fy07_sh-16637-07_acc-injury-prev2 ACCIDENT.ppt

ACCIDENT AND INJURY
PREVENTION

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 that’s an accident
waiting to happen…”
•“Someone ought to do
something…”
That someone is YOU!

Accident
Prevention

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 Risk  0 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. Vehicle Accidents 2413
2. Contact With Objects and Equipment 983
3. Falls 809
4. Assaults & Violent Acts 754

Fatal Accidents - Workplace
Washington State FATALITIES - 2006
1. Vehicle Accidents 40
2. Contact With Objects and Equipment 13
3. Falls 19
4. Assaults & Violent Acts 4
NO NOTE: If you wish to normalize or compare the
Washington data with the Federal data, just multiply the
Washington numbers by 47 (based on population)

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

Policy & Procedures
Environmental Conditions
Equipment/Plant Design
Human Behavior
Slip/Trip Fall
Energy Release
Pinched Between
Indirect Causes
Direct Causes
ACCIDENTACCIDENT
Personal Injury
Property Damage
Potential/Actual
Basic Causes
Unsafe

Acts
Unsafe
Conditions

Basic Causes
•Management
•Environment
•Equipment
•Human Behavior
Systems & Procedures
Natural & Man-made
Design & Equipment

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

Environment
•Physical
–Lighting
–Temperature
•Chemical
–vapors
–smoke
• Biological
–Bacteria
–Reptiles

Environment

Design and Equipment
•Design
–Workplace layout
–Design of tools &
equipment
–Maintenance

Design and Equipment
•Equipment
–Suitability
–Stability
•Guarding
•Ergonomic
•Accessibility

Human Behavior
Common to
all accidents
Not limited to person
involved in accident

Human Factors
•Omissions &
Commissions
•Deviations from
SOP
–Lacking Authority
–Short Cuts
–Remove guards

Competencies (how it needs to be done)
Human Behavior is a function of :
Activators (what needs to be done)
Consequences
(what happens if it is/isn’t done)

ABC Model
Antecedents
(trigger behavior)
Behavior
(human performance)
Consequences
(either reinforce or punish behavior)

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

•Negative Reinforcement (R-)
("Do this or else you'll be penalized")
Only 4 Types of
Consequences:
Behavior
•Punishment (P)
("If you do this, you'll be penalized")
•Extinction (E)
("Ignore it and it'll go away")

Consequences Influence
Behaviors Based Upon
Individual Perceptions of:
Timing - immediate or future
Consistency - certain or uncertain
• Significance
{
Magnitude
Impact
positive
or
negative

Human Behavior
•Behaviors that have consequences that are:
•Soon
•Certain
•Positive
Have a stronger effect on people’s behavior

Some examples of Consequences:

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

Human Behavior
•Soon
•A consequence that follows soon after a
behavior has a stronger influence than
consequences that occur later
•Silence is considered to be consent
•Failure to correct unsafe behavior
influences employees to continue the
behavior

Human Behavior
•Certain
•A consequence that is certain to follow a
behavior has more influence than an
uncertain or unpredictable consequence
•Corrective Action must be:
–Prompt
–Consistent
–Persistent

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

Human Behavior
•Example: Smokers find it hard to stop smoking
because the consequences are:
A) Soon (immediate)
B) Certain (they happen every time)
C) Positive (a nicotine high)
The other consequences are:
A) Late (years later)
B) Uncertain (not all smokers get lung cancer)
C) Negative (lung cancer)

Deviations from SOP
•No Safe Procedure
•Employee Didn’t know Safe Procedure
•Employee knew, did not follow Safe
Procedure
•Procedure encouraged risk-taking
•Employee changed approved procedure

Human Behavior
•Thought Question:
What would you do as a worker if you
had to take 10-15 minutes to don the
correct P.P.E. to enter an area to turn off
a control valve which took 10 seconds?

