Types of Accident , Accident

Investigations and case history

1
 Accident
Prevention

2
 An Accident is:
• 1 a. An unexpected and undesirable event, especially one resulting in damage
or harm: car accidents on icy roads due boiler rupture etc
• b. An unforeseen incident: A series of happy accidents led to his promotion.
• c. An instance of involuntary urination or defecation in one's clothing.
• 2. Lack of intention; chance: ran into an old friend by accident.
• 3. Logic A circumstance or attribute that is not essential to the nature of something.
http://www.thefreedictionary.com/accident

3
 Types of Accident based on
severity
• Minor accident(not reported to higher
management)
• Reportable Accidents(Injuries caused to the
worker to prevent him to working 48 hrs or
more,reported to higher management)
• Fatal Accident(Death of worker,reported to
higher managemnet) etc

4
 Types of Accidents
• FALL TO • CONTACT WITH
– same level – chemicals
– lower level – electricity
• CAUGHT – heat/cold
– in – radiation
– on • BODILY
– between REACTION FROM
– voluntary motion
– involuntary motion
5
 CAUSES OF ACCIDENT
• WORKERS (Poor knowledge about
work,lack of confidence,not following rules
and regulation,stree,using mobile,no
experience.bad habbit,fear etc)
• Management(provision of unsafe
workplace,lack of safe procedure,less
control on worker,untrained
worker,extraworkload)
6
 CAUSES OF ACCIDENT
• Unsafe Working Condition(poor work place
layout,lack of safe procedure,less control on
workers etc)
• Natural(eartquake, Flood etc)

7
 Effects of Accidents
• Worker(injury to body,loss of skills,loss of
job,financial loss etc)
• Family(loss of earning,hospitalization
realated time and money loss,stability of
family is disturbed etc)
• Management(time to solve the case,Issues
related to court,competators etc)
• Industry(production stoped,financial
loss,good will damaged etc) 8
Types of Accidents (continued)
• STRUCK • RUBBED OR
– Against ABRADED BY
• stationary or moving – friction
object
– pressure
• protruding object
• sharp or jagged edge – vibration
– By
• moving or flying
object
• falling object

9
 Fatal Accidents - Workplace
U.S. WORKPLACE FATALITIES - 2006
1. Vehicle Accidents 2413
2. Contact With Objects and Equipment 983
3. Falls 809
4. Assaults & Violent Acts 754

10
 Fatal Accidents - Workplace
Washington State FATALITIES - 2006
1. Vehicle Accidents 40
2. Contact With Objects and Equipment 13
3. Falls 19
4. Assaults & Violent Acts 4

NO NOTE: If you wish to normalize or compare the

Washington data with the Federal data, just multiply the
Washington numbers by 47 (based on population)

11
 Accident Causing Factors
• Basic Causes • Direct Causes
– Management – Slips, Trips, Falls
– Environmental – Caught In
– Equipment – Run Over
– Human Behavior – Chemical Exposure
• Indirect Causes
– Unsafe Acts
– Unsafe Conditions

12
 Policy & Procedures
Basic Causes Environmental Conditions
Equipment/Plant Design
Human Behavior

Unsafe Indirect Causes Unsafe

Conditions
Acts
Slip/Trip Fall
Direct Causes Energy Release
Pinched Between

ACCIDENT
Personal Injury
Property Damage
Potential/Actual 13
 Basic Causes
• Management Systems & Procedures

• Environment Natural & Man-made

• Equipment Design & Equipment

• Human Behavior
14
 Management

• Systems &
Procedures
– Lack of systems &
procedures
– Availability
– Lack of Supervision

15
 Environment

• Physical
– Lighting
– Temperature

• Chemical • Biological
– vapors –Bacteria
– smoke –Reptiles
16
 Design and Equipment

• Design

– Workplace layout
– Design of tools &
equipment
– Maintenance

17
Design and Equipment
• Equipment
– Suitability
– Stability
• Guarding

• Ergonomic

• Accessibility

18
 Human Behavior
Common to
all accidents

Not limited to person

involved in accident19
 Human Factors
• Omissions &
Commissions

• Deviations from
SOP
– Lacking Authority
– Short Cuts
– Remove guards

20
Human Behavior is a function of :

Activators (what needs to be done)

Competencies (how it needs to be done)

Consequences
(what happens if it is/isn’t done)
21
 ABC Model
Antecedents
(trigger behavior)

Behavior
(human performance)

Consequences
(either reinforce or punish behavior)
22
 Only 4 Types of
Consequences:
•Positive Reinforcement (R+)
("Do this & you'll be rewarded")

•Negative Reinforcement (R-)

("Do this or else you'll be penalized")
Behavior
•Punishment (P)
("If you do this, you'll be penalized")

•Extinction (E)
("Ignore it and it'll go away")
23
 Consequences Influence
Behaviors Based Upon
Individual Perceptions of:
Magnitude
{ positive
• Significance or
Impact negative

 Timing - immediate or future

 Consistency - certain or uncertain

24
 Human Behavior
• Behaviors that have consequences that are:

• Soon
• Certain
• Positive

Have a stronger effect on people’s behavior

25
Why is one sign often ignored, the
other one often followed?

26
 Human Behavior
• Soon
• A consequence that follows soon after a
behavior has a stronger influence than
consequences that occur later
• Silence is considered to be consent
• Failure to correct unsafe behavior
influences employees to continue the
behavior
27
 Human Behavior
• Certain
• A consequence that is certain to follow a
behavior has more influence than an
uncertain or unpredictable consequence
• Corrective Action must be:
– Prompt
– Consistent
– Persistent

28
 Human Behavior

• Positive
• A positive consequence influences
behavior more powerfully than a
negative consequence
• Penalties and Punishment don’t work
• Speeding Ticket Analogy

29
 Human Behavior
• Example: Smokers find it hard to stop smoking
because the consequences are:
A) Soon (immediate)
B) Certain (they happen every time)
C) Positive (a nicotine high)
The other consequences are:
A) Late (years later)
B) Uncertain (not all smokers get lung cancer)
C) Negative (lung cancer)
30
 Deviations from SOP
• No Safe Procedure
• Employee Didn’t know Safe Procedure
• Employee knew, did not follow Safe
Procedure
• Procedure encouraged risk-taking
• Employee changed approved procedure

31
 Human Behavior

• Thought Question:

What would you do as a worker if you

had to take 10-15 minutes to don the
correct P.P.E. to enter an area to turn off
a control valve which took 10 seconds?

