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1. COPYRIGHT 1995
©
, SAFETY SERVICES
® WORKER NEARLY
KILLED IN WELDING
ACCIDENT
ACCIDENT CASE STUDY

2. COPYRIGHT 1995
©
, SAFETY SERVICES
® Youareamemberofthesafetycommitteeandhavebeennotified
toreporttothemaintenancedepartmenttoconductan
investigationofanaccident.1workerhasbeentakentothe
hospitalwithsevereburnsandheartarythmiafromcontactwithan
electricalsource.Youandyourgroupmustconductanaccident
investigationandwriteareporttodeterminetherootcauseand
recommendcorrectiveactions.
1 WORK SEVERELY INJURED IN WELDING ACCIDENT
OVERVIEW OF THE INCIDENT
ACCIDENT CASE STUDY

3. COPYRIGHT 1995
©
, SAFETY SERVICES
® ACCIDENT CASE CHRONOLOGY
7:00am:Maintenance technician Madeline Hurt arrives to work
7:02am:Hurt unlocks tool chest
7:02am:Hurt turns on arc welder without area safety check
7:05am:Hurt notices and ignores water on floor in department
7:05am:Hurt searches for welding gloves, can’t find them
7:09am:Hurt resumes work on a welding job from previous day
7:09am:Table is not adjustable, part cannot be reoriented
7:10am:Hurt stoops over and attempts to weld at odd angle
7:10am:Hurt cannot properly weld hard-to-get-at section
7:11am:Hurt lowers to left knee and contacts water on floor
7:15am:Hurt resumes welding and is knocked unconscious
7:21am:Bill Smith (co-worker) finds her unconscious, calls 911
8:03am:Ambulance arrives, cares for, and transports victim
8:10am:Bill Smith notifies you

4. COPYRIGHT 1995
©
, SAFETY SERVICES
® ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
Date/TimeofIncident:1996Novem,30,about715
ACCEPTABLE
Date/TimeofIncident:11/30/96(Month/Day/Year),7:15a.m.
COMMENTS:
BeconsistentandaccuratewithDatesandTimes.Accurately
reconstructingtheaccidentmaydependonaccurate
timeframes.

5. COPYRIGHT 1995
©
, SAFETY SERVICES
® ACCIDENT INVESTIGATION
REPORT
AccidentWithInjury-Severityisnotafactor
AccidentWithoutInjury-VehicleorProperty
DamagesResult
NearMiss-HadtimingbeendifferentInjuryor
propertydamagewouldhaveresulted
ResultedinDeath-SelfExplanatory
DEFINITIONS

6. COPYRIGHT 1995
©
, SAFETY SERVICES
® ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
Name:MaddyHurt
ACCEPTABLE
Name:MadelineB.Hurt
COMMENTS:
Usefulllegalnamesonly,theuseofnicknamescan
sometimescauseconfusion.Iflegalconcernsarise,correct
nameswillbecomeimportant.Reviewpersonnelrecordsas
needed.

7. COPYRIGHT 1995
©
, SAFETY SERVICES
® ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
AssignedJob:MaintenanceMan
ACCEPTABLE
AssignedJob:MaintenanceTechnician
COMMENTS:
Usethefulldutytitleasitappearsintheirjobdescription.
Reviewpersonnelrecordsasneeded.

8. COPYRIGHT 1995
©
, SAFETY SERVICES
® ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
LengthofService:Almost15Years
About12Yearsonthisjob
ACCEPTABLE
LengthofService:14years11Months
11Years10Monthsonthisjob
COMMENTS:
Beconsistentandaccuratewithtimeframes.Reviewpersonnel
recordsasneeded.

9. COPYRIGHT 1995
©
, SAFETY SERVICES
® ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
LocationofAccident:Maintenancedepartment.
ACCEPTABLE
LocationofAccident:Maintenancedepartment,Adjacent
toArcWeldingMachine(Serial-011212)SWcornerof
room.
COMMENTS:
Fullydescribethelocationandpertinentsurroundings.
Thelocationcansometimescontributetotheaccident.
Accuracyisalsoneededforreconstruction.

