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Introduction to effective

Accident Investigation

OR-OSHA 102
0201

Presented by
The Public Education Section
Oregon Occupational
Safety and Health Division (OR-OSHA)
What do accidents cost your company?

Direct -
Insured Costs
Unseen costs can sink
the ship! “Just the tip of the iceberg”
Oregon average to close a claim = $10,000

1. Biaya kompensasi tenaga kerja


2. Biaya Kesehatan ( dokter, Rs, obat, ambulance, helikopter dan biaya pelayan kesehatan lainnya)

Indirect - Uninsured, hidden Costs - Out of pocket


Oregon estimated average = $18,000
Biaya perusahaan adalah biaya yg tidak diasuransikan berupa : Average direct and indirect accident costs
• Nilai uang akibat hilangnya waktu kerja bagi pekerja yang tidak
terluka
Lost time injury: $28,000
• Waktu terbuang untuk investigasi & pelaporan Fatality: $980,000
• Pemberian P3K
• Produksi terhenti Using National Safety Council average costs for 2000, includes both direct and
• Pelatihan bagi pekerja pengganti indirect costs, excludes property damage.

Contoh : • Biaya tambahan untuk lembur


1. Hilangnya waktu kerja dari pekerja yang terluka Direct to Indirect Accident Cost Ratios
2. Hilangnya waktu kerja dari teman pekerja tersebut Direct cost of claim Ratio of indirect to direct
3. Hilangnya efisiensi akibat pekerja2 lain terhenti costs

4. Hilangnya waktu kerja supervisor $0-2,999 4.5


$3,000 - 4,999 1.6
5. Biaya Pelatihan untuk pekerja baru/pengganti $5,000 - 9,999 1.2
6. Kerusakan peralatan $10,000 or more 1.1

7. Waktu perbaikan peralatan Studies show that the ratio of indirect to direct costs can vary widely, from a high of 20:1 to a low
of 1:1. Source: Business Roundtable, 1982.
8. Memperingati hari kejadian (produksi terhenti)
9. Kerusakan akibat kecelakaan : kebakaran, air, kimia, peledakan dll.
10. Kegagalan memenuhi target/pesanan
11. Biaya tambhan akibat pekerjaan terganggu , dll

1. Tragedi kemanusian
2. Mora
Unknown Costs -
3. Reputasi
2
Page 5

- Iceberg
Accidents – always the final event in an unplanned process. (selalu merupakan kejadian akhir dari suatu
proses yang tak terencana ?
True/False?
The Accident Weed
Direct Cause of Injury
• Paparan energi yang berbahaya
• Kinetik, panas, kima, Fisika dll.or Illness
Injury
Strains
Primary Surface Causes
Burns • Penyebab langsung cidera (injury event)
Cuts • Kondisi berbahaya yang unik
Un • Tindakan individual yg tdk aman
gu
ard • Faktor yang terkontrol & tidak dapat
edm
ac lay • Kejadian sebelum adanya cidera (injury event
hin sep
e Hor • Kegagalan melakukan kerja, prosedur, proses yang aman.
• Keterlibatan korban dan yang lainnya
B ro zard
ken r eate a ha
too C
ls Secondary Surface Causes
rd
Chem a haza • Penyebab tidak langsung cidera
ical sp Ignore
ill
rt in
jury • Kondisi tidak aman yang khusus
po
Defec
tive ils to re • Tindakan individu yang tidak aman
PPE F a
• Faktor yang terkontrol & tidak dapat
Untrained
worker Fails to inspect • Kejadian sebelum adanya cidera
• Kegagalan melakukan kerja, prosedur, proses yang aman.
Lack of time
Fails to enforce • Asisten pekerja, supervisor, kapan saja dan dimana saja

work Fails to tr Implementation Root Causes


To much ain
• Kondisi dan tindakan yang umum
• ketidaksempurnaan implentasi terhadap kebijakan,
Lack of vision No mission statement

