OHS Accidents

Introduction & Course Overview

PROaction versus REaction

• “Well that’s an accident waiting to happen…”

• “Someone ought to do something…”

That someone is YOU!

AccidentPrevention

What Is An Accident?

What Is An Accident?

An Accident is:• a. An unexpected and undesirable event, especially one

resulting in damage or harm: car accidents on icy roads.• 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

Hazard• Existing or Potential

Condition That Alone or Interacting With Other Factors Can Cause Harm

• A Spill on the Floor• Broken Equipment

Risk• A measure of the probability and

severity of a hazard to harm human health, property, or the environment

• A measure of how likely harm is to occur and an indication of how serious the harm might be

Risk 0

Safety

FREEDOM FROM DANGER OR HARM

Nothing is Free of

BUT - We can almost always make something SAFER

Safety Is Better Defined As….

A Judgement of the

Acceptability of Risk

RATIOS

OSHA METHOD

330 Incidents

29 Minor Injuries

1 Major or Loss-Time Accident

Candy Jar Example

Types of Accidents

• FALL TO– same level– lower level

• CAUGHT– in– on– between

• CONTACT WITH– chemicals– electricity– heat/cold– radiation

• BODILY REACTION FROM– voluntary motion– involuntary motion

Types of Accidents (continued)

• STRUCK– Against

• stationary or moving object• protruding object• sharp or jagged edge

– By• moving or flying object• falling object

• RUBBED OR ABRADED BY– friction– pressure– vibration

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

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)

Accident Causing Factors

• Basic Causes– Management– Environmental– Equipment – Human Behavior

• Indirect Causes– Unsafe Acts– Unsafe Conditions

• Direct Causes– Slips, Trips, Falls– Caught In– Run Over– Chemical Exposure

Policy & ProceduresEnvironmental Conditions

Equipment/Plant DesignHuman Behavior

Slip/Trip FallEnergy Release

Pinched Between

Indirect Causes

Direct Causes

ACCIDENTPersonal Injury

Property DamagePotential/Actual

Basic Causes

Unsafe Acts

Unsafe Conditions

Basic Causes

• Management

• Environment

• Equipment

• Human Behavior

Systems & Procedures

Natural & Man-made

Design & Equipment

Management

• Systems & Procedures– Lack of systems &

procedures– Availability– Lack of Supervision

Environment

• Physical – Lighting – Temperature

• Chemical– vapors– smoke

• Biological–Bacteria–Reptiles

Environment

Design and Equipment

• Design

– Workplace layout– Design of tools &

equipment– Maintenance

Design and Equipment

• Equipment – Suitability– Stability

• Guarding

• Ergonomic

• Accessibility

Human Behavior

Common to

all accidents

Not limited to person involved in accident

Human Factors

• Omissions & Commissions

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

Competencies (how it needs to be done)

Human Behavior is a function of :

Activators (what needs to be done)

Consequences (what happens if it is/isn’t done)

ABC Model

Antecedents (trigger behavior)

Behavior (human performance)

Consequences (either reinforce or punish behavior)

•Positive Reinforcement (R+)("Do this & you'll be rewarded")

•Negative Reinforcement (R-)("Do this or else you'll be penalized")

Only 4 Types of Consequences:

Behavior• Punishment (P)

("If you do this, you'll be penalized")

• Extinction (E)("Ignore it and it'll go away")

Consequences Influence Behaviors Based Upon

Individual Perceptions of:

Timing - immediate or future

Consistency - certain or uncertain

• Significance

{Magnitude

Impact

positive or

negative

Human Behavior

• Behaviors that have consequences that are:

• Soon• Certain• Positive

Have a stronger effect on people’s behavior

Some examples of Consequences:

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

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

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

Human Behavior

• Positive• A positive consequence influences

behavior more powerfully than a negative consequence

• Penalties and Punishment don’t work• Speeding Ticket Analogy

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)

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

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?

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

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

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”

Are inside a person’s head -therefore they are not observable nor measurable

Attitudes can be changed by changing behaviors

however

Attitudes

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

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

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

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

Human Behavior

Developing Personal Safety AwarenessA) Before starting, consider how to do job safelyB) Understand required P.P.E. and how to use itC) Determine correct tools and ensure they are in good

conditionD) Scan work area – know what is going onE) As you work, check work position – reduce any strainF) Any unsafe act or condition should be correctedG) Remain aware of any changes in your workplace – people

coming, going, etc.H) Talk to other workers about safetyI) Take safety home with you

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?

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”?

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”!

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!!