32
 Human Behavior

• Punishment or threatening workers is a

behavioral method used by some Safety
Management programs
• Punishment only works if:
– It is immediate
– Occurs every time there is an unsafe behavior
• This is very hard to do

33
 Human Behavior
• The soon, certain, positive reinforcement
from unsafe behavior outweighs the
uncertain, late, negative reinforcement
from inconsistent punishment

• People tend to respond more positively to

praise and social approval than any other
factors
34
 Human Behavior
• Some experts believe you can change worker’s
safety behavior by changing their “Attitude”
• Accident Report – “Safety Attitude”
• A person’s “Attitude” toward any subject is
linked with a set of other attitudes - Trying to
change them all would be nearly impossible
• A Behavior change leads to a new “Attitude”
because people reduce tension between
Behavior and their “Attitude”

35
 Attitudes
however

Are inside a person’s head -therefore they

are not observable nor measurable

Attitudes can be changed by

changing behaviors
36
 Human Behavior

• “Attention” Behavioral Safety approach

– Focuses on getting workers to pay
“Attention”
– Inability to control “Attention” is a
contributing factor in many injuries

• You can’t scare workers into a safety

focus with “Pay Attention” campaigns
37
 Reasons for Lack of Attention
1. Technology encourages short attention
spans (TV remote, Computer Mouse)
2. Increased Job Stress caused by
uncertainty (mergers & downsizing)
3. Lean staffing and increased workloads
require quick attention shifts between
tasks
4. Fast pace of work – little time to learn
new tasks and do familiar ones safely
38
 Reasons for Lack of Attention
5. Work repetition can lull workers into a loss of
attention
6. Low level of loyalty shown to employees by an
ever reorganizing employer may lead to:
a) Disinterested workers
b) Detached workers (no connection to employer)
c) Inattentive workers

39
 Human Behavior

• Focusing on “Awareness” is a typical

educational approach to change safety
behavior

• Example: You provide employees with a

persuasive rationale for wearing safety
glasses and hearing protection in certain
work areas
40
 Human Behavior
Developing Personal Safety Awareness
A) Before starting, consider how to do job safely
B) Understand required P.P.E. and how to use it
C) Determine correct tools and ensure they are in good
condition
D) Scan work area – know what is going on
E) As you work, check work position – reduce any strain
F) Any unsafe act or condition should be corrected
G) Remain aware of any changes in your workplace – people
coming, going, etc.
H) Talk to other workers about safety
I) Take safety home with you
41
 Human Behavior

Some Thought Questions:

1. Do you want to work safely?
2. Do you want others to work safely?
3. Do you want to learn how to prevent
accidents/injuries?
4. How often do you think about safety as you
work?
5. How often do you look for actions that
could cause or prevent injuries?
42
 Human Behavior
• More Thought Questions:
a) Have you ever carried wood without wearing gloves?
b) Have you ever left something in a walkway that was a
tripping hazard?
c) Have you ever carried a stack of boxes that blocked your
view?
d) Have you ever used a tool /equipment you didn’t know how
to operate?
e) Have you ever left a desk or file drawer open while you
worked in an area?
f) Have you ever placed something on a stair “Just for a
minute”?
g) Have you ever done anything unsafe because “I’ve always
done it this way”? 43
 Human Behavior

TIME!

“All this safety stuff takes time doesn’t it”?

“I’m too busy”!

“I can’t possibly do all this”!

“The boss wants the job done now”!

44
 Human Behavior

• Does rushing through the job, working quickly

without considering safety, really save time?

• Remember – if an incident occurs, the job may

not get done on time and someone could be
injured – and that someone could be YOU!!

45
 Safety Intervention Strategies
Approach # of Studies # of Subjects Reduction %
Behavior Based 7 2,444 59.6%
Ergonomics 3 n/a 51.6%
Engineering Change 4 n/a 29.0%
Problem Solving 1 76 20.0%
Gov’t. Action 2 2 18.3%
Mgt. Audits 4 n/a 17.0%
Stress Management 2 1,300 15.0%
Poster Campaign 26 100 14.0%
Personnel Selection 26 19,177 3.7%
Near-miss Reports 2 n/a 0%
46
OUTCOMES OF ACCIDENTS

NEGATIVE OUTCOMES

POSITIVE OUTCOMES

47
 $ Direct Costs
• Medical
• Insurance
• Lost Time
• Fines

48
 Compliance
• Failure to develop and implement a
program may be cited as a SERIOUS
violation (by itself or "Grouped" with
other violations)

Penalties (as high as $ 2,000) may be

assessed

49
 Compliance
• Up to 35% of the penalty can be
deducted based upon an employer's
"good faith“ - Good faith is based
upon:
– Awareness of the Law
– Efforts to comply with the Law before the
inspection
– Correction of hazards during the inspection
– Cooperation & Attitude during the inspection
– Overall safety and health efforts including the
Accident Prevention Program