Inadequate training
No recognition program dan rencana K3
No discipline procedures Inadequate labeling • Ketidaksempurnaan design of processes, procedures
• Adanya proses dan prosedur yang tidak terkontrol
No orientation process Outdated hazcom program • Terdapat di semua lapisan management, kapan saja dan

Inadequate training plan


dimana saja
No recognition plan
System Design Root Causes
No accountability policy No inspection policy • Ketidaksempurnaan design kebijakan, program dan
rencana K3
• telah ada penyebab-penyeba lain
• Pengawasan
• Direksi, top management, anytime, anywhere

External Environmental Causes


• Peraturan pemerintah (Government regulation)
Weed out the causes of injuries and illnesses
Strains
Direct Causes of Injury/Illness
Burns
Cuts

Surface Causes of the


Accident

Conditions Behaviors
Fails to enforce
Lack of time

Inadequate training

No discipline procedures Inadequate labeling procedures

No orientation process Outdated Procedures

Inadequate training plan

No accountability policy No inspection policy

Root Causes of the Accident


The causes of Injury, Illness and Accidents

1. Direct Cause of Injury


Strains

Direct Cause of Injury Burns


Cuts

 Acoustic - excessive noise and vibration


 Chemical - corrosive, toxic, flammable, or reactive substances
 Electrical - low/high voltage, current
 Kinetic - energy transferred from impact
 Mechanical - associated with components that move
 Potential - involves "stored energy" in objects that are under
pressure
 Radiant - ionizing and non-ionizing radiation
 Thermal - excessive heat, extreme cold.

• Ahli K3 harus mencoba menghilangkan atau mengurang sumber


energi yang membahayakan.
– 2. Surface Causes of the Accident Un
gu
ard
ed
ma
ch lay Sur
in sep
e Hor

• Kondisi atau tindakan tidak aman


Cau
Bro azard
ken te a h
too Crea

• Orang melakukan kesalahan atau


l s
zard
Chem e a ha
ical sp Ignor
ill
membantu melakukan kesalahan Defec
tive P
PE F ai ls to re
port
inju
r y

• Selalu ada dimana saja danConditions


kapan saja di
Untrained
worker Fails to inspect

suatu organisasi Lack of time


Fails to enforce
Beh

• Melibatkan korban atau yang lainnya To much


work Fails to tr
ain

• Tidak dilakukan pengawasan oleh


managemen

– 3. Root Causes of the Accident

• Kegagalan menerapakan 6s ( safety Inadequate training


No recognition

policies, programs, plans, processes, No discipline procedures

No orientation process
Inadequate labeling procedures

Outdated Procedures

procedures, practices (the 6-P's) Inadequate training plan No recognition plan

• Telah terdapat penyebab sebelumnya No accountability policy No inspection policy

Root Causes
• Menyebabkan potensi yang berulang
• Dibawah pengawasan managemen
• dapat terdai kapan dan dimana saja
The six-step process
Mengamankan area kecelakaan
Step 1 - _________________________________________
Pengumpulan Informasi

Mengumpulkan Fakta yang terjadi


Step 2 - _________________________________________
Secure the scene

Collect data about what happened


Mengembangkan urutan kejadian
Step 3 - _________________________________________
Develop the sequence of events

Menganalisa fakta
Menentukan penyebab Determine the surface and root causes
Step 4 - _________________________________________
Develop corrective actions

Rekomendasi perubahan-perbaikan
Write and submit the report
Step 5 - _________________________________________
Mengimplemtasi solusi
Menulis Laporan
Step 6 - _________________________________________

Ada Tiga level analisa

1. Analisa cidera (Injury Analysis). Menganalisa kejadian cidera (injury event) untuk mengidentifikasi direct cause of
injury.

