Working environment . Used ESAW VARIABLES

. Not used Jacinto and Aspinwall [11]

2. Working process . Used ”

. Not used

3. Specific physical activity . Used ”

. Not used

4. Deviation . Used ”

. Not used

5. Contact -mode of injury . Used ”

. Not used

6. Material agent of contact . Used ”

. Not used

7. Type of injury . Used ”

. Not used

8. Part of body injured . Used ”

. Not used

Variable	Assessment of Variable	Author
1. Working environment	. Used	ESAW VARIABLES
	. Not used	Jacinto and Aspinwall [11]
2. Working process	. Used	”
	. Not used
3. Specific physical activity	. Used	”
	. Not used
4. Deviation	. Used	”
	. Not used
5. Contact -mode of injury	. Used	”
	. Not used
6. Material agent of contact	. Used	”
	. Not used
7. Type of injury	. Used	”
	. Not used
8. Part of body injured	. Used	”
	. Not used

Table 3

Variables for statistical analysis of accident investigations. Identification of causes and Legal Factors- H&S Legislation

Variable	Assessment of Variable	Author
9. Individual Contributing Factors (ICF). No information or not applicable.	. Detected	Jacinto et al. [51]
	. Not detected
10. ICF. Temporary factors	. Detected	”
	. Not detected
11. ICF. Permanent factors	. Detected	”
	. Not detected
12. ICF. Other ICF not listed in this classification	. Detected	”
	. Not detected
13. Workplace Factors (WPF). No information	. Detected	”
	. Not detected
14. WPF. Physical environment/Working environment	. Detected	”
	. Not detected
15. WPF. Equipment/Tools	. Detected	”
	. Not detected
16. WPF. Task/Job-related	. Detected	”
	. Not detected
17. WPF. Competence: professional qualifications, training and experience	. Detected	”
	. Not detected
18. WPF. Information/Communication	. Detected	”
	. Not detected
19. WPF. External environment: Weather/Natural phenomena	. Detected	”
	. Not detected
20. WPF. Other WPF not listed in this classification	. Detected	”
	. Not detected
21. Organisational &Management Factors (OMF). No information.	. Detected	”
	. Not detected
22. OMF. General Management	. Detected	”
	. Not detected
23. OMF. Procedural	. Detected	”
	. Not detected
24. OMF. Technical.	. Detected	”
	. Not detected
25. OMF. Training &Competency	. Detected	”
	. Not detected
26. OMF. Safety-specific.	. Detected	”
	. Not detected
27. OMF. Other OMF not listed in this classification	. Detected	”
	. Not detected
28. Legal Factors- H&S Legislation	. Yes	Jacinto et al. [31]
	. No

Table 4

Variables for statistical analysis of accident investigations. Verify the Risk Assessment

Variable	Assessment of Variable	Author
29. Verify your Risk Assessment	. Yes	Harms-Ringdhal [36]
	. No

Table 5

Variables for statistical analysis of accident investigations. Determining preventive measures

Control measures	Variable	Assessment of Variable	Author
Preventive measures to eliminate or reduce risks	30. Preventive measures at source	. Determined	Salguero-Caparrós
		. Not determined	et al. [10]
	31. Organisational preventive measures	. Determined	”
		. Not determined
	32. Collective protective measures	. Determined	”
		. Not determined
	33. Personal protective measures	. Determined	”
		. Not determined
	34. Training and information measures	. Determined	”
		. Not determined
Monitoring measures	35. Monitoring workplace conditions	. Determined	”
		. Not determined
	36. Monitoring organisation and compliance with working methods	. Determined	”
		. Not determined
	37. Monitoring workers’ health	. Determined	”
		. Not determined

Table 6

Variables for statistical analysis of accident investigations. Additional information

Variable	Assessment of Variable	Author
38. Sketches	. Yes	Lindberg et al. [20]
	. No
39. Photographs	. Yes	”
	. No
40. Diagrams	. Yes	”
	. No
41. Specific method applied	. Yes	Roed–Larsen and Stoop [33]
	. No
42. Days elapsed since accident occurred until report signed	. 0 to 30 days	Rozental [41]
	. 0 to 60 days
	. Over 60 days
	. Not stated

Research Questions

To check the level of compliance with the quality criteria established, the following research questions are proposed:

Question 1. To what extent do the official accident investigation reports use the information provided by the ESAW variables during the recording phase?