50
Indirect Costs
• Injured, Lost Time
Wages
• Non-Injured, Lost
Time Wages
• Overtime
• Supervisor Wages
• Lost Bonuses
• Employee Morale
• Need For
Counseling
• Turn-over
51
Indirect Costs
• Equipment Rental
• Cancelled Contracts
• Lost Orders
• Equipment/Material
Damage
• Investigation Team Time
• Decreased Production
• Light Duty
• New Hire Learning Time
• Administrative Time
• Community Goodwill
• Public/Customer Perception
• 3rd Party Lawsuits
52
OUTCOMES OF ACCIDENTS
• POSITIVE ASPECTS
– Accident investigation
– Prevent repeat of accident
– Improved safety programs
– Improved procedures
– Improved equipment design

53
 Accident investigation
• Accident investigation focus on the
identification of root causes instead of
finding fault and blame.It carried out in 02
phases:
• Phase 1:Incident Logging(logging of basic
incident details either by victim or worker
present at the time of incidents ,the
information include location,activity
envolved etc)
54
 Accident investigation

• Phase 2:Incident Investigation(In case

where high risk score is high further
investigation takes place by team of
supervisors, recommendation are made on
the basis of finding from investigation etc)

55
 Information Collected in Incident Report(based on
following information
• Process(were Safety procedure inadequate etc)
• Technology(was the tech in safe operational
condition,was correct tech used for taskect)
• Physical Env.(Did any conventional factors
contribute to accident,was there free,safe access
to location)
• Human Resources(Was the person concerned
was doing normal duties?was person trained wrt
safty.How was behavior of worker? )
56
 Guide lines for Investigation
• The investigation should commence
immediately for high risk incidents
• Investigation techniques should be clear to
the team.
• Following steps should be followed :
Visit the site for high risk incident
Collect and analyse evidence
Listing finding for analysis
Preparing report

57
 Guide lines for Investigation
• Investigation techniques followed should
able to identify basic facts from evidence:
What happened?
What happened just before and after the incident?
What was operational and environmental condition
during incident?(use
photographs,skethes,interviews of personned
involved)?

58
 Formation of investigation team
• Team should be cross functional
• Team consists of:
Area/Site expert
Investigation technique expert
Site / area Saftey professional
HR/IR personnel
For high risk score should be senior manger etc

59
 Accident Prevention Program
• Must Be
– Written
– Tailored to particular hazards for a particular
plant or operation
• Minimum Elements
– Safety Orientation Program
– Safety and Health Committee

60
 Accident Prevention Program
• Safety Orientation
– Description of Total Safety Program
– Safe Practices for Initial Job Assignment
– How and When to Report Injuries
– Location of First Aid Facilities in Workplace
– How to Report Unsafe Conditions & Practices
– Use and Care of PPE
– Emergency Actions
– Identification of hazardous materials
61
 Accident Prevention Program
• Designated Safety and Health Committee
– Management Representatives
– Employee Elected Representatives
• Max. 1 year
• Must be equal # or more employee representatives than
employer representatives
– Elected Chairperson
– Self-determine frequency of meetings
• 1 hour or less unless majority votes
– Minutes
• Keep for 1 Year
• Available for review by OSHA Personnel
62
 Accident Prevention Program

• Safety Meeting instead of Safety

Committee
– If less than 11 employees
• Total
• Per shift
• Per location
– Meet at least once/month
– 1 Management Representative
63
 Safety Meeting
You Must
– Review inspection reports
– Evaluate accident investigations
– Evaluate APP and discuss recommendations
– Document attendance and topics

64
Safety Committees

65
 Proactive
Safety Committees Safety

They should meet as often as necessary

This will depend on volume of production and
conditions such as
• Number of employees
• Size of workplace covered
• Nature of work undertaken on site
• Type of hazards and degree of risk

Meetings should not be cancelled 66

 Safety Committees
The Goal of the committee is to facilitate a safe
workplace
Objectives that guide a committee towards the goal include:
Motivate, educate and train at all levels to ID, Reduce, &
Avoid Hazards
Incorporate safety into every aspect of the organization
Create a culture where each person is responsible for
safety of self and others
Encourage and utilize ideas from all sources

67
 Four points to Remember:
•Communication: Must be a loop system

•Dedication: From everyone

•Partnership: Between Management

and Employees
•Participation: An important part of
team working.
68
How effective
can a
Committee be?

69
 Safety Committee
Policy Statement
A written and publicized statement is an
effective means of providing guidance and
demonstrating commitment

70
 Safety Committee Focus
• Long Term Goals
– Objectives to Achieve
– Time Frame
• Short Term Goals
– Assignments between Meetings
– Work toward achieving Long-Term Plan

71
Planning the Safety Meeting

• Select topics
• Set & post the agenda
• Schedule safety meeting
• Prepare meeting site
• Encourage participation

72
 Conducting A Safety Meeting
Provide an attendance list or sign in sheet
Provide a meeting agenda
Call meeting to order and review meeting topics
Cover any old business
Primary meeting topic
Future agendas
Close meeting and document

73
Components of an Agenda
Opening statement including reason for
attendance, objective, and time
commitment
Items to be discussed
Generate alternative solutions
Decide among the alternatives
Develop a plan to solve the problem
Assign task to carry out plan
Establish follow-up procedures
Summarize and adjourn 74
 Regular Agenda Item
• Review Policies & Plans such as:
– Hazard Communication Program
– Personal Protective Equipment
– Respiratory Protection
– Housekeeping
– Machine Safeguarding
– Safety Audits
– Record Keeping
– Emergency Response Plans
75
 Emergency Plan

