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)

Accident
Prevention
Introduction & Course Overview

What Is An Accident?
PROaction versus REaction

• “Well that’s an accident

waiting to happen…”
• “Someone ought to do
something…”

That someone is YOU!

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 What Is An Accident? 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
An Accident is:
• a. An unexpected and undesirable event, especially one FREEDOM FROM DANGER OR HARM
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.
Nothing is Free of
• 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. BUT - We can almost always make
http://www.thefreedictionary.com/accident something SAFER

Hazard Safety Is Better Defined As….

• Existing or Potential
Condition That
Alone or Interacting A Judgement of the
With Other Factors
Can Cause Harm Acceptability of Risk

• A Spill on the Floor

• Broken Equipment

2
R
A
T
I
O
S

OSHA METHOD HW Heinrich’s Domino Theory

330 Incidents

29 Minor Injuries

1 Major Injurie / Fatality or

Loss-Time Accident

3
 Types of Accidents Fatal Accidents - Workplace
• FALL TO • CONTACT WITH Washington State FATALITIES - 2006
– same level – chemicals 1. Vehicle Accidents 40
– lower level – electricity 2. Contact With Objects and Equipment 13
• CAUGHT – heat/cold 3. Falls 19
– in – radiation 4. Assaults & Violent Acts 4
– on • BODILY
– between REACTION FROM NO NOTE: If you wish to normalize or compare the
– voluntary motion Washington data with the Federal data, just multiply the
– involuntary motion Washington numbers by 47 (based on population)

Types of Accidents (continued) Accident Causing Factors

• STRUCK • RUBBED OR • Basic Causes • Direct Causes
– Against ABRADED BY – Management – Slips, Trips, Falls
• stationary or moving – friction – Environmental – Caught In
object
– pressure – Equipment – Run Over
• protruding object
• sharp or jagged edge – vibration – Human Behavior – Chemical Exposure
– By • Indirect Causes
• moving or flying – Unsafe Acts
object
– Unsafe Conditions
• falling object

Policy & Procedures

Basic Causes Environmental Conditions
Fatal Accidents - Workplace Equipment/Plant Design
Human Behavior

U.S. WORKPLACE FATALITIES - 2006 Unsafe Indirect Causes Unsafe

Acts Conditions
1. Vehicle Accidents 2413
2. Contact With Objects and Equipment 983
Slip/Trip Fall
3. Falls 809 Direct Causes Energy Release
Pinched Between
4. Assaults & Violent Acts 754

ACCIDENT
Personal Injury
Property Damage
Potential/Actual

4
 Basic Causes Environment
• Management Systems & Procedures

• Environment Natural & Man-made

• Equipment Design & Equipment

• Human Behavior

Management Design and Equipment

• Systems & • Design

Procedures
– Lack of systems & – Workplace layout
procedures
– Design of tools &
– Availability
equipment
– Lack of Supervision
– Maintenance

Environment Design and Equipment

• Equipment
• Physical – Suitability
– Stability
– Lighting
• Guarding
– Temperature

• Ergonomic
• Chemical • Biological
– vapors –Bacteria • Accessibility
– smoke –Reptiles

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 Human Behavior ABC Model
Common to Antecedents
(trigger behavior)
all accidents
Behavior
(human performance)

Consequences
Not limited to person (either reinforce or punish behavior)
involved in accident

Only 4 Types of
Human Factors Consequences:
•Positive Reinforcement (R+)
("Do this & you'll be rewarded")
• Omissions &
Commissions
•Negative Reinforcement (R-)
("Do this or else you'll be penalized")
• Deviations from Behavior
SOP
•Punishment (P)
– Lacking Authority ("If you do this, you'll be penalized")
– Short Cuts
– Remove guards •Extinction (E)
("Ignore it and it'll go away")

Human Behavior is a function of : Consequences Influence

Behaviors Based Upon
Activators (what needs to be done) Individual Perceptions of:
Magnitude positive
Competencies (how it needs to be done) • Significance or
Impact negative

 Timing - immediate or future

Competencies  Consistency - certain or uncertain

(what happens if it is/isn’t done)

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 Human Behavior Human Behavior

• Behaviors that have consequences that are: • Soon

• A consequence that follows soon after a
• Soon behavior has a stronger influence than
• Certain consequences that occur later
• Positive • Silence is considered to be consent
• Failure to correct unsafe behavior
Have a stronger effect on people’s behavior influences employees to continue the
behavior

Some examples of Consequences:

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

Why is one sign often ignored, the

other one often followed? Human Behavior

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

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 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”
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 Attitudes
however
Are 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
Developing Personal Safety Awareness
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
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
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 Human Behavior 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?
• 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!!