Question 2. In the accident investigation and analysis phase, were all of the levels of causes associated with the accident identified? That is, human faults (ICF), technical faults (WPF) and organisational faults (OMF).

Question 3. During the investigation and analysis phase, to what extent were legal breaches identified in the occupational accidents analysed?

Question 4. During the plan of action phase, to what extent was risk assessment checked in the occupational accidents analysed?

Question 5. How frequently and to what extent did the official accident investigation reports include recommendations and proposals for preventive measures?

Question 6. In the complementary information phase, how frequently and to what extent was an accident investigation methodology selection process carried out or sources of information such as sketches, photographs and diagrams used?

Given that the hypotheses proposed refer to sets of variables, as in other studies [56], assessment of the level of compliance with the quality criteria achieved in each hypothesis was based on the method applied by Jacinto and Aspinwall [30], that is, taking the average percentage of acceptance to be the quotient of the values obtained in each item divided by the total factors identified. Next, to accept the hypothesis, following the findings of Jacinto and Aspinwall [30] and taking into account the validation study conducted by Hollnagel [57], we established that an average compliance of 67.8% was an adequate percentage.

2.4 Statistical analysis

To conduct the statistical analysis, the data obtained from the 98 official accident investigation reports were structured in tables according to the 42 variables described in Tables 2–6. Subsequently, using statistical software SPSS V15, we extracted the frequency and prevalence of the different variables individually and aggregately to obtain the results described below.

3 Results

3.1 Recording

Based on the study of the eight ESAW variables considered most important [11] during the information collection phase, it was determined that the mean frequency with which the information provided by these variables is used in the accident investigation reports equals 94%. That is, the coded information of these variables is not used in only 6% of cases, which answers Research Question No. 1 (to what extent do the official accident investigation reports use the information provided by the ESAW variables during the recording phase?).

Additionally, when the ESAW variables considered are analysed individually, as shown in Fig. 1, we found that the variables with the highest percentage of use in this phase are “working environment” with 99%, followed by the variable “working process” with 98%, “deviation” with 97% and “type of injury” with 96%.

Fig.1

Distribution of ESAW Variables.

In contrast, the variables “material agent of contact” in 14% of the cases, followed by the variables “contact-mode of injury” in 11%, “specific physical activity” in 7% and “part of body injured” in 6%, have the highest percentage of non-use.

3.2 Investigation and analysis. Identification of the causes of accidents

The analysis of the identification of accident causes in the investigation reports considered, led us to determine that 33% of these reports jointly identify at least one cause associated with the group of individual contributing factors (ICF), that is, human faults, workplace factors (WPF), or technical faults, and organisational and management factors (OMF), or occupational health and safety management system faults, which answers Research Question No. 2 (in the accident investigation and analysis phase, were the levels of causes associated with the accident identified? These levels are human faults (ICF), technical faults (WPF) and organisational faults (OMF)), (see Fig. 2).

Fig.2

Distribution of all level of causes detected.

As for the individual analysis of the various variables associated to identification of accident causes, Fig. 3 shows a uniform distribution of the three causal groups. It is noteworthy that 97% of the reports analysed detected WPF, 74% detected OMF, and this dropped to 47% for detection of ICF.

Fig.3

Distribution of the causes detected by level.

A closer look at the individual analysis of the causes identified in the official accident investigation reports is addressed in Fig. 4 which shows the distribution of the various underlying factors in the three causal groups analysed. We found that within human errors (ICF), “temporary factors” are those most often detected in up to 44% of the cases. The highest contribution in the workplace causal group (WPF), came from the “equipment/tools” factor with 65%, followed by the “task/job-related” factor with 49%. Finally, with respect to the organisational and management factors (OMF), the “procedural” variable ranked first with 45%, followed by the “safety-specific” factor with 37%.

