Investigating falls and building a prevention program

When someone slips, trips or falls, the organization has two jobs: to look after the injured person and to learn why it happened so that it does not happen again. A good investigation looks past the obvious, such as "the floor was wet" or "the worker was not watching", to the conditions and decisions that allowed the hazard to exist. This final lesson explains how to respond to a fall, how to investigate it, how to find root causes and choose effective corrective actions, and how to pull together everything in this course into a site-wide slip, trip and fall prevention program. The lesson ends with a capstone case study.

Immediate response

When someone falls, the first priority is the person. Do not rush to move them if they may have a head, neck or back injury, or a fracture. Call for first aid, and call emergency services if the injury appears serious, the person has hit their head and is confused or drowsy, cannot get up, or is in severe pain. Protect others from the same hazard by guarding the area, for example by standing by a spill or blocking off a stair. Once the person has been cared for, preserve the scene as far as practical: take photos of the floor, the lighting, the footwear and any objects involved before anything is cleaned up or moved, unless doing so would leave a danger in place.

In the US, OSHA's 1904.39 requires employers to report a work-related fatality within 8 hours, and an in-patient hospitalization, amputation or loss of an eye within 24 hours. Recordable injuries must be entered on the OSHA 300 log within seven calendar days. State workers' compensation laws set deadlines for employers to report injuries to their insurer, and employees must report injuries to their employer within set periods.

Gathering the facts

An investigation gathers information from four main sources: people, the physical scene, records and the sequence of events.

• People: interview the injured person (when they are able), witnesses, the supervisor, cleaners and maintenance staff. Ask open questions about what they were doing, what they saw, what was different that day and what they think would have prevented it. Interview people separately and promptly, and focus on facts rather than blame.
• Scene: photograph and measure the area: the floor surface and condition, any contaminant and its source, changes in level, lighting levels, handrails, mats, cords, weather and the route taken. Note the footwear worn and its condition. Consider slip resistance testing if the floor is suspected.
• Records: check cleaning logs, floor sweep logs, inspection reports, maintenance requests, previous incidents and near misses in the same location, snow removal records, training records and footwear policy.
• Sequence: build a timeline of events leading up to the fall, including the task, the timing, staffing and anything unusual.

Finding root causes

The immediate cause of most falls is simple to state: the worker slipped on a wet floor, tripped on a cord or missed a step. The useful question is why those conditions existed and why they were not found and fixed. Two common techniques help.

The five whys technique asks "why?" repeatedly until it reaches a cause that management can act on. It is simple but works best when the investigator is open to several branches of answers rather than one chain.

A cause category diagram, often called a fishbone or Ishikawa diagram, groups possible causes under headings such as environment, equipment, task, people, procedures and management. It encourages investigators to consider all categories rather than stopping at the first plausible cause.

Choosing corrective actions

Corrective actions should follow the hierarchy of controls and address the root causes, not just the immediate cause. For the dish room example, an action plan might include repairing the door seal immediately and changing the maintenance priority system so that leaks creating slip hazards are treated as urgent (organizational); installing a drainboard and drip trays between the machine and shelves and relocating or adding a floor drain (engineering); replacing the smooth tile with a high wet slip resistance floor when the area is next renovated (substitution); adding a squeegee and anti-fatigue drainage matting suitable for wet areas (engineering); confirming that dish room staff have suitable slip-resistant footwear (PPE); and tracking slip incidents and near misses in the kitchen monthly (administrative).

Each action should have an owner and a target date, and it should be followed up to confirm that it was done and that it worked. A good check is to ask: if we had done this before the incident, would it have prevented it? And could the same thing happen somewhere else? Share the lessons learned with similar areas and sites.

Building a site prevention program

The lessons in this course fit together into a slip, trip and fall prevention program. A practical program for most sites includes:

• Leadership commitment and a named coordinator, with slip, trip and fall prevention included in the health and safety policy and objectives.
• A hazard assessment of floors, stairs, ladders, outdoor areas, lighting and tasks, using incident data, inspections and worker input.
• Floor management: suitable flooring for each area, slip resistance testing where needed, planned maintenance and prompt repairs.
• Contamination control: source controls, entrance matting, spill response procedures and kits, and cleaning methods that keep floors dry.
• A footwear policy for areas where floors are likely to be wet or greasy, with support for purchase and replacement.
• Stairs, ramps and ladders: maintained, well lit, with handrails and guards, and ladder selection, inspection and training.
• A winter maintenance plan with priority routes, triggers, materials and records.
• Lighting, cord management, storage and 5S housekeeping standards.
• Inspections, hazard and near-miss reporting, and incident investigation.
• Training for workers, supervisors, cleaners and contractors.
• Measurement and review using both leading and lagging indicators.

Capstone case study

A regional distribution center has 260 workers across two shifts, a staff entrance and a visitor lobby, a cafeteria, a two-level office area connected by an interior stair, a racking area with order pickers, six loading docks and a large parking lot. In the past year it recorded 12 slip, trip and fall injuries in about 520,000 hours worked: five in the parking lot and at the staff entrance between December and March, three in the cafeteria, two on the office stair, one from a step stool in the stockroom and one tripping over shrink wrap in the racking area. Near-miss reporting is rare. The site manager asks you to recommend a prevention plan.

Where to go from here

This course has given you awareness of the main causes and controls for slips, trips and falls on the same level, and an introduction to stairs, ladders and edges. If your work involves working at height, using fall protection equipment, working on roofs, scaffolds or elevated platforms, or supervising such work, complete the working-at-heights course and any training required by your jurisdiction. Other courses in the safety stream cover hazard recognition and risk assessment, personal protective equipment, fire safety and emergency preparedness, and incident investigation in more depth.

Communicating findings

An investigation is only valuable if its lessons reach the people who can act on them. Prepare a short report that describes what happened, the causes found and the actions agreed, without naming or blaming individuals unnecessarily. Share it with the health and safety committee or representative, the supervisors and workers in the area, and other sites with similar hazards. Brief safety talks based on real local incidents are often more memorable than generic training. Follow up publicly on the actions taken, so that workers see that reporting and investigation lead to real improvements.

Return to work

Supporting the injured worker's recovery and return to work is part of a good response. Early, regular contact, modified duties that respect medical restrictions and a gradual return plan reduce the length and cost of absences and help the worker feel valued. Workers' compensation boards and insurers in both countries encourage or require employers to cooperate in return to work. A worker returning after a fall is also a valuable source of insight into what happened and what would help, provided the conversation is supportive rather than blaming.