• Anticipate What
Could Go Wrong
and Plan for
those Situations

• Drill for
Emergency
Situations

76
 Emergency Action Plan
• The following minimum elements shall be included :
– Alarm Systems
– Emergency escape procedures and route assignments;
– Procedures for employees who remain to operate critical
plant operations before evacuation
– Procedures to account for all employees
– Rescue and medical duties for those employees who are to
perform them
– The preferred means of reporting fires and other
emergencies
– Names / job titles of who can be contacted for further
information or explanation of duties under the plan
77
 Record Keeping & Updating
• Record each Recordable Injury & Illness on
OSHA 300 Log w/in 6 Days
– Recordable
• Occupational fatalities
• Lost workday
• Result in light-duty or termination or require medical
treatment (other than first aid) or involve loss of
consciousness or restriction of work or motion
• This information in posted every year from
February 1 to April 30 in the OSHA 300A
Summary
78
 Record Keeping and Updating
• First Aid - one-time treatment that could be
expected to be given by a person trained in
basic first-aid using supplies from a first-aid kit
and any follow-up visit or visits for the purpose
of observation of the extent of treatment
• NOTE: The new OSHA Recordkeeping
Rule lists the specific First Aid Treatments

79
 Immediately Report:
– Any accident that involves: 1. Injury 2. Illness 3.
Equipment or property damage

– Any near-misses. A near miss is an event that,

strictly by chance, does not result in actual or observable
injury, illness, death, or property damage. Examples:
slips, trips & falls, compressed gas cylinder falling,
overexposures to a chemical

– Any hazards such as: Exposed electrical wires,

Damaged PPE, Improper material storage, Improper
chemical use, Horseplay, Damaged equipment, Missing
or loose machine guards
80
HAZARD ANALYSIS

81
 Hazard Analysis
• Orderly process used to determine if a
hazard exists in the workplace
– Uncover hazards overlooked in design
– Locate hazards developed in-process
– Determine essential steps of a job
– Identify hazards that result from the
performance of the actual job

82
 Step 1: Identify Hazards

HAZARD –
condition with
the potential to
cause personal
injury, death and
property damage

83
 Hazard Identification
• Review Records
• Talk to Personnel
• Accident Investigations
• Follow Process Flow
• Write a Job Safety Analysis
• Use Inspection Checklists
84
 STEP 2: Assess Hazards
• Probability - How likely is the hazard?
– Likely
– Not likely
• Severity - What will happen if
encountered?
– Death
– Serious Injury
– Damage to property

85
 Levels of Risk Awareness
• Unaware: Doesn’t realize at-risk

• Post-Awareness: Realizes Risk After Task

Completion

• Engaged-Awareness: Recognizes Risk While

Performing Task(s) and corrects the situation

• Proactive-Awareness: Foresee Hazards and

Begins Task Only When Safe to Proceed
86
 Who is at Risk?
• Workers  Contractors
• Visitors  Janitorial
 Maintenance
– Invited
• Customers
• Emergency services  Others
• Delivery drivers
 Members of Public
– Uninvited  Passers-by
• Trespassers
 Neighbors
• Burglars

87
STEP 3: Make Risk Decisions

What can we do to reduce the risk?

Does the benefit outweigh the risk?

88
STEP 4: Implement Controls

• Substitution
• Engineering controls
• Administrative Controls
• Personal Protective Equipment

89
Hazard Controls
Source

Path

Receiver
90
 Hazard Control
Administrative Engineering

Protective Equipment/Clothing

91
 Engineering
Hazard Elimination Ventilation
Add-On Safety Design Design/Layout
“Active” vs. “Passive” Safety Devices
User Instructions
(Manual)

92
 Administrative

• Safety Rules
• Disciplinary Policy - Accountability
• Preventative Maintenance
• Training
• Proficiency/Knowledge Demonstrations

93
 Step 5: Supervise
• Ensure risk control
measures are
implemented
• Track progress
• Feedback

94
JOB SAFETY
ANALYSIS

95
 Job Safety Analysis

• Break down a task into its component steps

• Determine hazards connected with each key

step

• Identify methods to prevent or protect

against the hazard
96
Job Safety Analysis

97
 Job Safety Analysis Priorities
• New Jobs
• Potential of Severe Injuries
• History of Disabling Injuries
• Frequency of Accidents

98
Observation of the Actual Work
• Select experienced worker(s) to
participate in the JSA (job saftey
Analysis)process
• Explain purpose of JSA
• Observe the employee perform the job
and write down basic steps
• Completely describe each step
• Note any deviations (Very Important!)
99
 Identify Hazards &
Potential Accidents
• Search for Hazards
– Produced by Work
– Produced by Environment
• Repeat job observation as many times as
necessary to identify all hazards

100
JSA EXERCISE

101
INSPECTIONS

102
 Inspections
• Fact-Finding vs. Fault Finding
– Sound knowledge of the plant
– Knowledge of relevant standards & codes
– Systematic inspection steps
– Method of evaluating data

103
 Inspection Limitations
• “Blinder affect”
• Rote inspections
• All Check - No action
• Who is inspecting?

104
 Outcomes
• Improve Safety
– New Way to Do Job
– Change Physical Conditions
– Change Work Procedures
– Reduce Frequency of Dangerous Job

105
 New Way To Do The Job
• Determine the work goal of the job, and
then analyze the various ways of reaching
this goal to see which way is safest
• Consider work saving tools and
equipment

106
Change in Physical Conditions

• Tools, materials, equipment layout or

location
• Study change carefully for other benefits
(costs, time savings)
107
 Change in Work Procedures
• What should the worker do to eliminate
the hazard?
• How should it be done?
• Document changes in detail

108
 Reduce Frequency of
Dangerous Job
• What can be done to reduce the
frequency of the job??
• Identify parts that cause frequent repairs
- change
• Reduce vibration save machine parts

109
Performing Safety Audits

110
Guide for Personal Audits

The guide has five steps

• Audit
• React
• Communicate
• Follow up
• Raise standards

111
 Audit
• Get into one of the work areas on a
regular basis
• Develop your own system
• Do not combine a safety audit with other
visits
• Audit must be designed to evaluate safety
• Take notes
112
 React
• How you react is the strongest element in
improving the safety culture
• Your reaction tells what is acceptable and not
acceptable
• You must come away from each inspection with a
reaction:
1. Acceptable because...
2. Not acceptable because...
3. Deteriorated because...
4. Improved because…
113
 Communicate
• In order for the contact to be productive, your
subordinate/co-worker must understand that:
 You inspected his or her area
 You are pleased (or displeased) with what you saw
because of…
 You expect him or her to react to your comments and to
improve
 You will audit the area again in a specified number of
days
114
 Follow Up