10. COPYRIGHT 1995
©
, SAFETY SERVICES
® ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
HowAccidentOccurred:Maddywaszappedbythegreen
welder(realdirtyone)whensheputherkneeinwater
leakingfromthedrinkingfountainwhichTedwas
supposedtofixTuesday.Ifeelrealbadaboutthis.
COMMENTS:
1.Isthissufficientforyoutounderstandwhathappened?
2.Cantherootcausebedetermined?
3.Canyoudevelopmeasurestopreventrecurrence?
4.Specifically,whatiswrongwiththisnarrative?

11. COPYRIGHT 1995
©
, SAFETY SERVICES
® ACCIDENT INVESTIGATION
REPORT
ACCEPTABLE
HowAccidentOccurred:Theemployeereceivedahigh
voltageelectricshock(220v)whichincapacitatedher.At
thetimeoftheaccidentshewasweldingaT-Jointonmild
steelwiththevoltageregulatorsetat110amps.Sheknelt
onherleftkneetoobtainabetteranglefortheweldnot
realizingthatwaterwasleakingfromadrinkingfountain
ontheothersideofthepartitionseparatingthe
maintenancedepartmentfromthegeneralfacility.The
workingsurfacewaspouredcement.ArcWelding
Machine(Serial-011212)wasbeingusedatthetime,the
nonconductivehandlegripwascrackedwhichcausedan
electricalshortcausingtheinjury.Thewaterleakwasa
contributingfactor.

12. COPYRIGHT 1995
©
, SAFETY SERVICES
® HowAccidentOccurred:
COMMENTS:
1.Preventingrecurrencebyallowingreconstructionof
theaccidentshouldbetheprimaryoutcome.
2.Theuseofirrelevantinformationsuchasyourfeelings
maydisguisethecausesoftheaccidentandhinder
theinvestigation.
3.Accuracyiscriticalforreconstruction.
4.Atthispointyoushouldnotaffixblame.Theobjectof
theinvestigationistodeterminetherootcausenot
findthefall-guy(orgal).
ACCIDENT INVESTIGATION
REPORT

13. COPYRIGHT 1995
©
, SAFETY SERVICES
® ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
WhatFactorsLedToTheAccident:
1.Tedignoredwaterfountainworkorderrequest.
2.Maddyneverchecksherequipmentright.
3.Maddyhastroublefollowingdirections.
4.I’lltryandgetmypointsacrossbetterinthefuture.
COMMENTS:
1.Isthissufficientforyoutodeveloppreventativemeasures?
2.Cantherootcausebedetermined?
3.Specifically,whatiswrongwiththesestatements?

14. COPYRIGHT 1995
©
, SAFETY SERVICES
® ACCEPTABLE
WhatFactorsLedToTheAccident:
1.Possiblelackoftimelyrepairoftheleakingdrinkingfountain.
2.Possiblelackoftraininginpreoperationalequipmentchecks.
3.Possiblelackofpolicyforpreoperationalequipmentchecks.
4.Possiblelackofanadjustableweldingtable/surface.
5.Possiblelackofproperinspectionoftheweldingarea.
6.Possiblelackofahotworkpermit.
ACCIDENT INVESTIGATION
REPORT

15. COPYRIGHT 1995
©
, SAFETY SERVICES
® What Factors Led To The Accident:
COMMENTS:
1. Stick to the facts!
2. If needed break the sequence of events down chronologically.
3. Avoid affixing blame.
4. Think logically and objectively.
5. Think about what was missing from the safety equation.
6. What engineering controls failed or were missing/unavailable?
7. What administrative controls were lacking or unavailable?
8. What PPE was lacking or unavailable?
ACCIDENT INVESTIGATION
REPORT

16. COPYRIGHT 1995
©
, SAFETY SERVICES
® ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
PartofBodyInjured:Wasshockedrealbad.
ACCEPTABLE
PartofBodyInjured:Sustainedsevereelectricalburns
(2nddegree)totheleftkneeandlefthand(palm,thumb
and1stdigit).Minorheartarythmia(confirmedby
emergencyroom)alsosustainedbecauseofelectrical
discharge.
COMMENTS:
Fullydescribetheextentofinjuries.Reviewmedical
recordsifneeded.