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%

OUTCOMES OF ACCIDENTS

NEGATIVE OUTCOMES

POSITIVE OUTCOMES

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

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

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

Indirect Costs• Injured, Lost Time

Wages• Non-Injured, Lost

Time Wages• Overtime• Supervisor Wages• Lost Bonuses• Employee Morale• Need For

Counseling• Turn-over

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

“REAL” Costs


• POSITIVE ASPECTS– Accident investigation– Prevent repeat of accident– Improved safety programs– Improved procedures– Improved equipment design


• Must Be– Written– Tailored to particular hazards for a particular

plant or operation

• Minimum Elements– Safety Orientation Program– Safety and Health Committee


• 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


• 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


• Safety Meeting instead of Safety Committee– If less than 11 employees

• Total• Per shift• Per location

– Meet at least once/month – 1 Management Representative

Safety Meeting

You Must– Review inspection reports– Evaluate accident investigations– Evaluate APP and discuss recommendations– Document attendance and topics

Safety Committees

Safety Committees

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

Proactive Safety

Safety Committees

The Goal of the committee is to facilitate a safe workplaceObjectives 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

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.

How effective can a

Committee be?

Safety CommitteePolicy Statement

A written and publicized statement is an effective means of providing guidance and demonstrating commitment

Safety Committee Focus

• Long Term Goals – Objectives to Achieve– Time Frame

• Short Term Goals– Assignments between Meetings– Work toward achieving Long-Term Plan

Planning the Safety Meeting

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

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

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

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

Emergency Plan

• Anticipate What Could Go Wrong and Plan for those Situations

• Drill for Emergency Situations

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

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

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

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

HAZARD ANALYSIS

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

Step 1: Identify Hazards

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

Hazard Identification

• Review Records

• Talk to Personnel

• Accident Investigations

• Follow Process Flow

• Write a Job Safety Analysis

• Use Inspection Checklists

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

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

Who is at Risk?

• Workers• Visitors

– Invited• Customers• Emergency services• Delivery drivers

– Uninvited• Trespassers• Burglars

¨ Contractors¨ Janitorial¨ Maintenance

¨ Others¨ Members of Public¨ Passers-by¨ Neighbors

STEP 3: Make Risk Decisions

What can we do to reduce the risk?

Does the benefit outweigh the risk?

STEP 4: Implement Controls

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

Hazard Controls

Source

Path

Receiver

Hazard Control

Administrative Engineering

Protective Equipment/Clothing

Engineering

Hazard Elimination

Add-On Safety Design

“Active” vs. “Passive”

User Instructions (Manual)

Ventilation

Design/Layout

Safety Devices

Administrative

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

Step 5: Supervise

• Ensure risk control measures are implemented

• Track progress• Feedback

JOB SAFETY ANALYSIS

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

Job Safety Analysis

Job Safety Analysis Priorities

• New Jobs• Potential of Severe Injuries• History of Disabling Injuries• Frequency of Accidents

Observation of the Actual Work

• Select experienced worker(s) to participate in the JSA 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!)

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

Key Steps TOO MUCHChanging a Flat Tire

• Pull off road• Put car in “park”• Set brake• Activate emergency flashers• Open door• Get out of car• Walk to trunk• Put key in lock• Open trunk• Remove jack• Remove Spare tire

Key Steps NOT ENOUGHChanging a Flat Tire

• Park car• Take off flat

tire• Put on spare

tire• Drive away

Key Job Steps JUST RIGHTChanging a Flat Tire

• Park & set brake• Remove jack & tire

from trunk• Loosen lug nuts• Jack up car• Remove tire• Set new tire• Jack down car• Tighten lug nuts• Store tire & jack

Job Safety Analysis• Steps

– Park & set brake

– Remove Spare & Jack

– Loosen lugs

Job Safety Analysis

• Hazards– Hit by

traffic

– Back Strain

– Foot/Toe impact

– Shoulder strain

• Steps– Park & set

brake

– Remove Spare & Jack

– Loosen lugs

Job Safety Analysis

• Hazards– Hit by

traffic– Back Strain

– Foot/Toe impact

– Shoulder strain

• Steps– Park & set

brake– Remove Spare

& Jack

– Loosen lugs

• Prevention– Far off road as

possible– Pull items close

before lift– Lift in increments– Lift and lower

using leg power– Wide leg stance– Use full body, not

arm/shoulder

Develop Solutions

• Find a new way to do job

• Change physical conditions that create hazards

• Change the work procedure

• Reduce frequency

• Fix-A-Flat

• No off-road driving

• Buy self-sealing tires

• Maintenance / Change-out program

JSA EXERCISE

INSPECTIONS

Inspections

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

Inspection Limitations

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

Outcomes

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

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

Change in Physical Conditions

• Tools, materials, equipment layout or location

• Study change carefully for other benefits (costs, time savings)

Change in Work Procedures

• What should the worker do to eliminate the hazard?