• Critical for success of the safety program

• Allows you to demonstrate that it is
important
• Must communicate your assessment to the
employees

115
 Raise Standards

• Will see improvement if the first four

steps are followed
• Keep raising your expectations and help
provide leadership
• Solve the obvious problems then fine tune
the safety and housekeeping efforts

116
Key Points: Becoming a Good Observer

• Effective observation includes:

Be selective
Know what to look for
Practice
Keep an open mind
Guard against habit and familiarity
Do not be satisfied with general impressions
Record observations systematically
117
Observation Techniques

To become a good observer, a person

must:
• Stop for 10 to 30 seconds before entering an
area to ascertain where employees are
working
• Be alert for unsafe practices
• Observe activity -- do not avoid the action
118
 Observation Techniques
• Remember ABBI -- look Above, Below,
Behind, Inside
• Develop a questioning attitude

• Use all senses

• sight
• hearing
• smell
• touch
119
 Inspections and Field
Observations

• Use a checklist
• Ask questions
• Take notes
• Respect lines of communication
• Draw conclusions

120
 Unsafe Acts

• Conduct that unnecessarily increases the

likelihood of injury
• All safety rule and procedure violations
are unsafe acts
• All unsafe acts should be corrected
immediately

121
 Unsafe Conditions
• An unsafe condition is a situation, not
directly caused by the action or inaction
of one or more employees, in an area that
may lead to an incident or injury if
uncorrected
• Unsafe conditions are normally beyond
the direct control of employees in the
area where the condition is observed

122
 Audit Practices
• Concentrate on people and their actions
because actions of people account for more
than 96 percent of all injuries
 When to audit
 Where to audit
 How much to audit
 Auditing contractors
123
124
 Management Commitment

Should Management Consider Safety as a Priority

in Conducting Business

?? 125
Management Commitment

NO ! 126
PRIORITIES CHANGE

SAFETY
MUST BE A
VALUE!! 127
 Employee Participation

• Day-to-Day Knowledge • Accident Prevention

comes from where the Plan Development
work is actually done
and hazards actually • Safety Committee
exist.
• Safety Bulletin Board

• Crew-Leader Meetings

128
SHARED VISION
EXERCISE

129
 AVAILABLE RESOURCES
• OSHA Website: www.osha.gov

• Washington State Labor & Industries

Website: www.lni.wa.gov

130
 ACCIDENT
INVESTIGATION

131
 INTRODUCTION
• Thousands of accidents occur throughout the
United States every day
• Accident investigations determine how and why
these failures occur
• Conduct accident investigations with accident
prevention in mind - Investigations are NOT to
place blame
• Investigate all accidents regardless of the extent
of injury or damage

132
 THE ACCIDENT

WHAT IS AN ACCIDENT?
133
 THE ACCIDENT

An
unplanned and unwelcome event
that interrupts normal activity

134
Accidents are What Happens to
Somebody Else

BUT REMEMBER:
YOU
are somebody else
to somebody else

135
 THE ACCIDENT
MINOR ACCIDENTS:

• Such as paper cuts to fingers or dropping

a box of materials

136
 THE ACCIDENT
MORE SERIOUS ACCIDENTS

• Such as a forklift dropping a load or

someone falling off a ladder

137
 THE ACCIDENT
• Accidents that occur over an extended
time frame:
– Such as hearing loss or an illness resulting
from exposure to chemicals

138
 THE ACCIDENT
NEAR-MISS
• Also know as a “Near Hit”

• An accident that does not quite result in

injury or damage (but could have)

• Remember, a near-miss is just as serious

as an accident!
139
 THE ACCIDENT

ACCIDENTS HAVE TWO THINGS IN

COMMON

140
 THE ACCIDENT
They all have outcomes from the accident

141
 THE ACCIDENT

They all have contributory factors that

cause the accident

142
OUTCOMES OF ACCIDENTS

• NEGATIVE Results
– Injury & possible death
– Disease
– Damage to equipment & property
– Litigation costs, possible citations
– Lost productivity
– Morale

143
OUTCOMES OF ACCIDENTS
• POSITIVE Results
– Accident investigation
– Prevent repeat of accident
– Change to safety programs
– Change to procedures
– Change to equipment design

144
ACCIDENT INVESTIGATION
• Accidents are usually complex
• An accident may have 10 or more events
that can be causes
• A detailed analysis of an accident will
normally reveal three cause levels:
– direct
– indirect
– root

145
 Direct Cause
• An accident results only when a person
or object receives an amount of energy
or hazardous material that cannot be
absorbed safely - This energy or
hazardous material is the DIRECT
CAUSE of the accident
The direct cause is usually the result of one or
more unsafe acts or unsafe conditions or both
146
 Indirect and Root Causes
• Unsafe acts and conditions are the indirect
causes or symptoms of accidents
• Indirect causes are usually traceable to:
– poor management policies and decisions
– personal or environmental factors
• Root causes are the actual policies and
decisions by management and the actual
personal and environmental factors of the
workplace

147
ACCIDENT INVESTIGATION

You Must:
• Conduct a preliminary investigation for:
– serious injuries with immediate symptoms

• Document the investigation findings

148
 ACCIDENT INVESTIGATION
• Do Not move equipment involved in a work or work
related accident or incident if :
– A death
– A probable death
– 3 or more employees are sent to the hospital (WISHA -2)
• Unless, Moving the equipment is necessary to:
– Remove any victims
– Prevent further incidents and injuries