2. Analisa Kejadian (Event Analysis). Menganalisa setiap kejadian untuk mengidentifikasi potensi surface causes
kecelakaan. Cari hubungan kondisi bahay yng khusus dengan tindakan pekerja yang secara langsung atau ,membantu terjadinya kecelakaan

3. Analisa sistem (Systems Analysis). Menganalisa surface causes untuk mengidentifikasi root causes: memperhatikan
system managemen, dan kelemahan implementasi yang membantu terjadinya kecelakaan
Cari kebijakan, program, rencana, proses, prosedur (yg tidak sempurna) dan cara kerja yng mempengaruhi kondisi dan tindakan seacara
umum.

- Accident Analysis
Accident
investigation
The six-step process is
“fact-finding”
not
“fault-finding.”

Dua langkah pertama membantu untuk mengumpulkan informasi yang akurat mengenai kecelakaan

Step 1: Mengamankan area kecelakaan

Tujuan utama pada langkah ini adalah untuk mengumpulkan informasi kecelakaan
yang dapat memberikan petunjuk penyebab-penyebab kecelakaan. Untuk itu Anda
harus pertama : mengamankan area kecelakaan.

Kapan waktu yang tepat untuk memulai investigasi ?


______________________________________________________________
______________________________________________________________

Metoda apa yang efektif untuk mengamankan area kecelakaan ?


______________________________________________________________
______________________________________________________________
______________________________________________________________

3
Step 1: Secure the Scene

Kapan waktu yang tepat untuk memulai investigasi ?

What are effective methods to secure an accident scene?


Step 2: Mengumpulkan Fakta yang terjadi

Dalam langkah ini, ana harus menggunakan beberapa teknik untuk


mengumpulkan fakta yang tepat / jitu berkenaan dengan kecelakaan
dengan menentukan :

•Penyebab langsung cidera

•Kondisi yang berbahaya dan tindakan pekerja/managemen yg


berbahaya (surfacecauses) yang mengakibatkan kecelakaan

•Kelemahan system (root causes) yang mengakibatkan surface causes


Buatkan daftar (List ) untuk mencatat situasi tempat dan mengumpulkan fakta yang
terjadi _______________________________________________________________
_______________________________________________________________
Catatan mana yang kau anggap penting dilakukan interview ? Mengapa
_______________________________________________________________
_______________________________________________________________
Interviewing

Kapan waktu terbaik ?


Siapa yang harus diinterview?
Dimana harus dilakukan interview?

4
Step 2: Collect facts about what happened

List methods to document the scene and collect data about what happened.

What documents will you be interested in reviewing?

Why?
Dua langkah berikutnya membatu anda mengorganize dan menganalisa informasi yang diperoleh sehingga anda dapat dengan
akurat menentukan surfec cause dan root cause

Step 3: Menyusun urutan kejadian

An accident is the final event in an accident process


Kecelakaan adalah urutan terakhir dalam proses kecelakaan
Dalam langkai ini, kita mengambil informasi yang diperoleh dalam 2 langkah, untuk menentukan kejadian sesaat, selama dan setelah kejadian. Bila satu (kejadian) event
dapat dg jelas dimengerti, kita dapat melanjutkan untuk menguji setiap event baik kondisi atau tindakan yang berbahaya.

Setiap kejadian dalam proses kecelakaan yang tidak terencana, terdentifikasi :

Actor - Individual or object

• Seseorang mengawali suatu perubahan dengan melakukan atau mengagalkan sehingga membuahkan suatu tidakan
• Sesorang An actor may participate in the process or merely observe the process.

Action – Behavior the actor accomplishes

• Tindakan dapat atau tidak dapat diobservasi


• Tindakan dapat menjelaskan sesuati yang dikerjakan atau tidak dikerjakan

Circle the actor and action.

1. “Beverly slipped on a banana.”

_____________________________________________________

2. “As Beverly lay on the floor, a brick fell on her head .”

_____________________________________________________

3. “Sam discovered Beverly unconscious on the floor and immediately began initial first aid procedures.”

