accident+investigation+week2

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2. Accident Investigation and Analysis

• Proper procedures, Types of accidents and

Analysis, Investigation Process, Identification and Classification of Important factors, Sensory Illusion, Hazard analysis techniques and Methods of accident cost estimation.

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Questions…Questions…

• Identify the potential hazards in the workplace.

• What is the difference between Safety and Health?

• What is the difference between hazards and risks?

• What are the costs of accidents?

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Table 1: Employment Patterns in MalaysiaTable 1: Employment Patterns in Malaysia

Type of Sector Person (‘000) Labor Force%)

Manufacturing 1907.8 22.2

Community

social and personal

service 1787.5 20.7

Wholesale, retail trade,

hotel & restaurant 1616.0 18.8

Agricultural, forestry

& fishing 1616.5 18.8

Other sectors 925.9 10.8

Construction 745.9 8.7

Total 8599.6 100

Source: Department of Statistics, Malaysia, 2001.

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WHAT ARE THE POTENTIAL HAZARDS IN WHAT ARE THE POTENTIAL HAZARDS IN THE WORKPLACETHE WORKPLACE1. Slips, trips and falls 2. Asbestos • It is often found in roofs and exterior walls, boilers, vessels and pipework, ceilings,

interior walls and panels, flooring materials, air handling systems, domestic appliances, brake/clutch linings, fire blankets, etc

3. Hazardous substances• These can include chemicals that people make or work with directly, and also dust, fume

and bacteria which can be present in the workplace. Exposure can happen by breathing them in, contact with the skin, plashing them into the eyes or swallowing them. If exposure is not prevented or properly controlled, it can cause serious illness, including cancer, asthma and dermatitis, and sometimes even death.

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4. Working at height 5. Musculoskeletal disorders 6. Using computers or other display screen equipment7. Noise 8. Vibration9. Electricity 10.Work Equipment and Machinery11. Maintenance and building work 12.What are the risks from transport in your workplace

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13. Pressure systems 14. Fire and explosion15. Radiation16. Stress

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OCCUPATIONAL SAFETY ANDOCCUPATIONAL SAFETY AND HEALTH HEALTH

part 2

Accident Investigation and Analysis

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Definition of accidentDefinition of accident

• Any unplanned event that causes injury, illness, property damage or harmful disruption of work

process.

Dan Hartshorn

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Why is the accident investigation important?Why is the accident investigation important?

• When an accident occurs, it is important that it be investigated thoroughly, the results of a

comprehensive accident report can help safety and health professionals pinpoint the cause of the

accident.

This information can be used to prevent future accidents, which is the primary purpose of accident

investigation.

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What is the reason for investigating anWhat is the reason for investigating an accident? accident?

• The primary reason for investigating an accident is not to identify a scapegoat, but to determine the

cause of the accident.

• The investigation concentrates on gathering factual information about the details that led to the accident.

• If investigations are conducted properly, there is the added benefit of uncovering problems that did not

directly lead to the accident.

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Reasons for investigating an accidentReasons for investigating an accident

• This information benefits the ongoing effort of reducing the likelihood of accident.

• As problems are revealed during the investigation, action items and improvements that can prevent

similar accidents from happening in the future will be easier to identify than at any time.

(Society of Manufacturing Engineers)

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Types of accident investigationsTypes of accident investigations

There are two types of accident

investigation:

• Accident report

• Accident analysis report

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An accident report is completed when..An accident report is completed when..

When the accident in question represents only a minor incident, It answers the following questions:

Who, what , where, when and how, but it does not answer the why question.

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Who writes the accident report?Who writes the accident report?

• An accident report can be completed by a person with very little formal investigation and reporting training or experience.

• Supervisors often complete accident report which, in turn, might be used later as part one of a more in-

depth accident report.

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When is an accident analysis report completed?When is an accident analysis report completed?

• When the accident in question is serious, The level of report should answer the same questions as the

regular accident report plus one more-”why”.

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Reasons for the analysisReasons for the analysis

The analysis is undertaken for the purpose of determining the root cause of the accident. Accident analysis requires special skills and should be undertaken only by an individual with those skills.

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Reasons for the analysis…Reasons for the analysis…

1. The accident analysis must identify the actual root cause or the company will spend resources treating only

symptoms or even worse, solving the wrong problem.

