ACCIDENT INVESTIGATION CASE STUDY NO: 2

This is an accident investigation assignment. You are given a scenario

of minor injury accident in a Cleaning area. The description is not
complete but sufficient enough to allow you to write an accident
investigation report. To test your analytical responsibilities, you are
also required to put forward questions that you think will assist you in
finding the causal factors toward the accident.
Please read the Description of Events and answer all questions
asked.
Description of Event
On 29/3/2005 at Cleaning machine 011 approximately 7.45 am., the
operator was preparing for the new chemical at one of the chemical
bath. He wore personal protective equipments such as chemical long
glove, face shield and apron. He was then step on the stool and moved
his body partially inside the machine and started cleaning the chemical
bath before putting fresh chemical. The bath contains sodium
hydroxide 65 % solution .
He suddenly cried for help saying that his left eye was in pain. With the
help of his colleagues, he was taken to the eyewash nearby and his left
eye was rinsed. He was then referred to the in-house clinic which later
sent him to the hospital for further treatment. He was very fortunate
that nothing wrong with his eye.
With the above reference, please carry out the accident investigation.
Investigation Assignment:
1. The summary of the above accident is by no means
comprehensive, not exhaustive. However, it does provide some
information as to the possible causes of the accident. You are
required to write up an accident investigation report based on
the case study.
2. In writing his report, you may assume that you did the
investigation alone or with help. If necessary, you may also
assume that specialized equipment is used in your investigation.
3. There are numerous additional questions that must be asked in
order to identify all potential causal factors. Write those
questions in your report
4. Remember that an accident investigation is part of lose control.
Make sure your report addresses that objective too.
5. An investigation report also consist of appendices. List what
would be necessary to be included in your accident report as
appendices.

Instructions:
1.
Make a clear and large sketch pertinent to the accident.
2.
What may be the cause(s) of the accident according to the
multiple causation theory?
3.
What might be the solutions to prevent the accident from
recurring?
Note: Multiple Causation Theory
Behind every accident there are many contributing factors, causes and
sub causes. These factors combine in a random fashion causing
accidents. We must find the fundamental root causes and remove
them to prevent a recurrence.