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?
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  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  CONTACT WITH

 same level  chemicals
 lower level  electricity
 CAUGHT  heat/cold

 in  radiation

 on  BODILY REACTION FROM

 between  voluntary motion
 involuntary motion
Types of Accidents
(continued)
 STRUCK  RUBBED OR ABRADED BY
 Against  friction
 stationary or moving  pressure
object
 vibration
 protruding object
 sharp or jagged edge

 By
 moving or flying
object
 falling object
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  Direct Causes

 Management  Slips, Trips, Falls
 Environmental  Caught In
 Equipment  Run Over
 Human Behavior  Chemical Exposure
 Indirect Causes
 Unsafe Acts
 Unsafe Conditions
 Policy & Procedures
Basic Causes Environmental Conditions
Equipment/Plant Design
Human Behavior

Unsafe Indirect Causes Unsafe

Acts Conditions

Slip/Trip Fall
Direct Causes Energy Release
Pinched Between

ACCIDENT
Personal Injury
Property Damage
Potential/Actual
Basic Causes

 Management
Systems & Procedures
 Environment
Natural & Man-made
 Equipment

 Human Behavior 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
Human Behavior is a function of :

Activators (what needs to be done)

Competencies (how it 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)
 Only 4 Types of
Consequences:
Positive Reinforcement (R+)
("Do this & you'll be rewarded")

Negative Reinforcement (R-)

("Do this or else you'll be penalized")
Behavior
•Punishment (P)
("If you do this, you'll be penalized")

•Extinction (E)
("Ignore it and it'll go away")
Individual
Perceptions of:
Magnitude positive
• Significance or
Impact negative

 TIMING - IMMEDIATE OR FUTURE

 CONSISTENCY - CERTAIN OR UNCERTAIN

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”
 Attitudes
however

A re inside a person’s head -therefore they

are not observable nor measurable

Attitudes can be changed by

changing behaviors
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 7 2,444 59.6%
Ergonomics 3 n/a 51.6%
Engineering Change 4 n/a 29.0%
Problem Solving 1 76 20.0%
Gov’t. Action 2 2 18.3%
Mgt. Audits 4 n/a 17.0%
Stress Management 2 1,300 15.0%
Poster Campaign 26 100 14.0%
Personnel Selection 26 19,177 3.7%
Near-miss Reports 2 n/a 0%
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
 Proactive
Safety
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

 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
 Resultin 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  Contractors
 Visitors  Janitorial
 Invited  Maintenance
 Customers
 Emergency  Others
services
 Delivery drivers  Members of Public
 Uninvited  Passers-by
 Trespassers  Neighbors
 Burglars
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
Ventilation
Add-On Safety Design
“Active” vs. “Passive” Design/Layout
User Instructions (Manual) 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 Jobs
Potential of Severe Injuries
History of Disabling Injuries
Frequency 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

• Steps  Hazards

– Park & set  Hit by

brake traffic

– Remove Spare  Back

Strain
& Jack
 Foot/Toe
impact

– Loosen lugs
 Shoulder
strain
 Job Safety Analysis
• Steps  Hazards
• Prevention
– Park & set  Hit by – Far off road as
brake traffic possible
– Remove Spare  Back – Pull items close
& Jack Strain before lift
 Foot/Toe – Lift in increments
impact – Lift and lower
using leg power
– Wide leg stance
– Loosen lugs  Shoulder
– Use full body, not
strain arm/shoulder
Develop Solutions
 Find a new way
to do job • Fix-A-Flat

 Change • No off-road
physical
conditions that driving
create hazards
 Change the
work procedure • Buy self-sealing
 Reduce tires
frequency
• 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
PRIORITIES
CHANGE
SAFETY MUST
BE A VALUE!!
 Employee Participation

 Accident Prevention
• Day-to-Day Knowledge
Plan Development
comes from where the
work is actually done
and hazards actually  Safety Committee
exist.
 Safety Bulletin Board

 Crew-Leader
Meetings
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

You Must:
 Conduct a preliminary investigation for:
 serious injuries with immediate symptoms

 Document the investigation findings

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
 Otheremployees 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
Accidents

HOW TO FIND OUT WHAT REALLY HAPPENED

Why Investigate
Accidents?
Find the cause
 Prevent similar accidents
 Protect company interests
At which level do we investigate?

Death
Lost Time
Injury
Reportable Injury

Minor Injuries

Near Misses

Acts Conditions

Maintenance
Knowledge

Motivation

Design
Ability

Others
Action
of
Investigation Strategy
 Need For Investigation

 Control the Scene

 Gather Facts

 Analyze Data

 Establish Causes

 Write Report

 Take 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
11 1
10 2
9 3

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

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

8 4
7 5
6
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 DON’T
 Separate Witnesses • Suggest Answers
 Written Statements • Interrogate
 Open ended questions
• Focus on Blame
 Provide Diagrams
• Dismiss Details
 Encourage Details
• Bar Emotions
 Show Concern
• Make Judgments
 Record w/permission
 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
Systems & Procedures
 Environment

 Equipment

 Human Behavior 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

PIT Hits Wall

Failure To Stop

Environmental Equipment Procedural Human

Wet Floor Brakes Fail Steering Fails No Training No Inspection

No Fluid Did Not Know Intentional Omission

Break Line Leak NoTraining

Sudden Release Slow Leak

No Preshift Inspection
 Problem Solving
Fault Tree

PIT Hits Wall

Failure To Stop

Equipment Procedural Human

Did not Conduct Inspection

Brakes Fail Training Req'd

No Fluid Sup.Resp. Did Not Know Intentional Omission

Break Line Leak Supv. sick Training Not Received Time ltd.

Sudden Release Slow Leak NO TRAINING

No Preshift Inspection
 ISHIKAWA “FISHBONE”
DIAGRAM
Machinery Methods

EFFECT

Materials People Environment

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