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

Human Behavior
•The soon, certain, positive reinforcement
from unsafe behavior outweighs the
uncertain, late, negative reinforcement
from inconsistent punishment
•People tend to respond more positively to
praise and social approval than any other
factors

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

Are inside a person’s head -therefore they
are not observable nor measurable
Attitudes can be changed by
changing behaviors

however
Attitudes

Human Behavior
•“Attention” Behavioral Safety approach
–Focuses on getting workers to pay
“Attention”
–Inability to control “Attention” is a
contributing factor in many injuries
•You can’t scare workers into a safety
focus with “Pay Attention” campaigns

Reasons for Lack of Attention
1. Technology encourages short attention
spans (TV remote, Computer Mouse)
2. Increased Job Stress caused by
uncertainty (mergers & downsizing)
3. Lean staffing and increased workloads
require quick attention shifts between
tasks
4. Fast pace of work – little time to learn
new tasks and do familiar ones safely

Reasons for Lack of Attention
5. Work repetition can lull workers into a loss of
attention
6. Low level of loyalty shown to employees by an
ever reorganizing employer may lead to:
a) Disinterested workers
b) Detached workers (no connection to employer)
c) Inattentive workers

Human Behavior
•Focusing on “Awareness” is a typical
educational approach to change safety
behavior
•Example: You provide employees with a
persuasive rationale for wearing safety
glasses and hearing protection in certain
work areas

Human Behavior
Developing Personal Safety 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 didn’t know how
to operate?
e)Have you ever left a desk or file drawer open while you
worked in an area?
f)Have you ever placed something on a stair “Just for a
minute”?
g)Have you ever done anything unsafe because “I’ve always
done it this way”?

Human Behavior
TIME!
“All this safety stuff takes time doesn’t it”?
“I’m too busy”!
“I can’t possibly do all this”!
“The boss wants the job done now”!

Human Behavior
•Does rushing through the job, working quickly
without considering safety, really save time?
•Remember – if an incident occurs, the job may
not get done on time and someone could be
injured – and that someone could be YOU!!

Safety Intervention Strategies
Approach # of Studies # of Subjects Reduction %
Behavior Based 72,444 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 4n/a 17.0%
Stress Management 2 1,300 15.0%
Poster Campaign 26 100 14.0%
Personnel Selection 26 19,177 3.7%
Near-miss Reports 2 n/a 0%

OUTCOMES OF ACCIDENTS
NEGATIVE OUTCOMES
POSITIVE OUTCOMES

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

Compliance
•Failure to develop and implement a
program may be cited as a SERIOUS
violation (by itself or "Grouped" with
other violations)
Penalties (as high as $ 2,000) may be
assessed

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

Indirect Costs
•Injured, Lost Time
Wages
•Non-Injured, Lost
Time Wages
•Overtime
•Supervisor Wages
•Lost Bonuses
•Employee Morale
•Need For
Counseling
•Turn-over

Indirect Costs
•Equipment Rental
•Cancelled Contracts
•Lost Orders
•Equipment/Material
Damage
•Investigation Team Time
•Decreased Production
•Light Duty
•New Hire Learning Time
•Administrative Time
•Community Goodwill
•Public/Customer Perception
•3rd Party Lawsuits

“REAL” Costs

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
They should meet as often as necessary
This will depend on volume of production and
conditions such as
• Number of employees
• Size of workplace covered
• Nature of work undertaken on site
• Type of hazards and degree of risk
Meetings should not be cancelled
Proactive
Safety

Safety Committees
The Goal of the committee is to facilitate a safe
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: Doesn’t realize at-risk
•Post-Awareness: Realizes Risk After Task
Completion
•Engaged-Awareness: Recognizes Risk While
Performing Task(s) and corrects the situation
•Proactive-Awareness: Foresee Hazards and
Begins Task Only When Safe to Proceed

Who is at Risk?
•Workers
•Visitors
–Invited
•Customers
•Emergency services
•Delivery drivers
–Uninvited
•Trespassers
•Burglars
Contractors
Janitorial
Maintenance
Others
Members of Public
Passers-by
Neighbors

STEP 3: Make Risk Decisions
What can we do to reduce the risk?
Does the benefit outweigh the risk?