Human Behavior Safety Intervention Strategies

• More Thought Questions: Approach # of Studies # of Subjects Reduction %
a) Have you ever carried wood without wearing gloves?
Behavior Based 7 2,444 59.6%
b) Have you ever left something in a walkway that was a
tripping hazard? Ergonomics 3 n/a 51.6%
c) Have you ever carried a stack of boxes that blocked your Engineering Change 4 n/a 29.0%
view? Problem Solving 1 76 20.0%
d) Have you ever used a tool /equipment you didn’t know how Gov’t. Action 2 2 18.3%
to operate?
Mgt. Audits 4 n/a 17.0%
e) Have you ever left a desk or file drawer open while you
worked in an area? Stress Management 2 1,300 15.0%
f) Have you ever placed something on a stair “Just for a Poster Campaign 26 100 14.0%
minute”? Personnel Selection 26 19,177 3.7%
g) Have you ever done anything unsafe because “I’ve always Near-miss Reports 2 n/a 0%
done it this way”?

Human Behavior
OUTCOMES OF ACCIDENTS
TIME!

“All this safety stuff takes time doesn’t it”?

NEGATIVE OUTCOMES
“I’m too busy”!
POSITIVE OUTCOMES
“I can’t possibly do all this”!

“The boss wants the job done now”!

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

Indirect Costs
Compliance • Equipment Rental
• Cancelled Contracts
• Failure to develop and implement a • Lost Orders
• Equipment/Material
program may be cited as a SERIOUS Damage
violation (by itself or "Grouped" with • Investigation Team Time
other violations) • Decreased Production
• Light Duty
• New Hire Learning Time
Penalties (as high as $ 2,000) may be • Administrative Time
assessed • Community Goodwill
• Public/Customer
Perception
• 3rd Party Lawsuits

Compliance
• Up to 35% of the penalty can be “REAL” Costs
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

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 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

OUTCOMES OF ACCIDENTS
• Designated Safety and Health Committee
• POSITIVE ASPECTS – Management Representatives
– Accident investigation – Employee Elected Representatives
• Max. 1 year
– Prevent repeat of accident • Must be equal # or more employee representatives than
– Improved safety programs employer representatives
– Elected Chairperson
– Improved procedures
– Self-determine frequency of meetings
– Improved equipment design • 1 hour or less unless majority votes
– Minutes
• Keep for 1 Year
• Available for review by OSHA Personnel

Accident Prevention Program Accident Prevention Program

• Must Be
– Written • Safety Meeting instead of Safety
– Tailored to particular hazards for a particular Committee
plant or operation – If less than 11 employees
• Total
• Minimum Elements
• Per shift
– Safety Orientation Program • Per location
– Safety and Health Committee – Meet at least once/month
– 1 Management Representative

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Safety Meeting
You Must
– Review inspection reports
– Evaluate accident investigations
– Evaluate APP and discuss recommendations
– Document attendance and topics
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

Safety Committees
•Partnership: Between Management
and Employees
•Participation: An important part of
team working.