149
 ACCIDENT INVESTIGATION
• Within 8 hours of a work-related incident or
accident you must contact the nearest office of the
OSHA in person or by phone to report
– A death
– A probable death
– 3 or more employees are sent to the hospital (WISHA -2)
• (OSHA) 1-800-321-6742
• WISHA 1-800-4BE-SAFE (423-7233)

150
 ACCIDENT INVESTIGATION
• Assign witnesses and other employees to assist
OSHA personnel who arrive to investigate the
incident
Include:
– The immediate supervisor
– Employees who were witnesses to the incident
– Other employees the investigator feels are necessary
to complete the investigation

151
ACCIDENT INVESTIGATION
•Make sure your preliminary investigation is
conducted by the following people:
– A person designated by the employer
– The immediate supervisor
– Witnesses
– An employee representative
– Other persons with experience and skills to evaluate
the facts

152
ACCIDENT INVESTIGATION

A preliminary investigation includes noting

information such as the following:
–Where did the accident or incident occur?
–What time did it occur?
–What people were present?
–What was the employee doing at the time?
–What happened during the accident or
incident?

153
ACCIDENT INVESTIGATION

Provide the following information to OSHA within

30 days concerning any accident involving a fatality
or hospitalization of 3 or more employees:
– Name of the work place
– Location of the incident
– Time and date of the incident
– Number of fatalities or hospitalized employees
– Contact person
– Phone number
– Brief description of the incident
154
 Why Not Rely On OSHA &
Police To Investigate?
• Focus On Culpability
• Minor Accidents Not
Investigated
• PREVENTION
• Protect Company
Interests
• OSHA Requirements

155
 Investigating Accidents

How to find out what really happened

156
 Why Investigate Accidents?
• Find the cause
• Prevent similar accidents
• Protect company interests

157
At which level do we investigate?

Death
Lost Time
Injury
Reportable Injury

Minor Injuries

Near Misses

Acts Conditions

Maintenance
Knowledge

Motivation

Design
Ability

Others
Action
of
158
Investigation Strategy
• Need For Investigation

• Control the Scene

• Gather Facts

• Analyze Data

• Establish Causes

• Write Report

• Take Corrective Action 159

 Investigative Procedures

• The actual procedures used in a particular

investigation depend on the nature and results
of the accident
• All investigations start with a collection of data
and are followed by analysis of that data
• An investigation is not complete until all data
is analyzed and a final report is completed

160
 The Aim of the Investigation
• The key result should be to
prevent a repeat of the same
accident
• Fact finding:
– What happened?
– What was the root cause?
– What should be done to prevent
repeat of the accident?
161
 The Aim of the Investigation
IS NOT TO:
• Exonerate individuals or management

• Satisfy insurance requirements

• Defend a position for legal argument

• Or, to assign blame

162
 COMPANY ACCIDENT
FORMS
• Must be filled out completely by
the employee and employee’s
immediate supervisor (this includes
foremen)
• Must be turned in to Safety within
24 hours of incident

163
 BENEFITS OF ACCIDENT
INVESTIGATION

• Prevent repeat of the accident

• Identifying outmoded procedures
• Improvements to the work environment
• Increased productivity
• Improvement of operational & safety
procedures
• Raise safety awareness level
164
 BENEFITS OF ACCIDENT
INVESTIGATION

• WHEN AN ORGANIZATION REACTS

SWIFTLY AND POSITIVELY TO
ACCIDENTS AND INJURIES, ITS
ACTIONS REAFFIRM ITS
COMMITMENT TO THE SAFETY
AND WELL-BEING OF ITS
EMPLOYEES!

165
 Who Should Investigate?
Investigation TEAM
• Employer Designee (Management)
• Immediate Supervisor of affected area/personnel
• Experts (if needed)
• Employee Representative (one of the following:)
– Employee selected representative
– Employee representative of safety committee
– Union representative or shop steward

166
 **Immediate Actions

• Assess the scene

• CALL on Emergency no
• Activate In-House Response
• Scene Safety
• Provide Aid to Injured
• Provide Assistance to Affected
• Secure the Scene of Accident
167
 Isolate the Scene
• Barricade the area of the accident, and
keep everyone out!
• The only persons allowed inside the
barricade should be Rescue/EMS, law
enforcement, and investigators
• Protect the evidence until investigation is
complete

168
 Provide Care to the Injured
• Ensure that medical care is provided to
the injured people before proceeding
with the investigation

169
 Secure the Scene for Safety
• Eliminate the hazards:
– Control chemicals
– De-energize
– De-pressurize
– Light it up
– Shore it up
– Ventilate

170
Fact Finding
• Gather evidence from
many sources during an
investigation
• Get information from
witnesses and reports as
well as by observation
• Don’t try to analyze data
as evidence is gathered

171
 Gather Evidence

• Examine the accident scene - Look for things

that will help you understand what happened:
– Dents, cracks, scrapes, splits, etc. in equipment
– Tire tracks, footprints, etc.
– Spills or leaks
– Scattered or broken parts
– Any other possible evidence

172
 Gather Evidence

• Diagram the scene:

– Use blank paper or graph
paper. Mark the location of
all pertinent items;
equipment, parts, spills,
persons, etc.
– Note distances and sizes,
pressures and
temperatures
– Note direction (mark north
on the map) 173
 Gather Evidence
• Take photographs
– Photograph any items or scenes which may provide an
understanding of what happened to anyone who was
not there
– Photograph any items which will not remain, or which
will be cleaned up (spills, tire tracks, footprints, etc.)
– 35mm cameras, Polaroids, and video cameras are all
acceptable
• Digital cameras are not recommended -
digital images can be easily altered 174
 Photographs

• Unbiased Recording
• Keep Log of Photos
• Overall to Close-up
• Color if possible
• Supplement with Video