Fig.4

Distribution of the causes detected.

3.3 Investigation and analysis. Legal factors- H&S legislation

The investigation and analysis phase, once the relevant causes and contributing underlying factors have been found and recorded, continues with the identification of legal breaches that have come to light during investigation of the event.

Analysis results reveal that 46% of the official occupational accident investigation reports analysed identified some form of legal breach, which answers Research Question 3 (during the investigation and analysis phase, to what extent were legal breaches identified in the occupational accidents analysed?).

3.4 Plan of action. Verify the risk assessment

Before proposing preventive measures, it should be ensured that the assessment of applicable risks is sufficient and/or is duly revised based on the accident being analysed [31].

Our analysis shows that 89% of the official investigation reports checked the risk assessment of the company where the accident occurred, which answers Research Question 4 (during the plan of action phase, to what extent was risk assessment checked in the occupational accidents analysed?).

Moreover, in as many as 39% of the reports in which the risk assessment was checked, the latter was considered incorrect by the Technical Advisor. Therefore it was noted in the accident investigation that the risk assessment had to be corrected and again integrated to the company’s OHS management system.

3.5 Organisational learning. Determining preventive measures

The analysis of the preventive measures proposed in the official investigation reports led us to determine that 100% of the reports recommend a number of preventive measures, which answers Research Question No. 5 (how frequently and to what extent did the official accident investigation reports include recommendations and proposals for preventive measures?).

Nonetheless, as shown in Fig. 5, it is remarkable that the majority of these preventive measures relate to preventive actions intended to eliminate or reduce risks (“preventive measures to eliminate or reduce risks”). However, it is also noteworthy that 64% of the reports propose “monitoring measures” which include corrective actions and control measures.

Fig.5

Distribution of recommended preventive measures grouped by type.

From the in-depth analysis of this section, we found that with regard to preventive measures to eliminate or reduce risks, organisational preventive measures (labour procedure) represent the highest percentage, 71%, followed by 69% for measures aimed at planning information and training activities for workers, preventive measures at sources (devices and protection elements) with 36%, personal protective measures with 17% and collective protective measures with 13% (see Fig. 6).

Fig.6

Distribution of types of preventive measures determined.

As for monitoring measures, workplace conditions are the most frequently monitored in 45% of the cases, followed by monitoring organisation and compliance with working methods in 29%. Finally, regarding preventive measures for the monitoring of workers’ health -this being the control and monitoring measures proposed to improve the surveillance of the workers’ health conditions as consequence of the accident investigation- these are barely detected, only mentioned in 6% of the official investigation reports analysed.

3.6 Additional information

Analysis of the contribution of additional information to the investigation reports led us to determine that 99% of the cases included some type of additional information. It is noted that 41% of the official occupational accident investigation reports analysed included graphic information on the method used (fault tree) (see Fig. 7).

Fig.7

Distribution of the additional information included.

3.7 Overall results

Finally, Table 7 shows a summary of the percentage value at which each section of the accident investigation reports is deemed acceptable based on the research questions proposed, that is, taking the average percentage of acceptance to be the quotient of the values obtained in each item divided by the total factors identified [30]. The result is that 77% of the official investigation reports analysed were conducted following the quality criteria recommended in the literature (see Table 7).

Table 7
Summary of results

Factors Analysed % of agreement

Recording. Use of ESAW variables 94%

Investigation &Analysis: Include causes of the three levels (Identification of human faults, technical faults and organisational faults) 33%

Investigation &Analysis: Identification of legal breaches 46%

Plan of action: verify the risk assessment 89%

Organisational Learning: determining preventive measures 100%

Additional information (sketches, photographs, diagrams and method) 99%

Factors Analysed	% of agreement
Recording. Use of ESAW variables	94%
Investigation &Analysis: Include causes of the three levels (Identification of human faults, technical faults and organisational faults)	33%
Investigation &Analysis: Identification of legal breaches	46%
Plan of action: verify the risk assessment	89%
Organisational Learning: determining preventive measures	100%
Additional information (sketches, photographs, diagrams and method)	99%

Furthermore, several authors [20 , 41–43] have stressed that accident investigations should be conducted as soon as possible after the event since conditions can change almost immediately. To control this situation, the statistical analysis used the variable “Days Elapsed Until Preparation of the Investigation Report”, confirming that in 38% of the cases, investigation reports were prepared within 60 days from the event, while in 26% of the cases more than 60 days elapsed, compared to only 5% of cases with reports conducted within 30 days.