_____________________________________________________

7
Step 4: Menentukan Penyebab (Determine the causes)

W. H. Heinrich's Domino Theory


” Terjadinya suatu cidera disebabkan dari faktor-faktor yang berurutan secara kompleks, urutan terakhir adalah kecelakaan itu sendiri. Kecelakaan
disebabkan atau dimungkinkan adanya tindakan tidak aman atau mesin atau potensi physical lainnya
The occurrence of an injury invariably results from a completed sequence of factors, the last one of these being the accident itself. The accident in turn is
invariably caused or permitted directly by the unsafe act of a person and/or a mechanical or physical hazard." (W.H. Heinrich, Industrial Accident Prevention, 1931)

Do you agree with this theory? Why or why not?

Multiple Cause Theory


Dibelakang setiap kecelakaan ada banyak faktor2 (contributing factors, causes, and subcauses). Faktor2 iniberkombinasi secara random sebagai penyebab kecelakaan.
Kita harus menemukan root causes dan memperbaikinya untuk mencegah terulang lagi.
Behind every accident there are many contributing factors, causes, and subcauses. These factors combine in a random fashion causing accidents. We must find the
fundamental root causes and remove them to prevent a recurrence. (Dan Petersen, Safety Management: A Human Approach, ASSE , p. 10-11)

What may be the cause(s) of the accident according to the multiple causation theory?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
What might be the solutions to prevent the accident from recurring?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________________
What are the strengths of this approach?
_________________________________________________________________________
_________________________________________________________________________
Weaknesses?
_________________________________________________________________________________
_________________________________________________________________________________

9
Steps in cause analysis
1. Menaganlisa kejadian cidera (injury event) untuk mengidentifikasi dan menggambarkan direct cause of injury.

Examples:

• Luka sobek di siku disebabkan terkena dengan pisau yang berputar.


• Luka memar di kepala akaibat terbentur lantai

2. Menganalisa kejadian muncul sesaat sebelum kejian cidera untuk menidentifikasi kondisi dan tindakan tidak manan (primary surface causes) for
the accident.

Examples:

• Kejadian X , Event x. Pisau tidak berpengaman (condition or behavior?)


• Kejadian X. Working at elevation without proper fall protection. (condition or behavior?)

3. Menganalisa kondisi dan tindakan menentukan kondisi dan tindakan yang ikut khusus yang membantu terjadinya kecelakaan (contributing surface
causes) .

Examples:

• Supervisor tidak melakukan inspeksi mingguan (condition or behavior?)


• Peralatan APD hilang (condition or behavior?)

4. Menganalisa setiap contributing condition and behavior untuk menentukan apakah ada kelemahan pada kebijakan K3, program, perencanaan,
proses, prosedur dan cara kerja

Examples:

• Inspeksi K3 dilakukan tidak konsisten


• K3 tidak diberikan dengan memadai pada pekerja baru.

5. Menentukan kesalahan penerapan untuk menetapkan kelemahan

Examples:

• Kebijakan isnpeksi tidtidak jelas mengatur tanggungjawab siapa atau posisi


• Tidak ada pelatihan penggunaan APD atau penggunaan APD.

11
Flowchart analisa penyebab
1. Masukan penyebab langsung cidera .
2. Dafta kondisi berbahaya dan tindakan berbahaya..
3. Tentukan penyebab penunjang ( contributing surface causes ) terjadinya konsidi dan tindakan berbahaya tersebut .
4. Tentukan implementasi dan design yang menyebabkan timbulkanya penyebab penunjang (contributing surface
causes)

Direct Cause of Injury


________________________________
________________________________

Hazardous Condition Unsafe Behavior

__________________________________ _________________________________

Contributing conditions Contributing behaviors

__________________________________ _________________________________
__________________________________ _________________________________
__________________________________ _________________________________
__________________________________ _________________________________

Implementation root causes


Design root causes
__________________________________ _________________________________
__________________________________ _________________________________
__________________________________ _________________________________
__________________________________ _________________________________