175
 Gather Data
• Data includes:
– Persons involved
– Date, time, location
– Activities at time of accident
– Equipment involved
– List of witnesses

176
 Review Records
• Check training records
– Was appropriate training provided?
– When was training provided?
• Check equipment maintenance records
– Is regular PM or service provided?
– Is there a recurring type of failure?
• Check accident records
– Have there been similar incidents or injuries
involving other employees?
177
 Documents
• Collect All Related Documents
– Inspection Logs
– Policy & Procedures Manual
– JSA (Job Safety Analysis)
– Equipment Operations Manuals
– Insurance Records
– Employee Records
– Police Reports

178
 Samples
• Collect Perishables
First
• Fluids
• Open Containers
• Filings
• Chemicals
• Air

179
 Interviews
• Experienced personnel should conduct
interviews
• If possible the team assigned to this task
should include an individual with a legal
background
• After interviewing all witnesses, the team
should analyze each witness' statement

180
 Interviews
• Analyze this information along with data
from the accident site
• Not all people react in the same manner
to a particular stimulus
• A witness who has had a traumatic
experience may not be able to recall the
details of the accident
• A witness who has a vested interest in the
results of the investigation may offer
biased testimony 181
 Interviews
• Excellent Source of first hand knowledge

• May Present Pitfalls in form of:

– Bias
– Perspective
– Embellishment
– Omissions

182
 Ask “What Happened”
• Get a brief overview of
the situation from
witnesses and victims
• Not a detailed report
yet, just enough to
understand the basics
of what happened

183
Interview Victims & Witnesses
• Interview as soon as possible
after the incident
– Do not interrupt medical care
to interview
• Interview each person
separately
• Do not allow witnesses to
confer prior to interview

184
 The Interview
• Put the person at ease
– People may be reluctant to
discuss the incident, particularly
if they think someone will get in
trouble

• Reassure them that this is a

fact-finding process only
– Remind them that these facts
will be used to prevent a
recurrence of the incident 185
 The Interview
• Take Notes!
• Ask open-ended questions
– “What did you see?”
– “What happened?”
• Do not make suggestions
– If the person is stumbling over a word or
concept, do not help them out

186
 The Interview
• Use closed-ended questions later to gain
more detail
– After the person has provided their
explanation, these type of questions can be
used to clarify
– “Where were you standing?”
– “What time did it happen?”

187
 The Interview
• Don’t ask leading questions
– Bad: “Why was the forklift operator driving
recklessly?”
– Good: “How was the forklift operator driving?”

• If the witness begins to offer reasons, excuses,

or explanations, politely decline that knowledge
and remind them to stick with the facts

188
 The Interview
• Summarize what you have been told
– Correct misunderstandings of the events
between you and the witness

• Ask the witness/victim for

recommendations to prevent recurrence
– These people will often have the best
solutions to the problem

189
 The Interview
• Get a written, signed statement from the
witness
– It is best if the witness writes their own
statement; interview notes signed by the
witness may be used if the witness refuses to
write a statement

190
 Ask All Witnesses
• Name, address, phone number
• What did you see?
• What did you hear?
• Where were you standing/sitting?
• What do you think caused the accident?
• Was there anything different today?

191
 Ask Supervisors
• What is normal procedure for activities
involved in the accident?
• What type of training persons involved in
accident have had?
• What, if anything was different today?
• What they think caused the accident?
• What could have prevented the accident?

192
 Analysis of Accident Causes
• Immediate Causes
• What was done?
• What was not done?
• What hazardous condition existed?
• Root Causes
• Why did they do this?
• Why didn’t they do that?
• Why did the unsafe condition exist?
• Why wasn’t it corrected? 193
 Analyze Data
• Gather all photos, drawings, interview
material and other information collected
at the scene
• Determine a clear picture of what
happened
• Formally document sequence of events

194
 CONTRIBUTING FACTORS
INVESTIGATION STRATEGY
• INVESTIGATION TEAM

• EVALUATES ALL FACTORS CONCERNED

• ISOLATES THE KEY FACTOR(S) BY

ASKING THE FOLLOWING QUESTION....

• WOULD THE ACCIDENT HAVE HAPPENED

IF THIS PARTICULAR FACTOR WAS NOT
PRESENT?
195
 DETERMINE CAUSES
• Employee actions
• Safe behavior, at-risk behavior
• Environmental conditions
• Lighting, heat/cold, moisture/humidity, dust, vapors,
etc.
• Equipment condition
• Defective/operational, guards, leaks, broken parts,
etc.
• Procedures
• Existing (or not), followed (or not), appropriate (or
not)
• Training
• Was employee trained - when, by whom,
documentation
196
 Indirect Causes
• Unsafe conditions – what material
conditions, environmental conditions and
equipment conditions contributed to the
accident

• Unsafe Acts – what activities contributed

to the accident

197
 Breakdown of Unsafe Conditions

• Inadequately guarded or
unguarded equipment
• Defective tools, equipment or
materials
• Fire and explosion hazard
• Unexpected movement hazard
• Projection hazards
198
 Breakdown of Unsafe Conditions

• Housekeeping
• Hazardous environmental conditions
• Improper ventilation
• Improper illumination
• Unsafe dress or apparel

199
 Breakdown of Unsafe Acts
• Operating without authority
• Operating or working at unsafe speeds
• Making safety devices inoperative
• Using unsafe equipment
• Neglecting to wear PPE
• Unsafe loading, placing, mixing, combining
• Taking unsafe position or posture

200
 Basic Causes
• Management Systems & Procedures

• Environment

• Equipment Design & Equipment

• Human Behavior
201
 Management
• Was a hazard assessment conducted?
• Were the hazards recognized?
• Was control of the hazards addressed?
• Were employees trained?
• Did supervision detect/correct deviations?
• Was Supervisor trained in job/accident
prevention?
• What were the production rates?
202
 FIND ROOT CAUSES