2. Serious accidents are always accompanied by the potential for litigation. If there might be legal action as a

result of an accident, it is important to have a professional conduct the investigation even if it means

bringing in an outside consultant.

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An accident report is required when..An accident report is required when..

The accident is a minor incident that did notresult in :

1. Death,2. Loss of consciousness,

3. Professional medical treatment beyond first aid,4. More than one additional day of lost work beyond

the day of the accident, 5. Any kind of modifications to the employee's work

duties beyond those that might occur on the day of the accident.

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What is the First action after an What is the First action after an accident?accident?

• The first thing to do when an accident takes place is to implement emergency procedures. This involves

bringing the situation under control and caring for the injured worker.

• As soon as all emergency procedure have been accomplished, the accident investigation should

begin. Waiting too long to complete an investigation can harm the result.

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Why is it important to conduct investigations Why is it important to conduct investigations immediately?immediately?

• First, immediate investigations are more likely to produce accurate information.

• Second, it is important to collect information before the accident scene is changed and before witnesses begin comparing notes.

• Human nature encourages people to change their stories to agree with those of other

witnesses.

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The purpose of investigationThe purpose of investigation

• The purpose of an accident investigation is to collect facts.

• It is not to find fault. It is important that safety and health professionals make this distinction known to all

involved. Fault finding can cause reticence among witnesses who have valuable information to share.

Causes of the accident should be the primary focus.

• The investigation should be guided by the words of who, what, when, where, why and how.

The purpose of investigationThe purpose of investigationQuestions to ask when interviewing witnesses

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Questions to help the investigator Questions to help the investigator

1. What type of work was/were the injured person(s ) doing?

2. Exactly what was the injured persons doing or trying to do at time of the accident?

3. Was the injured person proficient in the task being performed at the time of the accident?

4. Was the injured person authorized to use the equipment or perform the process involved in the accident?

5. Were there other workers present at the time of the accident?

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Questions….Questions….

6. Was the task in question performed according to approved procedures?

7. Was proper equipment being used, including personal protective equipment?

8. Was the injured employee new to the job?

9. Was the process, equipment, or system involved new?

10. Was the injured person being supervised at the time of the accident?

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Questions.. Questions.. 11. Are there any established safety rules or procedures

that were clearly not being followed?

12. Where did the accident take place?

13. What was the condition of the accident site at the time on the accident?

14. Has a similar accident occurred before? If so, were corrective measures recommended? Were they implemented?

15. Are there obvious solutions that would have prevented the accident?

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Who should conduct the accident investigation?Who should conduct the accident investigation?

• Responsible supervisor?• The safety and health professional?• A higher-level manager?• An outside specialist?• Investigative team?

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What are the reasons for various approaches?What are the reasons for various approaches?

Factors considered: • Size of the company• Structure of the company’s safety and health program• Type of accident • Seriousness of the accident• Technical complexity • Number of times that similar accidents have occurred • Company’s management philosophy

• Company’s commitment to safety and health

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The steps of investigationThe steps of investigation

• Isolate the accident scene

• Record all evidence

• Photograph or videotape the scene

• Identify witnesses

• Interview witnesses

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OCCUPATIONAL SAFETY AND HEALTHOCCUPATIONAL SAFETY AND HEALTH

Cause & Effect diagram (group discussion)

Why do accidents Happen?

Man

Machine

Material Management

Method Environment

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Group discussionGroup discussion

Design a form to record work related injuries so that all relevant information is captured and further action and preventive measures can be taken

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1. Isolate Accident scene1. Isolate Accident scene

Maintain as closely as possible the conditions that existed at the time of the accident.

• Block off the entire area by barriers or heavy yellow tape.

• Keep curious on lookers from removing, disturbing, or unknowingly an destroying vital evidence.

• Remove the injured worker as soon as emergency procedures are being completed.

• Keep the scene until all pertinent evidence has been collected or observed and recorded.

• Put a security guard in the accident scene, if necessary.

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2. Recording the evidence2. Recording the evidence

Make a permanent record of all pertinent evidence:• Certain types of evidence may be perishable.

• The longer it must be isolated, the more likely the evidence will be disturbed, knowingly or unknowingly.

• A critical piece of equipment on a critical component

in a larger process, pressure to get it back in operation.