17. COPYRIGHT 1995
©
, SAFETY SERVICES
® ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
InvestigatorsComments:Billfrommaintenanceasked
metorespondtotheaccidentsceneacoupleofminutes
afterithappened.Iarrivedsoonthereafter,and
completedthisreport.
ACCEPTABLE
InvestigatorsComments:MaintenanceTechnician(Bill
Smith)notifiedme(11/30/96-8:10a.m.)thatasevere
electricalinjuryhadbeensustainedbyMadelineB.Hurt.I
arrivedattheaccidentsceneatapproximately8:15a.m.
Thevictimhadalreadybeentransportedbyambulanceto
NoHopeHospital.Thisreportistheresultofmy
investigation.

18. COPYRIGHT 1995
©
, SAFETY SERVICES
® Investigators Comments:
COMMENTS:
1. Describe the facts surrounding your involvement.
2. Identify key names, places, and timeframes.
3. Think logically and objectively.
4. Don’t be afraid to reword in the interest of clarity.
5. Don’t be redundant, save your comments for the proper place in
the report.
ACCIDENT INVESTIGATION
REPORT

19. COPYRIGHT 1995
©
, SAFETY SERVICES
® ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
SpecificAction(s)ThatWillBeTaken:
1.Getthewaterfountainfixed.
2.HaveMaddychecksherequipmenteverytime.
3.DisciplineMaddyfornotfollowingdirections.
4.Tryandgetmypointacrossbetterinthefuture.
COMMENTS:
1.Isthissufficienttoensurecompletionofcorrectiveactions?
2.Canestimatedcompletiondatesbeidentified?
3.Haveactionitemsbeassignedtoaspecificperson?
4.Isanyoneheldaccountabletoensurecompletion?

20. COPYRIGHT 1995
©
, SAFETY SERVICES
® ACCEPTABLE
SpecificAction(s)ThatWillBeTaken:
1.Establishresponsiblepartiesforactionitems.
2.Ensureaprioritysystemisinplaceforrepairofequipment.
3.Ensuretimelyrepairoffacilityequipmentisaccomplished.
4.Determineiftrainingorretrainingneedstobeconducted.
5.Conducttrainingorretrainingbeforesimilarworkisperformed.
6.Assessifanadjustableweldingtable/surfaceisneeded.
7.Review&updaterelatedsafetypoliciesandprocedures.
8.Review&updatecurrentpreoperationalweldingrequirements.
(i.e.,hotworkpermit,safetychecklistsetc.)
9.Askco-workersfortheirinput!
ACCIDENT INVESTIGATION
REPORT

21. COPYRIGHT 1995
©
, SAFETY SERVICES
® What caused the injury to occur?
Do you believe there is a single cause to this accident that, if
removed would have prevented it?
Do you believe there are multiple causes?
Are multiple OSHA Standard violations involved?
What could upper management have done?
What could the supervisor have done?
What could the co-workers have done?
To what extent is a lack of written policy responsible?
What written policies need to be developed?
To what extent is a lack of training responsible?
Were the hazards associated with welding fully understood?
QUESTIONS TO BE CONSIDERED

22. COPYRIGHT 1995
©
, SAFETY SERVICES
® ACCIDENT CASE FACTS
Safety discipline weak
Training deficiencies probably exist
Welding Safety Program not used, non-existent or ineffective
Hotwork permit not used, non-existent or ineffective
Maintenance department allowed “lone-wolf” situation
Hazards associated with welding not fully understood
PPE (lack of welding gloves) may have prevented contact
Repair priority system not used, non-existent or ineffective
Supervisor did not have established “rounds” in department
Written safety procedures not used, non-existent or ineffective
Written safety procedures did not address “lone-wolf” situation
Engineering controls may be a factor (i.e. lack of adjustable
table)