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Photo: Tulalip Bay by Diane L.

Wilson-Simon

ACCIDENT & INJURY


PREVENTION
Instructor: Kerrie Murphy
Edmonds Community College
This course is being supported under grant number
SH16637SH7 from the Occupational Safety and Health
Administration, U.S. Department of Labor. It does not
necessarily reflect the views or policies of the U.S. Department
of Labor, nor does mention of trade names, commercial
products, or organizations imply endorsement by the U.S.
Government.
With Thanks to & Cooperation of the Tulalip Occupational
Safety & Health Administration (TOSHA)

Introduction & Course Overview

PROaction versus REaction


Well thats an accident
waiting to happen
Someone ought to do
something
That someone is YOU!

Accident
Prevention

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

R
A
T
I
O
S

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.
2.
3.
4.

Vehicle Accidents
Contact With Objects and Equipment
Falls
Assaults & Violent Acts

2413
983
809
754

Fatal Accidents - Workplace


Washington State FATALITIES - 2006
1.
2.
3.
4.

Vehicle Accidents
Contact With Objects and Equipment
Falls
Assaults & Violent Acts

40
13
19
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

Basic Causes

Unsafe

Policy & Procedures


Environmental Conditions
Equipment/Plant Design
Human Behavior
Indirect Causes

Acts
Direct Causes

Slip/Trip Fall
Energy Release
Pinched Between

ACCIDENT
Personal Injury
Property Damage
Potential/Actual

Unsafe
Conditions

Basic Causes
Management

Systems & Procedures

Environment

Natural & Man-made

Equipment

Design & Equipment

Human Behavior

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

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/isnt done)

ABC Model
Antecedents
(trigger behavior)

Behavior
(human performance)

Consequences
(either reinforce or punish behavior)

Only 4 Types of
Consequences:
Positive Reinforcement (R+)
("Do this & you'll be rewarded")

Negative Reinforcement (R-)

Behavior

("Do this or else you'll be penalized")

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:
Impact

Significance

Magnitude

positive
or
negative

Timing - immediate or future


Consistency - certain or uncertain

Human Behavior
Behaviors that have consequences that are:
Soon
Certain
Positive
Have a stronger effect on peoples 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 dont 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 Didnt 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 workers
safety behavior by changing their Attitude
Accident Report Safety Attitude
A persons 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

Attitudes
however

Are inside a persons head -therefore they


are not observable nor measurable

Attitudes can be changed by


changing behaviors

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 cant 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 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

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 didnt 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 Ive always
done it this way?

Human Behavior
TIME!
All this safety stuff takes time doesnt it?
Im too busy!
I cant 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
Behavior Based
7
Ergonomics
3
Engineering Change 4
Problem Solving
1
Govt. Action
2
Mgt. Audits
4
Stress Management 2
Poster Campaign
26
Personnel Selection 26
Near-miss Reports
2

# of Subjects Reduction %
2,444
59.6%
n/a
51.6%
n/a
29.0%
76
20.0%
2
18.3%
n/a
17.0%
1,300
15.0%
100
14.0%
19,177
3.7%
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

OUTCOMES OF ACCIDENTS

POSITIVE ASPECTS

Accident investigation
Prevent repeat of accident
Improved safety programs
Improved procedures
Improved equipment design

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

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

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

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

Safety Meeting
You Must

Review inspection reports


Evaluate accident investigations
Evaluate APP and discuss recommendations
Document attendance and topics

Safety Committees

Safety Committees

Proactive
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

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

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 Committee
Policy 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: Doesnt 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 MUCH


Changing 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 ENOUGH


Changing a Flat Tire
Park car
Take off flat
tire
Put on spare
tire
Drive away

Key Job Steps JUST RIGHT


Changing 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


Steps

Hazards

Park & set


brake

Hit by
traffic

Remove Spare
& Jack

Back
Strain
Foot/Toe
impact

Loosen lugs

Shoulder
strain

Job Safety Analysis


Steps
Park & set
brake
Remove Spare
& Jack

Hazards
Hit by
traffic
Back Strain
Foot/Toe
impact

Loosen lugs

Shoulder
strain

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

Fix-A-Flat

Change physical
conditions that
create hazards
Change the work
procedure
Reduce
frequency

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 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

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

Accident Prevention
Plan Development
Safety Committee
Safety Bulletin Board
Crew-Leader
Meetings

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 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!