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To record the evidenceTo record the evidence

Evidence can be recorded by:

• Written notes• Sketches • Photography • Videotape• Dictated observations• Diagrams

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3. Photograph or videotape scene3. Photograph or videotape scene

• Safety and health professional should be proficient the operation of a camera.

• Camera should be on hand, loaded, and ready to use.

• Place a ruler or coin next to the object when making a close up photograph to help

demonstrate the object’s size or perspective.

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4. Identify witnesses4. Identify witnesses

Compile a witness list.- List in three categories :

i. Primary witnesses are eye witnesses to the accident.

ii. Secondary witnesses - did not actually see the accident happen, but were in the vicinity and arrived on the scene very shortly after the accident.

iii. Tertiary witnesses are witnesses who were not present at the time of the accident nor afterward but may still have relevant evidence to present

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How to interview witnessHow to interview witness

• Interview All witnesses

• Primary witnesses, followed by secondary and last tertiary .

• Techniques used should lead to objective, accurate and untainted information.

• Begin as soon as possible after compiling the list

• Best place to interview is at the accident scene, otherwise, elsewhere.

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Interview witnessInterview witness

• Removed all distractions, no interruptions and the witness is alone.

• All persons interviewed should be allowed to relate their

recollection without fear of contradiction by other witnesses.

• Select a neutral location in which witnesses will feel comfortable.

• Avoid the principal's office syndrome, by selecting a location that is not likely to be intimidation to witnesses

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Important actions on interview witnessImportant actions on interview witness

• Put the witness at ease and listen.

• Listen to what is said, how it is said, and what is not said.

• Ask question with open-ended format.

• Do not ask “ did you see the victim pull the red level?” ask tell me what you saw?

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Reporting accidents Reporting accidents

• An accident investigation should culminate in a comprehensive accident report.

• The purpose of the report is to record the findings of the accident investigation, the cause or causes of the accident, and recommendations for corrective action.

• If an accident results in the death of an employee or hospitalization of five or more employees, a report

must be submitted to the nearest OSHA office within 48 hours. This rule applies regardless of the size of

the company.

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Reporting accidentsReporting accidents

• Accident report forms vary from company to company. However, the information contained in them is fairly

standard.• Regardless of the type of form used, an accident

report should contain at least the information needed to meet the record-keeping requirements set forth by

OSHA.• According to the National Safety Council this

information includes at least the following:• Case number of the accident

• Victim’s department or unit

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• Location and date of the accident or date that an illness was first diagnosed.

• Victim’s name, social security number, gender, age, home address, and telephone number

• Victim’s normal job assignment and length of employment with the company

• Victim’s employment status at the time of the accident ( temporary, permanent, full-time, part-time)

• Case numbers and names of others injured in the accident

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• Type of injury and body part (s) injured (e.g., burn to right hand; broken bone, lower right leg) and severity

of injury (i.e., fatal, first aid only required, hospitalization required)

• Name, address, and telephone number of the physician called

• Name, address, and telephone number of the hospital to which the victim was taken

• Phase of the victim’s work day when the accident occurred (e.g., beginning of shift, during break, end of

shift, and so on) • Description of the accident and how it took place, including step be step sequence of event leading up

to the accident

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• Specific tasks and activities with which the victim was involved at the time of the accident

• Employee’s posture or proximity related to his or her surroundings at the time of the accident (standing on a

ladder,…)• Supervision status at the time of the accident

(unsupervised, directly supervised, indirectly supervised)

• Causes of the accident• Corrective actions that have been taken so far• Recommendations for additional corrective action

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Ten accident investigation mistakesTen accident investigation mistakes

1. Failing to investigate near misses.

A near miss is simply an accident that did not happen because of luck.

Investigating near misses can reveal critical accident prevention information.

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2.Taking ineffective corrective action.

Ineffective corrective action is often the result of a cursory accident investigation.

Should look for the root cause, not the symptoms.

Corrective action based on symptoms will not prevent future accidents.

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3.Allowing your biases to color the results of the investigation.

Look for facts and be objective when investigating

an accident. Do not make assumptions or jump to conclusions.

Eliminate bias in accident investigations - use a standard, structured routine and to skip no steps in

the routine.

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4. Failing to investigate in a timely manner. - investigations should begin as soon as possible after

the accident.

- evidence will be lost, corrupted, or compromised.

