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  1. Photo: “Tulalip Bay” by Diane L. Wilson-Simon
  2. 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)
  3. Introduction & Course Overview
  4. PROaction versus REaction • “Well that’s an accident waiting to happen…” • “Someone ought to do something…” That someone is YOU!
  5. Accident Prevention
  6. What Is An Accident?
  7. What Is An Accident?
  8. 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
  9. Hazard • Existing or Potential Condition That Alone or Interacting With Other Factors Can Cause Harm • A Spill on the Floor • Broken Equipment
  10. 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
  11. Safety FREEDOM FROM DANGER OR HARM Nothing is Free of BUT - We can almost always make something SAFER
  12. Safety Is Better Defined As…. A Judgement of the Acceptability of Risk
  13. R A T I O S
  14. OSHA METHOD 330 Incidents 29 Minor Injuries 1 Major or Loss-Time Accident
  15. Candy Jar Example
  16. 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
  17. 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
  18. 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
  19. 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)
  20. 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
  21. Policy & Procedures Environmental Conditions Equipment/Plant Design Human Behavior Slip/Trip Fall Energy Release Pinched Between Indirect Causes Direct Causes ACCIDENT Personal Injury Property Damage Potential/Actual Basic Causes Unsafe Acts Unsafe Conditions
  22. Basic Causes • Management • Environment • Equipment • Human Behavior Systems & Procedures Natural & Man-made Design & Equipment
  23. Management • Systems & Procedures – Lack of systems & procedures – Availability – Lack of Supervision
  24. Environment • Physical – Lighting – Temperature • Chemical – vapors – smoke • Biological –Bacteria –Reptiles
  25. Environment
  26. Design and Equipment • Design – Workplace layout – Design of tools & equipment – Maintenance
  27. Design and Equipment • Equipment – Suitability – Stability • Guarding • Ergonomic • Accessibility
  28. Human Behavior Common to all accidents Not limited to person involved in accident
  29. Human Factors • Omissions & Commissions • Deviations from SOP – Lacking Authority – Short Cuts – Remove guards
  30. 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)
  31. ABC Model Antecedents (trigger behavior) Behavior (human performance) Consequences (either reinforce or punish behavior)
  32. •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")
  33. Consequences Influence Behaviors Based Upon Individual Perceptions of:  Timing - immediate or future  Consistency - certain or uncertain • Significance Magnitude Impact positive or negative
  34. Human Behavior • Behaviors that have consequences that are: • Soon • Certain • Positive Have a stronger effect on people’s behavior
  35. Some examples of Consequences:
  36. Why is one sign often ignored, the other one often followed?
  37. 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
  38. 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
  39. Human Behavior • Positive • A positive consequence influences behavior more powerfully than a negative consequence • Penalties and Punishment don’t work • Speeding Ticket Analogy
  40. 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)
  41. 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
  42. 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?
  43. 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
  44. 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
  45. 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”
  46. Are inside a person’s head -therefore they are not observable nor measurable Attitudes can be changed by changing behaviors however Attitudes
  47. 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
  48. 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
  49. 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
  50. 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
  51. 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
  52. 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?
  53. 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”?
  54. 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”!
  55. 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!!
  56. 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%
  58. $ Direct Costs • Medical • Insurance • Lost Time • Fines
  59. 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
  60. 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
  61. Indirect Costs • Injured, Lost Time Wages • Non-Injured, Lost Time Wages • Overtime • Supervisor Wages • Lost Bonuses • Employee Morale • Need For Counseling • Turn-over
  62. 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
  63. “REAL” Costs
  64. OUTCOMES OF ACCIDENTS • POSITIVE ASPECTS – Accident investigation – Prevent repeat of accident – Improved safety programs – Improved procedures – Improved equipment design
  65. 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
  66. 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
  67. 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
  68. 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
  69. Safety Meeting You Must – Review inspection reports – Evaluate accident investigations – Evaluate APP and discuss recommendations – Document attendance and topics
  70. Safety Committees
  71. 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
  72. 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
  73. 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.
  74. How effective can a Committee be?
  75. Safety Committee Policy Statement A written and publicized statement is an effective means of providing guidance and demonstrating commitment
  76. Safety Committee Focus • Long Term Goals – Objectives to Achieve – Time Frame • Short Term Goals – Assignments between Meetings – Work toward achieving Long-Term Plan
  77. Planning the Safety Meeting • Select topics • Set & post the agenda • Schedule safety meeting • Prepare meeting site • Encourage participation
  78. 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
  79. 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
  80. 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
  81. Emergency Plan • Anticipate What Could Go Wrong and Plan for those Situations • Drill for Emergency Situations
  82. 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
  83. 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
  84. 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
  85. 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
  87. 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
  88. Step 1: Identify Hazards HAZARD – condition with the potential to cause personal injury, death and property damage
  89. Hazard Identification • Review Records • Talk to Personnel • Accident Investigations • Follow Process Flow • Write a Job Safety Analysis • Use Inspection Checklists