• How should it be done?• Document changes in detail

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

Performing Safety Audits

Guide for Personal Audits

The guide has five steps• Audit

• React

• Communicate

• Follow up

• Raise standards

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

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…

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

Follow Up

• Critical for success of the safety program

• Allows you to demonstrate that it is important

• Must communicate your assessment to the employees

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

Key Points: Becoming a Good Observer

• Effective observation includes:Be selectiveKnow what to look forPracticeKeep an open mindGuard against habit and familiarityDo not be satisfied with general impressionsRecord observations systematically

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

Observation Techniques• Remember ABBI -- look Above, Below,

Behind, Inside• Develop a questioning attitude

• Use all senses• sight

• hearing

• smell

• touch

Inspections and Field Observations

• Use a checklist

• Ask questions

• Take notes

• Respect lines of communication

• Draw conclusions

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

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

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

Management Commitment

Should Management Consider Safety as a Priority in Conducting Business

??

Management Commitment

NO !

PRIORITIES CHANGE

SAFETY MUST BE A

VALUE!!

Employee Participation

• Accident Prevention Plan Development

• Safety Committee

• Safety Bulletin Board

• Crew-Leader Meetings

• Day-to-Day Knowledge comes from where the work is actually done and hazards actually exist.

SHARED VISION EXERCISE

AVAILABLE RESOURCES

• OSHA Website: www.osha.gov

• Washington State Labor & Industries Website: www.lni.wa.gov

ACCIDENT INVESTIGATION

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

THE ACCIDENT

WHAT IS AN ACCIDENT?

THE ACCIDENT

An

unplanned and unwelcome event

that interrupts normal activity

Accidents are What Happens to Somebody Else

BUT REMEMBER:

YOU

are somebody else

to somebody else

THE ACCIDENT

MINOR ACCIDENTS:

• Such as paper cuts to fingers or dropping a box of materials

THE ACCIDENT

MORE SERIOUS ACCIDENTS

• Such as a forklift dropping a load or someone falling off a ladder

THE ACCIDENT

• Accidents that occur over an extended time frame:– Such as hearing loss or an illness resulting

from exposure to chemicals

THE ACCIDENTNEAR-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!

THE ACCIDENT

ACCIDENTS HAVE TWO THINGS IN COMMON

THE ACCIDENT

They all have outcomes from the accident

THE ACCIDENT

They all have contributory factors that cause the accident


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


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


• 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

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

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


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

symptoms

• Document the investigation findings

You Must:


• 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

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)


• 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


•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


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?


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

Why Not Rely On OSHA & Police To Investigate?

• Focus On Culpability• Minor Accidents Not

Investigated• PREVENTION• Protect Company

Interests• OSHA Requirements

Investigating Accidents

How to find out what really happened

Why Investigate Accidents?

• Find the cause• Prevent similar accidents• Protect company interests

Acts Conditions

Near Misses

Minor Injuries

Reportable Injury

Lost Time Injury

Death

Kn

ow

led

ge

Ab

ilit

y

Mo

tiva

tio

n

Des

ign

Ma

inte

na

nc

e

Acti

on

o

fO

thers

At which level do we investigate?

Investigation Strategy• Need For Investigation

• Control the Scene

• Gather Facts

• Analyze Data

• Establish Causes

• Write Report

• Take Corrective Action

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

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?

The Aim of the InvestigationIS NOT TO:

• Exonerate individuals or management

• Satisfy insurance requirements

• Defend a position for legal argument

• Or, to assign blame

121

2

5

4

7

8

6

39

10

11

121

2

5

4

7

8

6

39

10

11

121

2

5

4

7

8

6

39

10

11

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

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

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!

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

**Immediate Actions

• Assess the scene

• CALL 911 • Activate In-House Response• Scene Safety• Provide Aid to Injured• Provide Assistance to Affected• Secure the Scene of Accident

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

Provide Care to the Injured

• Ensure that medical care is provided to the injured people before proceeding with the investigation

Secure the Scene for Safety

• Eliminate the hazards:– Control chemicals– De-energize– De-pressurize– Light it up– Shore it up– Ventilate

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

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

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)

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

Photographs

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

Gather Data

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

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?

Documents• Collect All Related Documents

– Inspection Logs– Policy & Procedures Manual– JSA (Job Safety Analysis)– Equipment Operations Manuals– Insurance Records– Employee Records– Police Reports

Those who do not know the past are destined to:

RepeatRepeatRepeatRepeatRepeatRepeat

It.

