When a worker is killed on the job, it is a devastating tragedy. Each death represents a traumatic and deeply emotional loss for family members, friends, co-workers and employers. For employers and safety and health professionals, an occupational fatality represents the most serious kind of failure of efforts to protect workers from harm. Investigating incidents where a worker was killed, identifying contributing factors and best practices for preventing future similar cases, and sharing these findings with employers, is a sobering process and important responsibility.
For almost a decade Oregon has benefited from a unique collaborative occupational fatality investigation agreement between the Oregon Occupational Safety and Health Administration (OR-OSHA) and the Oregon Fatality Assessment and Control Evaluation (OR-FACE). OR-FACE is an enhanced fatality surveillance, investigation, research, and outreach program funded by the National Institute for Occupational Safety and Health (NIOSH). This agreement was recently renewed in October by OR-OSHA’s Interim Administrator Julie Love, and Drs. Ryan Olson and David Hurtado of the OR-FACE program. The agreement provides opportunities for the OR-FACE investigator, Barbara Hanley, MPH, to observe OR-OSHA fatality investigations (including site visits and interviews); discuss the case with OR-OSHA Safety Compliance Officers during and after the active investigation period; and, access evidence from completed OR-OSHA investigations. This provides OR-FACE with critical early access to primary evidence, and also enhances the quality and depth of recommendations in OR-FACE investigation reports and safety toolbox talks for supervisors.
For OR-OSHA Safety Compliance Officers, supporting the OR-FACE investigation process provides expanded outreach opportunities for their work and insights. OR-OSHA Safety Compliance Officers must necessarily focus on employer responsibilities, compliance with OR-OSHA standards, and violations of standards in their public reports (including citations). OR-FACE investigations employ root-cause analysis and can go beyond compliance to recommend additional preventive best practices that help employers prevent similar events from occurring in the future. These preventive practices are revealed in investigative processes, but may not necessarily be overtly stated in OR-OSHA reports given their focused function. OR-FACE investigation reports are written in a standardized NIOSH format and do not identify employers or workers. Each report is sent to a review panel for critical feedback prior to publication. When collaborating with OR-OSHA, the review panel includes the Safety Compliance Officer assigned to the case.
The OR-FACE staff give their thanks for OR-OSHA’s leadership, safety compliance officers, and policy analysts for their continued support as we enter a new 5-year cycle of funding from NIOSH for this important work!