  90. 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
  91. 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
  92. 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
  93. STEP 3: Make Risk Decisions What can we do to reduce the risk? Does the benefit outweigh the risk?
  94. STEP 4: Implement Controls • Substitution • Engineering controls • Administrative Controls • Personal Protective Equipment
  95. Hazard Controls Source Path Receiver
  96. Hazard Control Administrative Engineering Protective Equipment/Clothing
  97. Engineering Hazard Elimination Add-On Safety Design “Active” vs. “Passive” User Instructions (Manual) Ventilation Design/Layout Safety Devices
  98. Administrative • Safety Rules • Disciplinary Policy - Accountability • Preventative Maintenance • Training • Proficiency/Knowledge Demonstrations
  99. Step 5: Supervise • Ensure risk control measures are implemented • Track progress • Feedback
  101. 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
  102. Job Safety Analysis
  103. Job Safety Analysis Priorities • New Jobs • Potential of Severe Injuries • History of Disabling Injuries • Frequency of Accidents
  104. 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!)
  105. 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
  106. 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
  107. Key Steps NOT ENOUGH Changing a Flat Tire • Park car • Take off flat tire • Put on spare tire • Drive away
  108. 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
  109. Job Safety Analysis • Steps – Park & set brake – Remove Spare & Jack – Loosen lugs
  110. Job Safety Analysis • Hazards – Hit by traffic – Back Strain – Foot/Toe impact – Shoulder strain • Steps – Park & set brake – Remove Spare & Jack – Loosen lugs
  111. 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
  112. 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
  115. Inspections • Fact-Finding vs. Fault Finding – Sound knowledge of the plant – Knowledge of relevant standards & codes – Systematic inspection steps – Method of evaluating data
  116. Inspection Limitations • “Blinder affect” • Rote inspections • All Check - No action • Who is inspecting?
  117. Outcomes • Improve Safety – New Way to Do Job – Change Physical Conditions – Change Work Procedures – Reduce Frequency of Dangerous Job
  118. 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
  119. Change in Physical Conditions • Tools, materials, equipment layout or location • Study change carefully for other benefits (costs, time savings)
  120. Change in Work Procedures • What should the worker do to eliminate the hazard? • How should it be done? • Document changes in detail
  121. 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
  122. Performing Safety Audits
  123. Guide for Personal Audits The guide has five steps • Audit • React • Communicate • Follow up • Raise standards
  124. 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
  125. 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…
  126. 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
  127. Follow Up • Critical for success of the safety program • Allows you to demonstrate that it is important • Must communicate your assessment to the employees
  128. 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
  129. 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
  130. 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
  131. Observation Techniques • Remember ABBI -- look Above, Below, Behind, Inside • Develop a questioning attitude • Use all senses • sight • hearing • smell • touch
  132. Inspections and Field Observations • Use a checklist • Ask questions • Take notes • Respect lines of communication • Draw conclusions
  133. 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
  134. 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
  135. 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
  136. Management Commitment Should Management Consider Safety as a Priority in Conducting Business
  137. Management Commitment
  139. Employee Participation • Accident Prevention Plan Development • Safety Committee • Safety Bulletin Board • Crew-Leader • Day-to-Day Knowledge comes from where the work is actually done and hazards actually exist.
  141. AVAILABLE RESOURCES • OSHA Website: www.osha.gov • Washington State Labor & Industries Website: www.lni.wa.gov
  143. 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
  145. THE ACCIDENT An unplanned and unwelcome event that interrupts normal activity
  146. Accidents are What Happens to Somebody Else BUT REMEMBER: YOU are somebody else to somebody else
  147. THE ACCIDENT MINOR ACCIDENTS: • Such as paper cuts to fingers or dropping a box of materials
  148. THE ACCIDENT MORE SERIOUS ACCIDENTS • Such as a forklift dropping a load or someone falling off a ladder
  149. THE ACCIDENT • Accidents that occur over an extended time frame: – Such as hearing loss or an illness resulting from exposure to chemicals
  150. 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!
  152. THE ACCIDENT They all have outcomes from the accident
  153. THE ACCIDENT They all have contributory factors that cause the accident
  154. OUTCOMES OF ACCIDENTS • NEGATIVE Results – Injury & possible death – Disease – Damage to equipment & property – Litigation costs, possible citations – Lost productivity – Morale
  155. OUTCOMES OF ACCIDENTS • POSITIVE Results – Accident investigation – Prevent repeat of accident – Change to safety programs – Change to procedures – Change to equipment design
  156. 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
  157. 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
  158. 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
  159. ACCIDENT INVESTIGATION • Conduct a preliminary investigation for: – serious injuries with immediate symptoms • Document the investigation findings You Must:
  160. 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
  161. 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)
  162. 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
  163. 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
  164. 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?
  165. 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
  166. Why Not Rely On OSHA & Police To Investigate? • Focus On Culpability • Minor Accidents Not Investigated • PREVENTION • Protect Company Interests • OSHA Requirements
  167. Investigating Accidents How to find out what really happened
  168. Why Investigate Accidents? • Find the cause • Prevent similar accidents • Protect company interests
  169. Acts Conditions Near Misses Minor Injuries Reportable Injury Lost Time Injury Death Knowledge Ability Motivation Design Maintenance Action of Others At which level do we investigate?