4 Discussion

The appropriateness of using at least eight ESAW variables associated with the accident as main indicators for collecting information has been acknowledged by reference authors such as Jacinto et al. [15]. The analysis of Research Question No. 1, which asks to what extent official occupational accident investigations use the information provided by ESAW variables, proves that this is widely used. From the results of our study in the recording phase, we must especially highlight the extensive use of the “contact” and “deviation” variables based on the theories of “transfer of energy” and “deviation” by Nordic authors Kjellen [58] and Kjellen and Hovden [59]. The accurate identification of these two variables is of vital importance for the causal analysis of accidents, given that both help to precisely establish the circumstances in which the accidents occurred. Nevertheless, it should be noted that prior to the investigation, the official accident report is submitted with all ESAW variables and that the Safety Specialist possesses a copy before delivering the investigation report; this means that in all cases, even if the variables are not presented in the investigation report, they are available in the accident report.

Fig.8

Distribution of days elapsed between the time of the accident and the report.

With regard to the procedure for analysing and identifying the causes, in response to Research Question No. 2, which asked if all level of causes were identified in official accident investigations, we found that 1 in 3 reports were inclusive thereof. The work process understood as the interrelation between humans, machines and environment based on their organisation context implies that all accident investigations must include a detailed analysis of these three causal groups: human, technical and organisational factors. In short, coinciding with Reason’s theory [24], public investigation of accidents must seek opportunities for improvement in this respect. Nonetheless, the fact that the causes at certain levels are not identified does not necessarily imply that they exist and have not been detected; however, the report should expressly evidence that said aspects have been analysed and considered and that they were not the cause of the accident in question.

In relation to the detection of legal breaches in investigation reports, the results obtained from the analysis of Research Question 3 show that a considerable percentage of reports (46%) identified legal breaches. Laws and regulations are examples of intangible barriers [31]; when legislation is properly implemented, companies can prevent, control and even mitigate the results of unwanted events. Furthermore, the “public” model of accident investigations analysed in this study takes on an expert nature and therefore could be presented or defended in legal proceedings. This is why, as concluded by the European Agency for Safety and Health at Work (2001) [60] and confirmed by studies such as that by Roed Larsen and Stoop [33], this type of investigation must not only adopt a traditional technical focus but also a judicial and legal one. Labour Authorities must act forcefully against employers who, by breaching occupational health and safety regulations, leave their workers unprotected [61]. Despite this, it must be borne in mind that the occurrence of an occupational accident does not necessarily imply a legal breach or failure to comply with quality criteria established. Moreover, as stated by Saleh et al. [34], the fear of litigation can curtail open communication about the events in the accident investigation.

Similarly, Technical experts of the Labour Authorities conducting official accident investigations are always unrelated to the company where the event occurs. This reinforces the value of the high results (89%) obtained in Research Question 4, confirming the thesis proposed by Harms-Ringdahl [36] whereby verifying the risk assessment is essential since examination of the accident may establish which specific type of event needs to be assessed. Along the same lines as Research Question 3, an inadequate risk assessment would be the first legal breach detected.

Likewise, the results obtained from Research Question No. 5, confirm that preventive measures are unanimously included in accident investigations, with more preventive than corrective actions being proposed in the reports analysed. In accordance with the Encyclopaedia of Occupational Health and Safety, Part VIII – Chapters 56 and 57 [62], preventive measures to eliminate or reduce risks coincide with the first level of feedback not leading to organisational learning based on accident experience. In contrast, monitoring measures are carried out with higher feedback levels and whose execution requires learning. Therefore, a detailed investigation of an accident is justified to the extent that preventive actions cover initial factors with the same interest adopting lasting and efficient measures. In spite of this, as stated by Vestrucci [63], accident investigation within a legal proceeding is aimed at reconstructing the event and trying to discover its causes, undermining the establishment of preventive measures.

