Laboratories are potentially dangerous work environments, and while proper training, engineering controls and administrative precautions can help to effectively manage risk, accidents can and do happen. Accidents, while unfortunate, present an opportunity to improve the performance of a laboratory safety program. EH&E has identified a six-step process for an effective laboratory accident investigation program that will help to identify root causes, prescribe appropriate corrective measures, and implement performance metrics to insure a safer workplace.

The accident investigation must be carefully and thoughtfully executed to realize the full benefits of an accident investigation program. The most effective investigation and mitigation program should involve the following six steps:

1. Notification and Response
2. Site Investigation and Interviews
3. Root Cause Analysis (or similar analysis technique)
4. Report of Findings and Review
5. Implement Corrective Measures
6. Monitoring

1. Notification and Response
The notification and response protocol for any accident must be clearly understood by all staff. The investigation should be lead by the supervisor or a committee and the safety professional should serve as a facilitator throughout the accident investigation process.

An effective and rapid response will help insure that the injured person(s) receives proper medical attention, prevent potential injury to others, and improve the quality of data collected during the site investigation and interviews. The need to obtain complete and accurate information must also be considered in light of any potential environmental health and safety concerns posed by the nature of the accident (e.g., release of a material to the indoor or outdoor environment).

2. Site Investigation and Interviews
The site investigation, and the interviews with the affected party or witnesses, is the core of the accident investigation program. The accident analysis and resulting corrective action(s) will be guided by the data and information gathered during this phase of the accident investigation. Data quality is therefore critical, and a uniform approach to conducting both the site investigation and the interviews is essential for consistency.

Obtaining relevant facility information during the site visit is essential. This information may include items such as testing and verification records for safety equipment and product recalls on laboratory equipment. During the visit, reporting requirements must also be assessed during this phase to determine if federal, state, or local agencies need to be notified.

The interview process, for both the injured party and potential witnesses, is a key factor in the investigation and must be highly organized to ensure an accurate accounting of the facts. A clear set of rules must be established in advance for items such as the timeframe of the interview (taking into account the severity of the injuries), the environment, and the tone. The types of questions are important to ensure that witnesses are not lead to a particular conclusion and have an opportunity to reflect on the events leading up to the accident.

3. Root Cause Analysis
A Root Cause Analysis (RCA) is a retrospective analysis of an event using the information collected during the site investigation and interviews. In this case, the RCA provides a systematic method to trace the cause of an accident back to its source(s). The goal of the RCA is to reveal the true causes of the accident by better defining what happened, exploring how it happened, and ultimately determining why it happened. Once these questions are answered, effective corrective measures can be implemented and monitored, preventing similar accidents in the future.

4. Report of Findings and Review
The results of the investigation need to be communicated in a report to the supervisor of the area in which the accident took place. Allow the individuals involved in the accident to review the draft report in order to insure that it accurately reflects their understanding of events.

The reporting of findings and the analysis must be completed rapidly, while attention is still focused on the event. This will allow appropriate time to consider and implement corrective measures and obtain the appropriate level of resources to effect the necessary changes.

5. Implement Corrective Measures
Based on the findings of the Root Cause Analysis, an implementation plan for appropriate corrective measures should be developed soon after acceptance of the investigation findings. At a minimum, the plan should include:

• Scope of the corrective measure (e.g., specific to a particular laboratory or department, or organization-wide)
• Resources needed for implementation
• Expected outcome 
• Metrics to assess performance
  

6. Monitoring
Corrective measures need to be monitored to insure they are being implemented and that they are having the intended effect. Where possible, metrics should be integrated into existing systems (e.g., laboratory inspections or audits) in order to streamline the performance improvement process and to increase the likelihood of acceptance.

Accidents are an unfortunate reality in workplaces, including research environments. If the accident is properly investigated, there is an opportunity to improve safety performance. Incorporating these six steps into your accident investigation program will allow your investigation team to identify root causes, prescribe appropriate corrective measures, and implement performance metrics to insure a safer workplace.

This article is an excerpt from a white paper published by EH&E on this topic. The complete paper is available for download at http://www.eheinc.com/lab_accident_nf.htm.

Kevin Coghlan, M.S., C.I.H., is the Director of EH&S Compliance & Strategic Support for EH&E and is responsible for oversight of the EH&S programs managed by EH&E at client facilities.