12
Step 5: Recommend corrective actions & Improvements

The Hierarchy of Controls


1. Engineering Controls – Memindahkan atau mengurangi potensi bahaya (Remove or
reduce the hazard)
•Menghilangkan atau mengurangi potensi bahaya melelui redesgin, menutup, mensubtitusi,
memindahkan atau perubahan teknis lainnya
• Kelebihan : menghilangkan potensi bahaya. Tidak tergantung pada perubahan sikap manusia.
•Kelemahan: mahal dan memerlukan waktu perbaikan

2. Management Controls - Memindahkan atau mengurangi paparan (Remove or reduce the


exposure)
•Mengurangi durasi, frekwensi, tingkat paparan dari potensi bahaya melelui (1) perubhaan prosedur
dan cara kerja dan (2) scheduling/pergantian jadwal, job rotasi, breaks/istirahat.
•Kelebihan : murah
•Kelemahan : sangat tergantung dengan (1) sistem pengawasan (2) perilaku/ dukungan pekerja

3. Personal protective equipment (PPE) - menghalangi potensi bahaya /Put up a


barrier
•Peralatan yang digunakan oleh pekerja yang berfungsi menghalamgi pekerja dengan potensi bahaya.
•Kelemahan : sangat tergantung dengan (1) sistem pengawasan (2) jenis PPE/APD (3)
perilaku/ dukungan pekerja
13
Ada Tiga level analisa

1. Analisa cidera (Injury Analysis). Menganalisa kejadian cidera (injury event) untuk mengidentifikasi
direct cause of injury.

• Lecet pada siku kanan disebabkan oleh kontak dengan pisau yang berputar (mechanical energy)
• Memar di kepala karena benturan ke lantai (kinetic energy)
• Luka bakar di lengan akibat kontak dengan asam batrey (chemical energy)

2. Analisa Kejadian (Event Analysis). Menganalisa setiap kejadian untuk mengidentifikasi potensi
surface causes kecelakaan. Cari hubungan kondisi bahay yng khusus dengan tindakan pekerja yang secara
langsung atau ,membantu terjadinya kecelakaan

• Pisau tdk berpengaman. (condition)


• Bekerja pada ketingggian tanpa alat pelindung (behavior)
• Pekerja tidak peduli terhadap bahaya asam baterry (condition)
• Inspeksi mingguan terhadap mata pisau tidak dilakukan (behavior)
• Pekerja baru tidak dilatih cara perlindungan terhadap bahaya jatuh. (condition)
• Supervisor tidak memberikan syarat untuk memperbaiki tindakan yang tidak aman. (behavior)

3. Analisa sistem (Systems Analysis). Menganalisa surface causes untuk mengidentifikasi root causes:
memperhatikan system managemen, dan kelemahan implementasi yang membantu terjadinya
kecelakaan
4. Cari kebijakan, program, rencana, proses, prosedur (yg tidak sempurna) dan cara kerja yng mempengaruhi
kondisi dan tindakan seacara umum.

• Kebijakan inspeksi tidak dg jelas menunjuk tanggungjawab orang atau posisi (design)
• Tidak ada pelatihan kerja diketinggian. (design)
• Supervisors are not administering discipline when required. (implementation)
• Safety is not being addressed during new employee orientation (implementation)
Step 6: Menulis laporan

Alasan utama kegagalan investigasi kegagalan dalam menghilangkan/mencegah kecelakaan yang sama adalah bentuk laporan kecelakaan hanya memuat.
Let's take a look at one format for ensuring an effective report.

SAMPLE ACCIDENT INVESTIGATION REPORT

Number _________ Date _________

Prepared by ________________________ ____________________________

SECTION I. BACKGROUND

WHO Victim: _________________________________________

Witnesses (1) ___________ Address ________________ Phone (H) _________ (W) ____________
Job Title ______________ Length of Service ______

Witnesses (2) ___________ Address ________________ Phone (H) _________ (W) ____________
Job Title ______________ Length of Service ______

WHEN Date _____________ Time of day _____________ Work shift __________________


Date Accident Reported ____________

WHERE Department ________________ Location ____________________ Equipment _________

SECTION II. DESCRIPTION OF THE ACCIDENT PROCESS. (Describe the sequence of relevant events prior to, during, and immediately after the accident. Attach separate page if
necessary)

Events prior to: _____________________________________________________________________


Injury event: _____________________________________________________________________
Events after: _____________________________________________________________________

SECTION III. FINDINGS AND JUSTIFICATIONS. (Attach separate page if necessary)

Surface Cause(s) (Unsafe conditions and/or behaviors at any level of the organization)
___________________________________________________________________________

Justification: (Describe evidence or proof that substantiates your finding.)