Proactive
Safety Committees Safety

They should meet as often as necessary How effective

This will depend on volume of production and
conditions such as can a
• Number of employees
• Size of workplace covered
Committee be?
• Nature of work undertaken on site
• Type of hazards and degree of risk

Meetings should not be cancelled

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 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
• Review Policies & Plans such as:
• 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
– Hazard Communication Program
– Personal Protective Equipment
– Respiratory Protection
– Housekeeping
– Machine Safeguarding
– Safety Audits
– Record Keeping
– Emergency Response Plans
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 Emergency Plan Record Keeping and Updating
• Anticipate What • First Aid - one-time treatment that could be
Could Go Wrong expected to be given by a person trained in
and Plan for basic first-aid using supplies from a first-aid kit
those Situations and any follow-up visit or visits for the purpose
of observation of the extent of treatment
• Drill for • NOTE: The new OSHA Recordkeeping Rule
Emergency lists the specific First Aid Treatments
Situations

Emergency Action Plan Immediately Report:

• The following minimum elements shall be included : – Any accident that involves: 1. Injury 2. Illness 3.
Equipment or property damage
– Alarm Systems
– Emergency escape procedures and route assignments;
– Procedures for employees who remain to operate critical – Any near-misses. A near miss is an event that,
plant operations before evacuation strictly by chance, does not result in actual or observable
injury, illness, death, or property damage. Examples:
– Procedures to account for all employees slips, trips & falls, compressed gas cylinder falling,
– Rescue and medical duties for those employees who are to overexposures to a chemical
perform them
– The preferred means of reporting fires and other
emergencies – Any hazards such as: Exposed electrical wires,
Damaged PPE, Improper material storage, Improper
– Names / job titles of who can be contacted for further chemical use, Horseplay, Damaged equipment, Missing
information or explanation of duties under the plan or loose machine guards

Record Keeping & Updating

• Record each Recordable Injury & Illness on
OSHA 300 Log w/in 6 Days
– Recordable
• Occupational fatalities
• Lost workday
HAZARD ANALYSIS
• Result in light-duty or termination or require medical
treatment (other than first aid) or involve loss of
consciousness or restriction of work or motion
• This information in posted every year from
February 1 to April 30 in the OSHA 300A
Summary

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 Hazard Analysis STEP 2: Assess Hazards

• Orderly process used to determine if a • Probability - How likely is the hazard?

hazard exists in the workplace – Likely
– Not likely
– Uncover hazards overlooked in design
– Locate hazards developed in-process • Severity - What will happen if
– Determine essential steps of a job encountered?
– Death
– Identify hazards that result from the
– Serious Injury
performance of the actual job
– Damage to property

Step 1: Identify Hazards

Levels of Risk Awareness
• Unaware: Doesn’t realize at-risk
HAZARD –
condition with • Post-Awareness: Realizes Risk After Task
the potential to Completion
cause personal
• Engaged-Awareness: Recognizes Risk While
injury, death and Performing Task(s) and corrects the situation
property damage
• Proactive-Awareness: Foresee Hazards and
Begins Task Only When Safe to Proceed

Hazard Identification Who is at Risk?

• Review Records • Workers  Contractors
 Janitorial
• Talk to Personnel • Visitors
 Maintenance
– Invited
• Accident Investigations • Customers
• Emergency services  Others
• Follow Process Flow • Delivery drivers  Members of Public
– Uninvited  Passers-by
• Write a Job Safety Analysis • Trespassers
 Neighbors
• Burglars
• Use Inspection Checklists

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 Hazard Control
STEP 3: Make Risk Decisions
Administrative Engineering

What can we do to reduce the risk?

Does the benefit outweigh the risk?
Protective Equipment/Clothing

Engineering
STEP 4: Implement Controls
Hazard Elimination Ventilation
Add-On Safety Design
• Substitution Design/Layout
“Active” vs. “Passive” Safety Devices
• Engineering controls User Instructions
• Administrative Controls (Manual)
• Personal Protective Equipment

Hazard Controls Administrative

Source • Safety Rules
• Disciplinary Policy - Accountability
• Preventative Maintenance
Path
• Training
• Proficiency/Knowledge Demonstrations
Receiver

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 Job Safety Analysis
Step 5: Supervise

• Ensure risk control

measures are
implemented
• Track progress
• Feedback

Job Safety Analysis Priorities

• New Jobs
JOB SAFETY • Potential of Severe Injuries
ANALYSIS • History of Disabling Injuries
• Frequency of Accidents