• When you have determined

the contributing factors, dig
deeper!
– If employee error, what
caused that behavior?
– If defective machine, why
wasn’t it fixed?
– If poor lighting, why not
corrected?
– If no training, why not?
203
 Contribution of Safety
Controls such as:
• Engineering Controls - machine guards, safety
controls, isolation of hazardous areas,
monitoring devices, etc.
• Administrative Controls - procedures,
assessments, inspection, records to monitor and
ensure safe practices and environments are
maintained.
• Training Controls - initial new hire safety
orientation, job specific safety training and
periodic refresher training.
204
 What controls failed?
• List the specific engineering,
administrative and training controls that
failed and how these failures contributed
to the accident

205
 What controls worked?
• List any controls that prevented a
more serious accident or
minimized collateral damage or
injuries

206
 Determine
• What was not normal before the
accident
• Where the abnormality occurred
• When it was first noted
• How it occurred

207
 Report Causes
• Analysis of the Accident – HOW &
WHY
a. Direct causes (energy sources;
hazardous materials)
b. Indirect causes (unsafe acts and
conditions)
c. Basic causes (management policies;
personal or environmental factors)
208
 Unable to Identify Root Causes
• Timeliness
• Poor development of information
• Reluctance to accept responsibility
• Narrow interpretations of
environmental causes
• Erroneous emphasis on a single cause
• Allowing solutions to determine causes
• Wrong person(s) investigating 209
 PREPARE A REPORT
• Accident Reports should contain
the following:
– Description of incident and injuries
– Sequence of events
– Pertinent facts discovered during
investigation
– Conclusions of the investigator(s)
– Recommendations for correcting
problems

210
PREPARE A REPORT, (CONT.)
• Be objective!
– State facts
– Assign cause(s), not blame
– If referring to an individual’s actions, don’t
use names in the recommendation
• Good: All employees should…….
• Bad: George should……..

211
 Recommendations
• Action to remedy
– Basic causes
– Indirect causes
– Direct causes

• Recommendations - as a result of the finding is

there a need to make changes to:
– Employee training?
– Work Stations Design?
– Policies or procedures?
212
 Recommendations
• Consider
-Effectiveness -Cost
-Feasibility -Effect on Productivity
-Time to Implement -Employee
Acceptance
-Management Acceptance

213
Accepting Inadequate Reports
• There is no surer way to destroy a
program's effectiveness than to accept
substandard work
• This immediately sends a signal to
subordinates that accident investigation
is not a high priority and does not receive
significant attention from management

214
 Common Problems
• Accidents not reported
• Unable to identify basic causes
• Accepting inadequate reports
• Neglecting to implement corrective
actions

215
 Accidents Not Reported
• Nothing is learned from unreported
accidents
• Accident causes are left uncorrected
• Infections and injury aggravations result
• Neglecting to report tends to spread and
become a common practice

216
 Why Workers Fail to Report
• Fear of discipline
• Concern for reputation
• Fear of medical treatment
• Desire to keep personal record clean
• Avoidance of red tape
• Concern about attitudes of others
• Poor understanding of importance
217
 Combat Reporting Problems
• Indoctrinate new employees
• Encourage workers to report minor accidents
• Focus on accident prevention and loss control
• Be positive
• Discuss past accidents
• Take corrective action promptly

218
 Neglecting to Implement
Corrective Action
• The whole purpose of the investigation
process is negated if management fails to
remedy the causes
• Here again, management sends a signal
to subordinates that it's not important,
and subordinates develop the attitude
that it's an exercise in futility and "why
bother?

219
 Improving the Quality of
Accident Investigation
• Insist on reporting of all injuries
• Adopt a well-designed accident report form
• Train all levels of management
• Insist on the investigation of all accidents
• Participate actively in serious accident
investigations

220
 Improving the Quality of
Accident Investigation
• Review and comment
• Refuse to accept inadequate reports
• Establish controls to follow up on corrective
actions
• Be responsive to recommendations
• Hold responsible persons accountable
• Emphasize that accident investigations are
FACT-finding, not FAULT-finding
• Encourage investigators to challenge the system
221
 Summary
• Most accident investigations follow
formal procedures
• An investigation is not concluded until
completion of a final report
• A successful accident investigation
determines what happened and how and
why the accident occurred
• Investigations are an effort to prevent a
similar or perhaps more disastrous
sequence of events 222
Other Accident Investigation Tools

223
 Problem Solving
Fault Tree

• Deductive, top-down method of analyzing

• Identify all elements that could cause
Accident
• Performed graphically using AND and OR
gates
• Create symbolic representation of events
resulting in the Accident
• Entire system and human interactions are
analyzed
224
 Problem Solving
Fault Tree

PIT Hits W all

Failure To Stop

Environmental Equipment Procedural Human

W et Floor Brakes Fail Steering Fails No Training No Inspection

No Fluid Did Not Know Intentional Omission

Break Line Leak NoTraining

Sudden Release Slow Leak

No Preshift Inspection
225
 Problem Solving
Fault Tree
PIT Hits W all

Failure To Stop

Equipment Procedural Human

Did not Conduct Inspection

Brakes Fail Training Req'd

No Fluid Sup.Resp. Did Not Know Intentional Omission

Break Line Leak Supv. sick Training Not Received Time ltd.

Sudden Release Slow Leak NO TRAINING

No Preshift Inspection 226

 ISHIKAWA “FISHBONE”
DIAGRAM
Machinery Methods
 

 
 
 
  EFFECT
 
 

Materials People Environment

 
 

227
 FIVE WHYs DIAGRAM
Undesired Event
Why?
Direct Cause
Why?
Contributing Cause
Why?
Contributing Cause
Why?
Contributing Cause
Why?
Root Cause 228
229