___________________________________________________________________________

Root Cause(s) (Missing/inadequate Programs, Plans, Policies, Processes, Procedures)


___________________________________________________________________________

Justification: (Describe evidence or proof that substantiates your finding.)


___________________________________________________________________________

15
SECTION IV. RECOMMENDATIONS AND RESULTS (Attach separate page if necessary)

Corrective actions. (To eliminate or reduce the hazardous conditions/unsafe behaviors that directly caused the accident)
___________________________________________________________________________

Results. (Describe the intended results and positive impact of the change.)
___________________________________________________________________________

System improvements. (To revise and improve the programs, plans, policies, processes, and procedures that indirectly caused/allowed the hazardous conditions/unsafe behaviors.)
___________________________________________________________________________

Results. (Describe the intended results and positive impact of the change.)
___________________________________________________________________________

SECTION V: SUMMARY (Estimate costs of accident. Required investment and future benefits of corrective actions)

___________________________________________________________________________

SECTION VI: REVIEW AND FOLLOW-UP ACTIONS: (Describe equipment/machinery repaired, training conducted, etc. Describe system components developed/revised. Indicate persons responsible for
monitoring quality of the change. Indicate review official.)

Corrective Actions Taken: Responsible Individual: Date Closed:


______________________________ ______________________ ____________
______________________________ ______________________ ____________

System improvements made: Responsible Individual: Date Closed:


______________________________ ______________________ ____________
______________________________ ______________________ ____________

Person(s) monitoring status of follow-up actions: ________________________________

Reviewed by ___________________ Title __________________


Date ____________ Department ___________

SECTION VII: ATTACHMENTS: (Photos, sketches, interview notes, etc.)

The report is an open document until all actions are complete!

When the accident investigator completes the report, he or she will give it to someone who must do something with it. That’s
the job of the decision-maker. For accident investigation to be effective, management must consider the findings and
develop an action plan for taking corrective action and making system improvements. Finally, periodic evaluation of the
quality of accident investigation and report is critical to maintaining an effective program.

16
Strategi Pengembangan untuk menjaga sistem penecagahan kecelakaan

selalu memperbaiki kebijakan, program, rencana, proses dan prosedur pada elemen-
elemen managemen sistem dibawah ini :

1. Komitmen managemen (Management Commitment)


2. Akuntabilitas ( Accountability)
3. Keterlibatan pekerja (Employee Involvement)
4. Identifikasi bahaya (Hazard Identification/Control)
5. Analisa kecelakaan (Incident/Accident Analysis)
6. Pelatihan ( Training)
7. Evaluasi (Evaluation)

Membuat perbaikan yang mencakup :


• rencana K3 yang meliputi elemen di atas
• kebijakan K3 sehingga jelas menunjuk tanggungjawab dan accountability.
• rencana pelatihan sesuai dengan kebutuhan.
• kebijakan pembelian yang belum beraspek K3.
• proses inspeksi k3.
Team Exercise: Fix the system…not the blame

Purpose: In this exercise you’ll develop and recommend one improvement to make sure the case study accident does not recur.

Instructions. Develop and write a recommendation to improve one or more policies, plans, programs, processes, procedures, and practices identified as
design weaknesses.