Job Safety Analysis Observation of the Actual Work

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

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 Key Job Steps JUST RIGHT
Identify Hazards &
Changing a Flat Tire
Potential Accidents
• Park & set brake
• Search for Hazards • Remove jack & tire
– Produced by Work from trunk
• Loosen lug nuts
– Produced by Environment
• Jack up car
• Repeat job observation as many times as • Remove tire
necessary to identify all hazards • Set new tire
• Jack down car
• Tighten lug nuts
• Store tire & jack

Key Steps TOO MUCH

Job Safety Analysis
Changing a Flat Tire
• Steps
• Pull off road
• Put car in “park”
– Park & set
• Set brake brake
• Activate emergency flashers – Remove
• Open door Spare &
• Get out of car Jack
• Walk to trunk
• Put key in lock – Loosen lugs
• Open trunk
• Remove jack
• Remove Spare tire

Key Steps NOT ENOUGH Job Safety Analysis

Changing a Flat Tire
• Steps • Hazards
• Park car – Park & set – Hit by
traffic
• Take off flat brake

tire – Back
– Remove Spare
• Put on spare & Jack
Strain
– Foot/Toe
tire impact
• Drive away
– Loosen lugs – Shoulder
strain

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 Job Safety Analysis
• Steps • Hazards • Prevention
– Park & set – Hit by – Far off road as
brake traffic possible
– Remove Spare
& Jack
– Back Strain – Pull items close
before lift INSPECTIONS
– 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
Inspections
• Find a new way • Fix-A-Flat
to do job • Fact-Finding vs. Fault Finding
• No off-road – Sound knowledge of the plant
• Change physical
conditions that driving – Knowledge of relevant standards & codes
create hazards – Systematic inspection steps
• Change the • Buy self-sealing – Method of evaluating data
work procedure tires
• Reduce • Maintenance /
frequency
Change-out
program

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

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 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
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 Guide for Personal Audits Communicate

• In order for the contact to be productive, your

The guide has five steps subordinate/co-worker must understand that:
• Audit  You inspected his or her area
• React  You are pleased (or displeased) with what you saw
• Communicate because of…
 You expect him or her to react to your comments and to
• Follow up
improve
• Raise standards  You will audit the area again in a specified number of
days

Audit Follow Up
• Get into one of the work areas on a • Critical for success of the safety program
regular basis
• Allows you to demonstrate that it is
• Develop your own system important
• Do not combine a safety audit with other • Must communicate your assessment to the
visits employees
• Audit must be designed to evaluate safety
• Take notes

React
Raise Standards
• How you react is the strongest element in
improving the safety culture
• Your reaction tells what is acceptable and not • Will see improvement if the first four
acceptable steps are followed
• You must come away from each inspection with a
reaction: • Keep raising your expectations and help
provide leadership
1. Acceptable because...
2. Not acceptable because... • Solve the obvious problems then fine tune
3. Deteriorated because... the safety and housekeeping efforts
4. Improved because…

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 Inspections and Field
Key Points: Becoming a Good Observer
Observations
• Effective observation includes:
Be selective • Use a checklist
Know what to look for • Ask questions
Practice
• Take notes
Keep an open mind
Guard against habit and familiarity
• Respect lines of communication
Do not be satisfied with general impressions • Draw conclusions
Record observations systematically

Observation Techniques Unsafe Acts

To become a good observer, a person • Conduct that unnecessarily increases the

must: likelihood of injury
• Stop for 10 to 30 seconds before entering an • All safety rule and procedure violations
area to ascertain where employees are are unsafe acts
working • All unsafe acts should be corrected
• Be alert for unsafe practices immediately
• Observe activity -- do not avoid the action

Observation Techniques Unsafe Conditions

• Remember ABBI -- look Above, Below,
Behind, Inside
• An unsafe condition is a situation, not
directly caused by the action or inaction
• Develop a questioning attitude of one or more employees, in an area that
may lead to an incident or injury if
• Use all senses uncorrected
• sight • Unsafe conditions are normally beyond
• hearing the direct control of employees in the
• smell area where the condition is observed
• touch

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 Audit Practices Management Commitment
• Concentrate on people and their actions
because actions of people account for more

NO !
than 96 percent of all injuries
 When to audit
 Where to audit
 How much to audit
 Auditing contractors

PRIORITIES CHANGE

SAFETY
MUST BE A
VALUE!!