STEP 4: Implement Controls
•Substitution
•Engineering controls
•Administrative Controls
•Personal Protective Equipment

Hazard Controls
Source
Path

Receiver

Hazard Control
Administrative Engineering
Protective Equipment/Clothing

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

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

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

JOB SAFETY
ANALYSIS

Job Safety Analysis
•Break down a task into its component steps
•Determine hazards connected with each key
step
•Identify methods to prevent or protect
against the hazard

Job Safety Analysis

Job Safety Analysis Priorities
•New JobsNew Jobs
•Potential of Severe InjuriesPotential of Severe Injuries
•History of Disabling InjuriesHistory of Disabling Injuries
•Frequency of AccidentsFrequency 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
•Hazards
–Hit by
traffic
–Back
Strain
–Foot/Toe
impact
–Shoulder
strain
•Steps
–Park & set
brake
–Remove Spare
& Jack
–Loosen lugs

Job Safety Analysis
•Hazards
–Hit by
traffic
–Back Strain
–Foot/Toe
impact
–Shoulder
strain
•Steps
–Park & set
brake
–Remove Spare
& Jack
–Loosen lugs
•Prevention
–Far off road as
possible
–Pull items close
before lift
–Lift in increments
–Lift and lower
using leg power
–Wide leg stance
–Use full body, not
arm/shoulder

Develop Solutions
•Find a new way
to do job
•Change physical
conditions that
create hazards
•Change the work
procedure
•Reduce frequency
•Fix-A-Flat
•No off-road driving
•Buy self-sealing
tires
•Maintenance /
Change-out
program

JSA EXERCISE

INSPECTIONS

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

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

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

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

Change in Physical Conditions
•Tools, materials, equipment layout or
location
•Study change carefully for other benefits
(costs, time savings)

Change in Work Procedures
•What should the worker do to eliminate
the hazard?
•How should it be done?
•Document changes in detail

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

Performing Safety Audits

Guide for Personal Audits
The guide has five steps
•Audit
•React
•Communicate
•Follow up
•Raise standards

Audit
•Get into one of the work areas on a
regular basis
•Develop your own system
•Do not combine a safety audit with other
visits
•Audit must be designed to evaluate safety
•Take notes

React
•How you react is the strongest element in
improving the safety culture
•Your reaction tells what is acceptable and not
acceptable
•You must come away from each inspection with a
reaction:
1.Acceptable because...
2.Not acceptable because...
3.Deteriorated because...
4.Improved because…

Communicate
•In order for the contact to be productive, your
subordinate/co-worker must understand that:
You inspected his or her area
You are pleased (or displeased) with what you saw
because of…
You expect him or her to react to your comments and to
improve
You will audit the area again in a specified number of
days

Follow Up
•Critical for success of the safety program
•Allows you to demonstrate that it is
important
•Must communicate your assessment to the
employees

Raise Standards
•Will see improvement if the first four
steps are followed
•Keep raising your expectations and help
provide leadership
•Solve the obvious problems then fine tune
the safety and housekeeping efforts

Key Points: Becoming a Good Observer
•Effective observation includes:
Be 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
•Accident Prevention
Plan Development
•Safety Committee
•Safety Bulletin Board
•Crew-Leader Meetings
•Day-to-Day Knowledge
comes from where the
work is actually done
and hazards actually
exist.

SHARED VISION
EXERCISE

AVAILABLE RESOURCES
•OSHA Website: www.osha.gov
•Washington State Labor & Industries
Website: www.lni.wa.gov

ACCIDENT
INVESTIGATION

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

THE ACCIDENT
WHAT IS AN ACCIDENT?

THE ACCIDENT
An
unplanned and unwelcome event
that interrupts normal activity

Accidents are What Happens to
Somebody Else
BUT REMEMBER:
YOU
are somebody else
to somebody else

THE ACCIDENT
MINOR ACCIDENTS:
•Such as paper cuts to fingers or dropping
a box of materials

THE ACCIDENT
MORE SERIOUS ACCIDENTS
•Such as a forklift dropping a load or
someone falling off a ladder

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

THE 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
•Conduct a preliminary investigation
for:
–serious injuries with immediate
symptoms
•Document the investigation findings
You Must:

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

Acts Conditions
Near Misses
Minor Injuries
Reportable Injury
Lost Time
Injury
Death
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At which level do we investigate?