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

OUTCOMES OF ACCIDENTS
NEGATIVE Results

Injury & possible death


Disease
Damage to equipment & property
Litigation costs, possible citations
Lost productivity
Morale

OUTCOMES OF ACCIDENTS
POSITIVE Results

Accident investigation
Prevent repeat of accident
Change to safety programs
Change to procedures
Change to equipment design

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

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

ACCIDENT INVESTIGATION
You Must:
Conduct a preliminary
investigation for:
serious injuries with immediate
symptoms

Document the investigation


findings

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

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)

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

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

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?

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

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

At which level do we investigate?


Death
Lost Time
Injury
Reportable Injury
Minor Injuries
Near Misses

O
thers

of

A
ction

M
aintenance

M
otivation

A
bility

K
now
ledge

D
esign

Conditions

Acts

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 Investigation


IS NOT TO:
Exonerate individuals or management
Satisfy insurance requirements
Defend a position for legal argument
Or, to assign blame

11

12

10

3
8

4
7

11

12

10

3
8

4
7

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12

10

3
8

4
7

COMPANY ACCIDENT FORMS


Must be filled out completely by
the employee and employees
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
Dont 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:
Repeat
Repeat
Repeat
Repeat
Repeat
Repeat

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
Objective
Not 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.

Subjective
Interpretations - Based on

personal
interpretations/biases.
Non-observable - Based on
events not directly observed.
Unreliable - Two or more
people dont agree on what
they observed.
Non-Measurable - A number
isnt used.
General - Based on nondetailed descriptions.

INVESTIGATION TRAPS
Put your emotions aside!
Dont 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
Dont 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
DONT

DO

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

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 didnt they do that?

Why did the unsafe condition exist?

Why wasnt 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

Systems & Procedures

Environment
Equipment
Human Behavior

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
wasnt 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 &
WHY
a. 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 individuals actions, dont
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

Problem Solving
Fault Tree
P IT H its W a ll
F a ilu r e T o S t o p

E n v ir o n m e n ta l
W e t F lo o r

E q u ip m e n t
B r a k e s F a il

S te e r in g F a ils

P ro c e d u ra l

Hum an

N o T r a in in g

N o In s p e c tio n

N o F lu id

D id N o t K n o w

B r e a k L in e L e a k

N o T r a in in g

S u d d e n R e le a s e

S lo w L e a k
N o P r e s h ift In s p e c tio n

In te n tio n a l O m is s io n

Problem Solving
Fault Tree

P IT H its W a ll
F a ilu r e T o S to p
E q u ip m e n t

P ro c e d u ra l

Hum an

B r a k e s F a il

T r a in in g R e q 'd

D id n o t C o n d u c t In s p e c tio n

N o F lu id

S u p .R e s p .

D id N o t K n o w

In te n tio n a l O m is s io n

B r e a k L in e L e a k

S u p v . s ic k

T r a in in g N o t R e c e iv e d

T im e ltd .

S u d d e n R e le a s e

S lo w L e a k
N o P r e s h ift In s p e c tio n

N O T R A IN IN G

Machinery

Materials

ISHIKAWA FISHBONE
DIAGRAM
Methods

EFFECT

People

Environment

FIVE WHYs DIAGRAM


Undesired Event
Why?
Direct Cause
Why?
Contributing Cause
Why?
Contributing Cause
Why?
Contributing Cause
Why?
Root Cause

ACCIDENT
ANALYSIS AND
REPORT
(Handout)

TEST