Management Commitment Employee Participation

• Day-to-Day Knowledge • Accident Prevention

Should Management Consider Safety as a Priority comes from where the Plan Development
in Conducting Business work is actually done
and hazards actually • Safety Committee

??
exist.
• Safety Bulletin
Board

• Crew-Leader
Meetings

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 INTRODUCTION
• Thousands of accidents occur throughout the
United States every day
SHARED VISION • Accident investigations determine how and why
these failures occur
EXERCISE • 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

AVAILABLE RESOURCES THE ACCIDENT

• OSHA Website: www.osha.gov

• Washington State Labor & Industries

Website: www.lni.wa.gov

WHAT IS AN ACCIDENT?

THE ACCIDENT

An
ACCIDENT
unplanned and unwelcome event
INVESTIGATION
that interrupts normal activity

25
 Accidents are What Happens to
Somebody Else
THE ACCIDENT
• Accidents that occur over an extended
BUT REMEMBER: time frame:
– Such as hearing loss or an illness resulting
YOU from exposure to chemicals
are somebody else
to somebody else

THE ACCIDENT
THE ACCIDENT NEAR-MISS
MINOR ACCIDENTS: • Also know as a “Near Hit”

• Such as paper cuts to fingers or dropping • An accident that does not quite result in
a box of materials injury or damage (but could have)

• Remember, a near-miss is just as serious

as an accident!

THE ACCIDENT THE ACCIDENT

MORE SERIOUS ACCIDENTS

• Such as a forklift dropping a load or ACCIDENTS HAVE TWO THINGS IN

someone falling off a ladder COMMON

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 THE ACCIDENT OUTCOMES OF ACCIDENTS

They all have outcomes from the accident • NEGATIVE Results

– Injury & possible death
– Disease
– Damage to equipment & property
– Litigation costs, possible citations
– Lost productivity
– Morale

THE ACCIDENT OUTCOMES OF ACCIDENTS

• POSITIVE Results
They all have contributory factors that – Accident investigation
cause the accident – 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

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 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
– Other employees the investigator feels are
necessary to complete the investigation
28
ACCIDENT INVESTIGATION Why Not Rely On OSHA &
Police To Investigate?
•Make sure your preliminary investigation
is conducted by the following people: • Focus On Culpability
– A person designated by the employer • Minor Accidents Not
– The immediate supervisor Investigated
– Witnesses
• PREVENTION
– An employee representative
– Other persons with experience and skills to • Protect Company
evaluate the facts Interests
• OSHA Requirements

Investigating Accidents
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 How to find out what really happened
incident?

ACCIDENT INVESTIGATION
Why Investigate Accidents?
Provide the following information to OSHA
within 30 days concerning any accident
• Find the cause
involving a fatality or hospitalization of 3 or
more employees:
• Prevent similar accidents
– Name of the work place • Protect company interests
– 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

29
At which level do we investigate?
The Aim of the Investigation
Death
Lost Time
• The key result should be to
Injury prevent a repeat of the same
Reportable Injury
accident
Minor Injuries
• Fact finding:
Near Misses
– What happened?
Acts Conditions
– What was the root cause?
Maintenance

– What should be done to prevent

Knowledge

Motivation

Design

repeat of the accident?

Ability

Others
Action
of

Investigation Strategy
The Aim of the Investigation
• Need For Investigation
IS NOT TO:
• Control the Scene
• Exonerate individuals or management
• Gather Facts
• Satisfy insurance requirements
• Analyze Data

• Establish Causes • Defend a position for legal argument

• Write Report • Or, to assign blame

• Take Corrective Action

Investigative Procedures 12
11 1
• The actual procedures used in a particular 10 2
investigation depend on the nature and results
of the accident 9 3
• All investigations start with a collection of data
and are followed by analysis of that data
• An investigation is not complete until all data 8 4
is analyzed and a final report is completed
7 5
6

30
 12 BENEFITS OF ACCIDENT
11 1
INVESTIGATION
10 2
• Prevent repeat of the accident
9 3 • Identifying outmoded procedures
• Improvements to the work environment
• Increased productivity
8 4 • Improvement of operational & safety
procedures
7 5 • Raise safety awareness level
6

12 BENEFITS OF ACCIDENT
11 1
INVESTIGATION
10 2
• WHEN AN ORGANIZATION REACTS
9 3 SWIFTLY AND POSITIVELY TO
ACCIDENTS AND INJURIES, ITS
ACTIONS REAFFIRM ITS
8 4 COMMITMENT TO THE SAFETY
AND WELL-BEING OF ITS
EMPLOYEES!
7 5
6

COMPANY ACCIDENT FORMS Who Should Investigate?