As for the time when official accident investigations are conducted, as shown in the results obtained, 1 out of every 4 reports are prepared 60 days after the accident. This situation, as indicated both in Rozental’s study [41], and the technical guidelines describing the procedure for preparing accident investigations for Safety Specialists of Occupational Risk Prevention Centres, could be considered unacceptable. However, in this type of accident investigations conducted by the Labour Authorities, it should be analysed if this aspect is conclusive and binding on the possible results obtained, or at least whether the interview and work condition analysis phase is conducted within the recommended time frame, even if due to organisational reasons it is not possible to issue the report sooner.

On the other hand, the answer to Research Question 6, confirms that up to 41% of the official investigation reports explicitly include graphic representation of a fault tree [64]. However, all investigations followed the fault tree method, and graphic representation should be included to facilitate communication of results. This evidences that even though these investigations are carried out in accordance with the internal procedure proposed by the Labour Authorities [54], it would be advisable to use other more holistic, progressive methods of accident investigation, applicable to the field of work as shown by reference studies and reviews [19 , 66].

Finally, regarding the estimated valuation of accident costs in the official accident investigation reports, this criteria has not been applied in this study as they are not provided for in the investigation procedure analysed.

However, as established in the literature, reducing accidents decreases the long-term costs of the companies suffering them [67]. Similarly, as indicated in the report by the European Agency for Safety and Health at Work [68] occupational accidents generate substantial costs to governments every year in terms of payment of social expenses. In spite of this, as noted by Swuste et al. [69] the cost of accidents is barely perceptible in the financial statements of large corporations. These are compelling reasons to include a calculation of the cost of accidents in official occupational accident investigations.

5 Conclusions

Official accident investigations are a useful tool to analyse occupational safety. The Labour Authorities in Europe must be a reference with regard to the quality of the implementation of this technique in a reliable, balanced and impartial manner. The information and lessons learnt from public accident investigations can help make Europe a safer, healthier and more productive place to work. Nonetheless, aside from the investigation quality, the learning mechanisms should also be reviewed as well as how companies incorporate the investigation results into their preventive systems.

This study has detected potential for improvement, bearing in mind that 77% of the official occupational accident investigations carried out by the Labour Authorities followed all the quality criteria recommended by the literature. To enhance global learning, and better disseminate results, it would be advisable to create a common European model for official occupational accident investigation reports.

In the context of ESAW, some minimum requirements regarding the quality of the accident data collection process should be included. The concern about the quality of ESAW data and the importance of ESAW data in the design of public policy advise the implementation of an audit system to evaluate the quality of data.

Further to the project for harmonisation of European occupational accident statistics led by Eurostat, similar to the coding system for circumstances, it would be extremely useful to have a common classification and coding of the causes of accidents for all European Union Member States. Along these same lines, we propose a classification of preventive and control measures to be used in the investigations.

The development of tools to facilitate the detection of noncompliance with health and safety regulations in official accident investigations should be a future area of research. These tools, both quantitative and qualitative, could be created through a Delphi process [70].

We also believe that continuous education programmes should be developed for the Safety Technicians of the Labour Authorities conducting these types of public accident investigations. These programmes should focus on investigation techniques and methodologies recognised by the international scientific community.

The focus on proposing preventive measures found in official investigations is noteworthy, far beyond the mere identification of regulatory breaches. Therefore, these results are useful as a reference for OHS practitioners, so it would be recommendable that these investigations were published. In light of the usefulness of these reports in terms of prevention, there should be a European database with records of official occupational accident investigation reports in different industries including the results of the investigations, coding and classification of circumstances, and causes and preventive measures proposed, which would certainly reinforce the undertaking of public occupational accident investigations.

Conflict of interest

None to report.

Footnotes

Acknowledgments

We should like to express our gratitude to the General Directorate of Occupational Health and Safety of the Regional Government of Andalusia which has collaborated in the preparation of this study, providing the accident reports on which our research has been based.

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