  170. Investigation Strategy • Need For Investigation • Control the Scene • Gather Facts • Analyze Data • Establish Causes • Write Report • Take Corrective Action
  171. 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
  172. 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?
  173. 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
  174. 12 1 2 5 4 7 8 6 3 9 10 11
  175. 12 1 2 5 4 7 8 6 3 9 10 11
  176. 12 1 2 5 4 7 8 6 3 9 10 11
  177. 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
  178. 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
  180. 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
  181. **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
  182. 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
  183. Provide Care to the Injured • Ensure that medical care is provided to the injured people before proceeding with the investigation
  184. Secure the Scene for Safety • Eliminate the hazards: – Control chemicals – De-energize – De-pressurize – Light it up – Shore it up – Ventilate
  185. 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
  186. 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
  187. 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)
  188. 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
  189. Photographs • Unbiased Recording • Keep Log of Photos • Overall to Close-up • Color if possible • Supplement with Video
  190. Gather Data • Data includes: – Persons involved – Date, time, location – Activities at time of accident – Equipment involved – List of witnesses
  191. 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?
  192. Documents • Collect All Related Documents – Inspection Logs – Policy & Procedures Manual – JSA (Job Safety Analysis) – Equipment Operations Manuals – Insurance Records – Employee Records – Police Reports
  193. Those who do not know the past are destined to: Repeat Repeat Repeat Repeat Repeat Repeat It.
  194. 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
  195. 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 don’t agree on what they observed. Non-Measurable - A number isn’t used. General - Based on non- detailed descriptions.
  196. 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
  197. Record Evidence • Keep All Notes in Bound Notebook • Include Date - Time - Place – Vantage Point • Keep Originals • Rewrite in Report Form
  198. Samples • Collect Perishables First • Fluids • Open Containers • Filings • Chemicals • Air
  199. 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
  200. 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
  201. Interviews • Excellent Source of first hand knowledge • May Present Pitfalls in form of: – Bias – Perspective – Embellishment – Omissions
  202. 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
  203. 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
  204. 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
  205. 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
  206. 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?”
  207. 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
  208. 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
  209. 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
  210. 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?
  211. 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?
  212. 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
  213. 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?
  214. 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
  216. 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
  217. Indirect Causes • Unsafe conditions – what material conditions, environmental conditions and equipment conditions contributed to the accident • Unsafe Acts – what activities contributed to the accident
  218. Breakdown of Unsafe Conditions • Inadequately guarded or unguarded equipment • Defective tools, equipment or materials • Fire and explosion hazard • Unexpected movement hazard • Projection hazards
  219. Breakdown of Unsafe Conditions • Housekeeping • Hazardous environmental conditions • Improper ventilation • Improper illumination • Unsafe dress or apparel
  220. 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
  221. Basic Causes • Management • Environment • Equipment • Human Behavior Systems & Procedures Design & Equipment
  222. 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?
  223. 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?
  224. 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.
  225. What controls failed? • List the specific engineering, administrative and training controls that failed and how these failures contributed to the accident
  226. What controls worked? • List any controls that prevented a more serious accident or minimized collateral damage or injuries
  227. Determine • What was not normal before the accident • Where the abnormality occurred • When it was first noted • How it occurred
  228. 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)
  229. 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
  230. 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
  231. 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……..
  232. 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?
  233. Recommendations • Consider -Effectiveness -Cost -Feasibility -Effect on Productivity -Time to Implement -Employee Acceptance -Management Acceptance
  234. 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
  235. Common Problems • Accidents not reported • Unable to identify basic causes • Accepting inadequate reports • Neglecting to implement corrective actions
  236. 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
  237. 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
  238. 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
  239. 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?
  240. 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
  241. 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
  242. 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
  243. Other Accident Investigation Tools
  244. 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
  245. Problem Solving Fault Tree Wet Floor Environmental Sudden Release No Preshift Inspection SlowLeak Break Line Leak No Fluid Brakes Fail Steering Fails Equipment No Training Procedural NoTraining Did Not Know Intentional Omission No Inspection Human Failure To Stop PIT Hits Wall
  246. Problem Solving Fault Tree Sudden Release No Preshift Inspection SlowLeak Break Line Leak No Fluid Brakes Fail Equipment NOTRAINING Supv. sick Sup.Resp. Training Req'd Procedural Training Not Received Did NotKnow Time ltd. IntentionalOmission Did not Conduct Inspection Human Failure To Stop PIT Hits Wall
  247. ISHIKAWA “FISHBONE” DIAGRAM Machinery Methods Materials People Environment EFFECT
  248. FIVE WHYs DIAGRAM Undesired Event Why? Direct Cause Why? Contributing Cause Why? Contributing Cause Why? Contributing Cause Why? Root Cause
  250. TEST