Safety study for mariners for practical use.pptx

Safety study for mariners for practical use.

1. Safety Committees

2. 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 Proactive Safety

3. 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

4. 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.

5. How effective can a Committee be?

6. Safety Committee Policy Statement A written and publicized statement is an effective means of providing guidance and demonstrating commitment

7. Safety Committee Focus Long Term Goals Objectives to Achieve Time Frame Short Term Goals Assignments between Meetings Work toward achieving Long-Term Plan

8. Planning the Safety Meeting Select topics Set & post the agenda Schedule safety meeting Prepare meeting site Encourage participation

9. 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

10. 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

11. 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

12. Emergency Plan Anticipate What Could Go Wrong and Plan for those Situations Drill for Emergency Situations

13. 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

14. Record Keeping & Updating Record each Recordable Injury & Illness on ISM DOCS 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

15. 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

16. 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

17. HAZARD ANALYSIS

18. 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

19. Step 1: Identify Hazards HAZARD – condition with the potential to cause personal injury, death and property damage

20. Hazard Identification Review Records Talk to Personnel Accident Investigations Follow Process Flow Write a Job Safety Analysis Use Inspection Checklists

21. 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

22. 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

23. 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

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

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

26. Hazard Controls Source Path Receiver

27. Hazard Control Administrative Engineering Protective Equipment/Clothing

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

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

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

31. JOB SAFETY ANALYSIS

32. 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

33. Job Safety Analysis

34. Job Safety Analysis Priorities New Jobs Potential of Severe Injuries History of Disabling Injuries Frequency of Accidents

35. 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!)

36. 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

37. 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

38. Key Steps NOT ENOUGH Changing a Flat Tire Park car Take off flat tire Put on spare tire Drive away

39. 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

40. Job Safety Analysis Steps Park & set brake Remove Spare & Jack Loosen lugs

41. Job Safety Analysis Hazards Hit by traffic Back Strain Foot/Toe impact Shoulder strain Steps Park & set brake Remove Spare & Jack Loosen lugs

42. 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

43. 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

44. INSPECTIONS

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

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

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

48. 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

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

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

51. 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

52. Performing Safety Audits

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

54. 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

55. 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: Acceptable because... Not acceptable because... Deteriorated because... Improved because…

56. 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

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

58. 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

59. 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

60. 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

61. Observation Techniques Remember ABBI -- look A bove, B elow, B ehind, I nside Develop a questioning attitude Use all senses sight hearing smell touch

62. Inspections and Field Observations Use a checklist Ask questions Take notes Respect lines of communication Draw conclusions

63. 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

64. 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

65. 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

66. Management Commitment Should Management Consider Safety as a Priority in Conducting Business ??

67. Management Commitment NO !

68. PRIORITIES CHANGE SAFETY MUST BE A VALUE!!

69. 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.

70. SHARED VISION EXERCISE

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

72. ACCIDENT INVESTIGATION

73. 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

74. THE ACCIDENT WHAT IS AN ACCIDENT?

75. THE ACCIDENT An unplanned and unwelcome event that interrupts normal activity

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

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

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

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

80. 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!

81. THE ACCIDENT ACCIDENTS HAVE TWO THINGS IN COMMON

82. THE ACCIDENT They all have outcomes from the accident

83. THE ACCIDENT They all have contributory factors that cause the accident

84. OUTCOMES OF ACCIDENTS NEGATIVE Results Injury & possible death Disease Damage to equipment & property Litigation costs, possible citations Lost productivity Morale

85. OUTCOMES OF ACCIDENTS POSITIVE Results Accident investigation Prevent repeat of accident Change to safety programs Change to procedures Change to equipment design

86. 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

87. 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

88. 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

89. ACCIDENT INVESTIGATION Conduct a preliminary investigation for: serious injuries with immediate symptoms Document the investigation findings You Must:

90. 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

91. ACCIDENT INVESTIGATION Within 8 hours of a work-related incident or accident y ou 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)

92. 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

93. 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

94. 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?

95. 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

96. Why Not Rely On OSHA & Police To Investigate? Focus On Culpability Minor Accidents Not Investigated PREVENTION Protect Company Interests OSHA Requirements

97. Investigating Accidents How to find out what really happened

98. Why Investigate Accidents? Find the cause Prevent similar accidents Protect company interests

99. At which level do we investigate?

100. Investigation Strategy Need For Investigation Control the Scene Gather Facts Analyze Data Establish Causes Write Report Take Corrective Action

101. 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

102. 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?

103. 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

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105. 12 1 2 5 4 7 8 6 3 9 10 11

106. 12 1 2 5 4 7 8 6 3 9 10 11

107. 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

108. 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

109. 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!

110. 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

111. **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

112. 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

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

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

115. 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

116. 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

117. 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)

118. 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

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

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

121. 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?

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

123. Those who do not know the past are destined to: Repeat Repeat Repeat Repeat Repeat Repeat It.

124. ISOLATE FACT FROM FICTION Use NORMS-based analysis of information N ot an interpretation O bservable R eliable M easurable S pecific If an item meets all five of above, it is a fact

125. 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.

126. 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

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

128. Samples Collect Perishables First Fluids Open Containers Filings Chemicals Air

129. 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

130. 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

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

132. 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

133. 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

134. 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

135. 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

136. 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?”

137. 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

138. 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

139. 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

140. 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?

141. 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?

142. 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

143. 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?

144. 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

145. 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?

146. 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

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

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

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

150. 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

151. Basic Causes Management Environment Equipment Human Behavior Systems & Procedures Design & Equipment

152. 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?

153. 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?

154. 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.

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

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

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

158. 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)

159. 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

160. 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

161. 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……..

162. 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?

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

164. 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

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

166. 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

167. 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

168. 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

169. 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?

170. 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

171. 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

172. 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

173. Other Accident Investigation Tools

174. 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

175. Problem Solving Fault Tree

176. Problem Solving Fault Tree

177. FIVE WHYs DIAGRAM Undesired Event Why? Direct Cause Why? Contributing Cause Why? Contributing Cause Why? Contributing Cause Why? Root Cause

178. ACCIDENT ANALYSIS AND REPORT (Handout)