Investigation TEAM
• Must be filled out completely by the • Employer Designee (Management)
employee and employee’s immediate • Immediate Supervisor of affected area/personnel
supervisor (this includes foremen) • Experts (if needed)
• Employee Representative (one of the following:)
• Must be turned in to Safety within – Employee selected representative
24 hours of incident – Employee representative of safety committee
– Union representative or shop steward

31
 **Immediate Actions Secure the Scene for Safety
• Eliminate the hazards:
• Assess the scene – Control chemicals
• CALL 911 – De-energize
• Activate In-House Response – De-pressurize
• Scene Safety – Light it up
• Provide Aid to Injured
– Shore it up
• Provide Assistance to Affected
– Ventilate
• Secure the Scene of Accident

Isolate the Scene Fact Finding

• Barricade the area of the accident, and • Gather evidence from

keep everyone out! many sources during an
investigation
• The only persons allowed inside the
• Get information from
barricade should be Rescue/EMS, law witnesses and reports as
enforcement, and investigators well as by observation
• Protect the evidence until investigation is • Don’t try to analyze data
complete as evidence is gathered

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

32
 Gather Evidence Gather Data
• Diagram the scene: • Data includes:
– Use blank paper or graph – Persons involved
paper. Mark the location of
all pertinent items; – Date, time, location
equipment, parts, spills, – Activities at time of accident
persons, etc. – Equipment involved
– Note distances and sizes, – List of witnesses
pressures and
temperatures
– Note direction (mark north
on the map)

Gather Evidence Review Records

• 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
• 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?

Photographs
Documents
• Collect All Related Documents
• Unbiased Recording
– Inspection Logs
• Keep Log of Photos – Policy & Procedures Manual
• Overall to Close-up – JSA (Job Safety Analysis)
– Equipment Operations Manuals
• Color if possible
– Insurance Records
• Supplement with Video – Employee Records
– Police Reports

33
 Those who do not know the INVESTIGATION TRAPS
past are destined to:
• Put your emotions aside!
Repeat – Don’t let your feelings interfere -
stick to the facts!
Repeat • Do not pre-judge
Repeat – Find out the what really happened
Repeat – Do not let your beliefs cloud the
Repeat facts
Repeat • Never assume anything
It. • Do not make any judgements

ISOLATE FACT FROM

FICTION Record Evidence
• Use NORMS-based analysis of
• Keep All Notes in Bound Notebook
information
– Not an interpretation
– Observable • Include Date - Time - Place – Vantage Point
– Reliable
– Measurable • Keep Originals
– Specific
• If an item meets all five of above, it • Rewrite in Report Form
is a fact

NORMS OF OBJECTIVITY
Samples
Objective Subjective
Not an Interpretation - Based on Interpretations - Based on • Collect Perishables
a factual description. personal
Observable - Based on what is seen interpretations/biases. First
or heard. Non-observable - Based on • Fluids
Reliable - Two or more people events not directly observed. • Open Containers
independently agree on what they
observed.
Unreliable - Two or more • Filings
people don’t agree on what
Measurable - A number is used to they observed. • Chemicals
describe behavior or situation.
Specific - Based on detailed
Non-Measurable - A • Air
number isn’t used.
definitions of what happened.
General - Based on non-
detailed descriptions.