ISOLATE FACT FROM FICTION

• Use NORMS-based analysis of information– Not an interpretation– Observable– Reliable– Measurable– Specific

• If an item meets all five of above, it is a fact

NORMS OF OBJECTIVITY

ObjectiveNot an Interpretation - Based on

a factual description.

Observable - Based on what is seen or heard.

Reliable - Two or more people independently agree on what they observed.

Measurable - A number is used to describe behavior or situation.

Specific - Based on detailed definitions of what happened.

SubjectiveInterpretations - Based on

personal interpretations/biases.

Non-observable - Based on events not directly observed.

Unreliable - Two or more people don’t agree on what they observed.

Non-Measurable - A number isn’t used.

General - Based on non-detailed descriptions.

INVESTIGATION TRAPS

• Put your emotions aside!– Don’t let your feelings interfere -

stick to the facts! • Do not pre-judge

– Find out the what really happened– Do not let your beliefs cloud the

facts• Never assume anything• Do not make any judgements

Record Evidence

• Keep All Notes in Bound Notebook

• Include Date - Time - Place – Vantage Point

• Keep Originals

• Rewrite in Report Form

Samples

• Collect Perishables First

• Fluids• Open Containers• Filings• Chemicals• Air

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

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

Interviews

• Excellent Source of first hand knowledge

• May Present Pitfalls in form of:– Bias– Perspective– Embellishment– Omissions

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

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

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

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

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?”

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

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

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

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?

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?

Witness Interviews

DO• Separate Witnesses• Written Statements• Open ended questions• Provide Diagrams• Encourage Details• Show Concern• Record w/permission

DON’T• Suggest Answers• Interrogate• Focus on Blame• Dismiss Details• Bar Emotions• Make Judgments

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?

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

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?

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

Indirect Causes

• Unsafe conditions – what material conditions, environmental conditions and equipment conditions contributed to the accident

• Unsafe Acts – what activities contributed to the accident

Breakdown of Unsafe Conditions

• Inadequately guarded or unguarded equipment

• Defective tools, equipment or materials

• Fire and explosion hazard

• Unexpected movement hazard

• Projection hazards

Breakdown of Unsafe Conditions

• Housekeeping

• Hazardous environmental conditions

• Improper ventilation

• Improper illumination

• Unsafe dress or apparel

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

Basic Causes

• Management

• Environment

• Equipment

• Human Behavior

Systems & Procedures

Design & Equipment

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?

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?

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.

What controls failed?

• List the specific engineering, administrative and training controls that failed and how these failures contributed to the accident

What controls worked?

• List any controls that prevented a more serious accident or minimized collateral damage or injuries

Determine

• What was not normal before the accident

• Where the abnormality occurred• When it was first noted• How it occurred

Report Causes

• Analysis of the Accident – HOW & WHYa. Direct causes (energy sources; hazardous materials)b. Indirect causes (unsafe acts and conditions)c. Basic causes (management policies; personal or environmental factors)

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

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

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……..

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?

Recommendations

• Consider -Effectiveness -Cost

-Feasibility -Effect on Productivity

-Time to Implement -Employee Acceptance

-Management Acceptance

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

Common Problems

• Accidents not reported

• Unable to identify basic causes

• Accepting inadequate reports

• Neglecting to implement corrective actions

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

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

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

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?

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

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

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

Other Accident Investigation Tools

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


W et F loor

E nv ironm enta l

Sudden R e lease

N o P resh ift Inspection

S low Leak

Break L ine Leak

N o F lu id

B rakes Fa il S teering Fa ils

E quipm ent

N o Tra in ing

Procedura l

N oTra in ing

D id N ot Know In ten tiona l O m ission

N o Inspection

H um an

F a ilu re To S top

P IT H its W all


Sudden R e lease

No Preshift Inspection

Slow Leak

Break L ine Leak

N o F lu id

Brakes Fa il

Equ ipm ent

N O TR AIN IN G

Supv . s ick

Sup.R esp.

Tra in ing R eq 'd

Procedura l

Tra ining N ot R eceived

D id N ot Know

Tim e ltd .

In ten tiona l O m ission

D id n o t C on d u c t In sp ec tion

H um an

Failu re To S top

PIT H its W all

“FISHBONE” DIAGRAM

Machinery Methods

Materials People Environment

EFFECT

FIVE WHYs DIAGRAM

Undesired EventWhy?

Direct CauseWhy?

Contributing CauseWhy?



Root Cause

ACCIDENT ANALYSIS AND

REPORT(Handout)

TEST

Education

OHS Accidents