Investigation Strategy
•Need For InvestigationNeed For Investigation
•Control the SceneControl the Scene
•Gather FactsGather Facts
•Analyze DataAnalyze Data
•Establish CausesEstablish Causes
•Write ReportWrite Report
•Take Corrective ActionTake 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

12
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2
5
4
7
8
6
39
10
11

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

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

BENEFITS OF ACCIDENT
INVESTIGATION
•WHEN AN ORGANIZATION REACTS
SWIFTLY AND POSITIVELY TO
ACCIDENTS AND INJURIES, ITS
ACTIONS REAFFIRM ITS
COMMITMENT TO THE SAFETY
AND WELL-BEING OF ITS
EMPLOYEES!

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

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

Isolate the Scene
•Barricade the area of the accident, and
keep everyone out!
•The only persons allowed inside the
barricade should be Rescue/EMS, law
enforcement, and investigators
•Protect the evidence until investigation is
complete

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

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

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

Gather Evidence
•Examine the accident scene - Look for things
that will help you understand what happened:
–Dents, cracks, scrapes, splits, etc. in equipment
–Tire tracks, footprints, etc.
–Spills or leaks
–Scattered or broken parts
–Any other possible evidence

Gather Evidence
•Diagram the scene:
–Use blank paper or graph
paper. Mark the location of
all pertinent items;
equipment, parts, spills,
persons, etc.
–Note distances and sizes,
pressures and
temperatures
–Note direction (mark north
on the map)

Gather Evidence
•Take photographs
–Photograph any items or scenes which may provide an
understanding of what happened to anyone who was
not there
–Photograph any items which will not remain, or which
will be cleaned up (spills, tire tracks, footprints, etc.)
–35mm cameras, Polaroids, and video cameras are all
acceptable
•Digital cameras are not recommended -
digital images can be easily altered

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

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

Review Records
•Check training records
–Was appropriate training provided?
–When was training provided?
•Check equipment maintenance records
–Is regular PM or service provided?
–Is there a recurring type of failure?
•Check accident records
–Have there been similar incidents or injuries
involving other employees?

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

Those who do not know the
past are destined to:
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 don’t agree on what
they observed.
Non-Measurable - A
number isn’t used.
General - Based on non-
detailed descriptions.

INVESTIGATION TRAPS
•Put your emotions aside!
–Don’t let your feelings interfere -
stick to the facts!
•Do not pre-judge
–Find out the what really happened
– Do not let your beliefs cloud the
facts
•Never assume anything
•Do not make any judgements

Record Evidence
•Keep All Notes in Bound Notebook
•Include Date - Time - Place – Vantage Point
• Keep Originals
•Rewrite in Report Form

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

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

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

Interviews
•Excellent Source of first hand knowledge
•May Present Pitfalls in form of:
–Bias
–Perspective
–Embellishment
–Omissions

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

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

The Interview
•Put the person at ease
–People may be reluctant to
discuss the incident, particularly
if they think someone will get in
trouble
•Reassure them that this is a
fact-finding process only
–Remind them that these facts
will be used to prevent a
recurrence of the incident

The Interview
•Take Notes!
•Ask open-ended questions
–“What did you see?”
–“What happened?”
•Do not make suggestions
–If the person is stumbling over a word or
concept, do not help them out

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

The Interview
•Don’t ask leading questions
–Bad: “Why was the forklift operator driving
recklessly?”
–Good: “How was the forklift operator driving?”
•If the witness begins to offer reasons, excuses,
or explanations, politely decline that knowledge
and remind them to stick with the facts

The Interview
•Summarize what you have been told
–Correct misunderstandings of the events
between you and the witness
•Ask the witness/victim for
recommendations to prevent recurrence
–These people will often have the best
solutions to the problem

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

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

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

Witness Interviews
DO
•Separate Witnesses
•Written Statements
•Open ended questions
•Provide Diagrams
•Encourage Details
•Show Concern
•Record w/permission
DON’T
•Suggest Answers
•Interrogate
•Focus on Blame
•Dismiss Details
•Bar Emotions
•Make Judgments

Analysis of Accident Causes
•Immediate Causes
•What was done?
•What was not done?
•What hazardous condition existed?
•Root Causes
•Why did they do this?
•Why didn’t they do that?
•Why did the unsafe condition exist?
•Why wasn’t it corrected?