34
 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
35
 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?
36
 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?
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

Witness Interviews
DO
• Separate Witnesses
• Written Statements
• Open ended questions
• Provide Diagrams
• Encourage Details
• Show Concern
• Record w/permission
CONTRIBUTING FACTORS
INVESTIGATION STRATEGY
DON’T • INVESTIGATION TEAM
• Suggest Answers
• Interrogate • EVALUATES ALL FACTORS CONCERNED
• Focus on Blame
• ISOLATES THE KEY FACTOR(S) BY
• Dismiss Details
ASKING THE FOLLOWING QUESTION....
• Bar Emotions
• Make Judgments • WOULD THE ACCIDENT HAVE HAPPENED
IF THIS PARTICULAR FACTOR WAS NOT
PRESENT?

Analysis of Accident Causes DETERMINE CAUSES

• Immediate Causes • Employee actions
• What was done? • Safe behavior, at-risk behavior
• Environmental conditions
• What was not done? • Lighting, heat/cold, moisture/humidity, dust,
vapors, etc.
• What hazardous condition existed?
• Equipment condition
• Root Causes • Defective/operational, guards, leaks, broken parts,
etc.
• Why did they do this? • Procedures
• Existing (or not), followed (or not), appropriate (or
• Why didn’t they do that? not)
• Why did the unsafe condition exist? • Training
• Was employee trained - when, by whom,
• Why wasn’t it corrected? documentation

37
 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 Design & Equipment
• Human Behavior
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?
38
 FIND ROOT CAUSES
What controls worked?
• When you have determined • List any controls that prevented a
the contributing factors, dig more serious accident or
deeper!
minimized collateral damage or
– If employee error, what
caused that behavior? injuries
– 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: Determine
• Engineering Controls - machine guards, safety • What was not normal before the
controls, isolation of hazardous areas,
monitoring devices, etc.
accident
• Administrative Controls - procedures, • Where the abnormality occurred
assessments, inspection, records to monitor and • When it was first noted
ensure safe practices and environments are
maintained. • How it occurred
• Training Controls - initial new hire safety
orientation, job specific safety training and
periodic refresher training.

What controls failed? Report Causes

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

39
 Unable to Identify Root Causes Recommendations
• Timeliness
• Action to remedy
• Poor development of information – Basic causes
– Indirect causes
• Reluctance to accept responsibility
– Direct causes
• Narrow interpretations of
environmental causes • Recommendations - as a result of the finding is
there a need to make changes to:
• Erroneous emphasis on a single cause – Employee training?
• Allowing solutions to determine causes – Work Stations Design?
– Policies or procedures?
• Wrong person(s) investigating

PREPARE A REPORT
Recommendations
• Accident Reports should contain
the following: • Consider
– Description of incident and injuries -Effectiveness -Cost
– Sequence of events -Feasibility -Effect on Productivity
– Pertinent facts discovered during -Time to Implement -Employee Acceptance
investigation
-Management Acceptance
– Conclusions of the investigator(s)
– Recommendations for correcting
problems

PREPARE A REPORT, (CONT.) Accepting Inadequate Reports

• 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……..
• 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

40
 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
41
 Improving the Quality of Problem Solving
Accident Investigation Fault Tree

• 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
• 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

Summary Problem Solving

Fault Tree
• Most accident investigations follow
formal procedures PIT Hits Wall

• An investigation is not concluded until Failure To Stop

completion of a final report Environmental Equipment Procedural Human

• A successful accident investigation Wet Floor Brakes Fail Steering Fails No Training No Inspection
determines what happened and how and
No Fluid Did Not Know Intentional Omission
why the accident occurred
Break Line Leak NoTraining
• Investigations are an effort to prevent a
similar or perhaps more disastrous Sudden Release Slow Leak

sequence of events No Preshift Inspection

Problem Solving
Fault Tree
PIT Hits Wall

Failure To Stop

Equipment Procedural Human

Other Accident Investigation Tools Brakes Fail Training Req'd Did not Conduct Inspection

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

42
 ISHIKAWA “FISHBONE”
DIAGRAM
Machinery Methods
ACCIDENT
ANALYSIS AND
EFFECT REPORT
Materials People Environment
(Handout)

FIVE WHYs DIAGRAM

Undesired Event
Why?
Direct Cause
Why?
Contributing Cause TEST
Why?
Contributing Cause
Why?
Contributing Cause
Why?
Root Cause

43