Recommendation: _______________________________________________________
______________________________________________________________________________

14
Weed out the causes of injuries and illnesses
Strains
Direct Causes of Injury/Illness
Burns
Slide Cuts

Surface Causes of the


Accident

Conditions Behaviors
Fails to enforce
Lack of time

Inadequate training

No discipline procedures Inadequate labeling procedures

No orientation process Outdated Procedures

Inadequate training plan

No accountability policy No inspection policy

Root Causes of the Accident

Page 19

- Accident Weed
Investigating Incidents and Accidents

OAR 765, Div 1, Rule (6) (g) Accident investigation. The safety committee shall establish procedures for
investigating all safety-related incidents including injury accidents, illnesses and deaths. This rule shall not be
construed to require the committee to conduct the investigations.

The basic steps for conducting an accident investigation

1. Secure the accident scene


Gather Information 2. Collect facts about what happened

3. Develop the sequence of events


Analyze the Facts
4. Determine the causes

5. Recommend improvements
Implement
Solutions 6. Write the report
Secure the accident scene
The six-step process Step 1 - _________________________________________

Collect facts about what happened


Gather information Step 2 - _________________________________________

Develop the sequence of events


Slide
Step 3 - _________________________________________

Analyze the facts Determine the causes


Step 4 - _________________________________________

Recommend improvements
Step 5 - _________________________________________

Implement Solutions
Write the report
Step 6 - _________________________________________

Three levels of analysis Slide

1. Injury Analysis. Analyze the injury event to identify the direct cause of injury.

• Laceration to right forearm from contacting rotating saw blade. (mechanical energy)
• Contusion from head impacting concrete floor. (kinetic energy)
• Burn injury to right lower leg from contact by battery acid. (chemical energy)

2. Event Analysis. Analyze each event to identify potential surface causes for the accident. Look for a related specific hazardous conditions and
employee behaviors that directly caused or contributed to the accident.

• Unguarded saw blade. (condition)


• Working at elevation without proper fall protection. (behavior)
• Employee unaware of hazards associated with battery acid. (condition)
• Weekly inspection of saws is not being regularly conducted. (behavior)
• New employees are not trained on fall protection methods. (condition)
• Supervisor is not administering corrective actions for unsafe behaviors. (behavior)

3. Systems Analysis. Analyze surface causes to identify related root causes: those underlying management system design and implementation
weaknesses that contributed to the accident. Look for inadequate policies, programs, plans, processes, procedures and practices affecting general conditions and
behaviors.

• Inspection policy does not clearly specify responsibility by name or position. (design)
• No fall protection training plan or process in place. (design)
• Supervisors are not administering discipline when required. (implementation)
• Safety is not being addressed during new employee orientation (implementation)

Page 21

- Accident Analysis
Writing Recommendations
OAR 437, Div 1, Rule (6)(d) Hazard assessment and control. … and recommend to the employer
how to eliminate hazards and unsafe work practices in the workplace.

The Hierarchy of Controls

•Engineering controls. Eliminates/reduces


hazards that existed, through equipment redesign, replacement, substitution. Most effective strategy.

•Management Controls. Reduce the frequency and duration of exposure to the hazards primarily
through scheduling strategies. Strategies might include reducing the frequency or duration of a
particular task, more frequent breaks, reducing the number of employees, etc. Again, these
strategies must be managed, supervised, trained, etc.

•Personal Protective Equipment (PPE). In conjunction with engineering and administrative


controls, consider personal protective equipment.

Why should we first consider engineering controls to reduce accidents?


Instructor Notes:
The six-step process
There are three general phases in the accident investigation process. In the first phase, the accident scene is secured, if necessary, and facts are gathered at the scene and
other locations about what happened. In the second phase, the sequence of events is developed and each event is analyzed to see if there are hazardous conditions or
unsafe/inappropriate acts that occurred. In the third phase, we take what we've learned to develop corrective actions and safety management system improvements. Finally
we write the report. OR-OSHA Course 102 has more information on this process.

Three levels of analysis


The initial analysis is conducted to determine the direct cause of injury.
Next, event analysis conducted to determine hazardous conditions and unsafe behaviors that may have directly caused or contributed to the accident.
Finally, the conditions and behaviors are analyzed to determine if safety management system weaknesses contributed in some way to the accident.