Analyze Data
•Gather all photos, drawings, interview
material and other information collected
at the scene
•Determine a clear picture of what
happened
•Formally document sequence of events

CONTRIBUTING FACTORS
INVESTIGATION STRATEGY
•INVESTIGATION TEAM
•EVALUATES ALL FACTORS CONCERNED
•ISOLATES THE KEY FACTOR(S) BY
ASKING THE FOLLOWING QUESTION....
•WOULD THE ACCIDENT HAVE HAPPENED
IF THIS PARTICULAR FACTOR WAS NOT
PRESENT?

DETERMINE CAUSES
•Employee actions
•Safe behavior, at-risk behavior
•Environmental conditions
•Lighting, heat/cold, moisture/humidity, dust, vapors,
etc.
•Equipment condition
•Defective/operational, guards, leaks, broken parts,
etc.
•Procedures
•Existing (or not), followed (or not), appropriate (or
not)
•Training
•Was employee trained - when, by whom,
documentation

Indirect Causes
•Unsafe conditions – what material
conditions, environmental conditions and
equipment conditions contributed to the
accident
•Unsafe Acts – what activities contributed
to the accident

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

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

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

Basic Causes
•Management
•Environment
•Equipment
•Human Behavior
Systems & Procedures
Design & Equipment

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

FIND ROOT CAUSES
•When you have determined
the contributing factors, dig
deeper!
–If employee error, what
caused that behavior?
–If defective machine, why
wasn’t it fixed?
–If poor lighting, why not
corrected?
–If no training, why not?

Contribution of Safety
Controls such as:
•Engineering Controls - machine guards, safety
controls, isolation of hazardous areas,
monitoring devices, etc.
•Administrative Controls - procedures,
assessments, inspection, records to monitor and
ensure safe practices and environments are
maintained.
•Training Controls - initial new hire safety
orientation, job specific safety training and
periodic refresher training.

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

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

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

Report Causes
•Analysis of the Accident – HOW &
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 individual’s actions, don’t
use names in the recommendation
•Good: All employees should…….
•Bad: George should……..

Recommendations
•Action to remedy
–Basic causes
–Indirect causes
–Direct causes
•Recommendations - as a result of the finding is
there a need to make changes to:
–Employee training?
–Work Stations Design?
–Policies or procedures?

Recommendations
•Consider
-Effectiveness -Cost
-Feasibility -Effect on Productivity
-Time to Implement -Employee
Acceptance
-Management Acceptance

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

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

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

Why Workers Fail to Report
• Fear of discipline
• Concern for reputation
• Fear of medical treatment
• Desire to keep personal record clean
• Avoidance of red tape
• Concern about attitudes of others
• Poor understanding of importance

Combat Reporting Problems
•Indoctrinate new employees
•Encourage workers to report minor accidents
•Focus on accident prevention and loss control
•Be positive
•Discuss past accidents
•Take corrective action promptly

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

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

Improving the Quality of
Accident Investigation
•Review and comment
•Refuse to accept inadequate reports
•Establish controls to follow up on corrective
actions
•Be responsive to recommendations
•Hold responsible persons accountable
•Emphasize that accident investigations are
FACT-finding, not FAULT-finding
•Encourage investigators to challenge the system

Summary
•Most accident investigations follow
formal procedures
•An investigation is not concluded until
completion of a final report
•A successful accident investigation
determines what happened and how and
why the accident occurred
•Investigations are an effort to prevent a
similar or perhaps more disastrous
sequence of events

Other Accident Investigation Tools

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

Problem Solving
Fault Tree
W et Floor
Environm ental
S udden R elease
N o P reshift Inspection
S low Leak
B reak Line Leak
N o Fluid
Brakes Fail S teering Fails
Equipm ent
N o Training
P rocedural
N oTraining
D id N ot K now Intentional O m ission
N o Inspection
Hum an
F a ilu r e T o S t o p
PIT Hits W all

Problem Solving
Fault Tree
S udden R elease
N o P reshift Inspection
S low Leak
B reak Line Leak
N o Fluid
B rakes Fail
E quipm ent
N O TR A IN IN G
S upv. sick
S up.R esp.
Training R eq'd
P rocedural
Tra ining N o t R e c e ive d
D id N ot Know
Tim e ltd.
Intentional O m ission
D id n o t C o n d u c t I n s p e c t io n
H um an
Failure To S top
PIT Hits W all

ISHIKAWA “FISHBONE”
DIAGRAM
Machinery Methods

Materials People Environment

EFFECT

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

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