- influenced by the opinions of their fellow workers and witnesses.

People walking through an accident scene can compromise the integrity of the scene by unwittingly

destroying evidence.

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5. Failing to account for human nature when conducting interviews.

Those involved in an accident as well as witnesses to an accident will say during an interview will be shaped by their desire to escape blame, deflect blame to someone else, or

protect a friend.

It is important to interview witnesses and others involved privately

and individually, and to look for corroborating evidence to support (or refute) their input.

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6. Failing to learn investigation techniques.

Safety and health professionals should complete specialized training or undertake self-study to learn

investigation techniques.

An unskilled investigator is not likely to conduct a valid investigation.

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7. Allowing politics to enter into an investigation.

The goal of an investigation is and must be to identify the root cause so that appropriate corrective action

can be taken.

Personal likes, dislikes, favoritism, and office politics will corrupt an investigation from the outset.

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8. Failing to conduct an in-depth investigation.

- in a hurry - pressure from higher management to “get this thing behind us.”

- can lead to a rushed investigation

- the goal is to get it over with, - not to find the root cause of the accident.

Surface-level investigations almost ensure that the same type of

accident will happen again.

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9. Allowing conflicting goals to enter into an investigation.

The ultimate goal of an accident investigation is to prevent future accidents and injuries.

Some may see the investigation as: - an opportunity to deflect blame,

- others may see it as an opportunity to protect the organization from litigation,

- to explain not meeting production quotas or performance standards.

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10. Failing to account for the effects of uncooperative people.

- People will not always cooperate for a variety of reasons, all growing out of the concept of received

self-interest.

Safety and health professionals need to understand that self-interest is one of the most powerful

motivators of human beings and factor this into their planning for accident investigations.

Figure 2.3Figure 2.3 OSHA Form 300: Log of Work-Related Injuries and Illnesses. (This form is available in larger format on the OSHA Form 300: Log of Work-Related Injuries and Illnesses. (This form is available in larger format on the Companion Website.)Companion Website.)

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Safety and Health EconomicsSafety and Health Economics

• Need to formulate prevention of employee injuries and illnesses into economic objectives not merely humanitarian aspirations

• Prevention of employee injuries and illnesses can be formulated as an economic objective : more meaningful to management than mere humanitarian aspirations

• Accidents, injuries and illnesses have undeniable costs that contribute nothing to the value of products manufactured by the firm or services performed

• Annual cost of injuries and illnesses in many industries dwarfs the total profit picture but many of these costs are subtle and difficult to estimate.

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Case studyCase study

A metal products fabrication and assembly plant employs 250 workers and has the following injury-illness experience for the year (workers are employed on a regular 40-hr-workweek basis)

• File 1 January 31: Press-blanking operator lacerates hand on strip stock scrap from punch press; first aid received no medical treatment ;worker remains on the job

• File 2 February 19:Maintenance worker, not wearing eye protection, operating grinding machine in tool room, incurs eye injury from flying chip; medical treatment required; injury occurs on Tuesday , employee returns to regular job at regular time on Thursday

• File 3 February 27: Assembly worker becomes “ill” owing to noxious odour from remodelling operation in the assembly area; receive permission from supervisor to take the rest of the day off; does not go to a doctor or clinic; reports to regular work on time the next day

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• File 4 March 2: Sewing machine operator’s right finger pulled into unguarded drive belt pulley on sewing machine; small fractured revealed by X ray; splint applied; worker returns to regular work at regular time the next day.

• File 5 March 19: Dockworker sprains ankle on loading dock; moved to office job for two workweeks.

• File 6 May 2: Maintenance worker entangles finger in rope as winch is released; taken to clinic for X ray; no fractures found; no treatment; worker returns to regular work the next day.

• File 7 June 7: Yard worker exposed to poison ivy while clearing weeds in tank farm area behind plant; rash develops; treated with prednisone adrenocortical steroid drug precribed; no time lost

• File 6 July 6: Assembly worker loses two workdays recuperating from severe allergic reaction to wasp stings incurred while cleaning his attic at home; medical treatment with prescription drugs

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• File 9 August 4: Maintenance worker ungrounded portable electric drill to repair equipment in assembly area is electrocuted. Date of death: August 4

• File 10 August 7: Loaded pallet in loading dock area falls from forklift on dock worker’s left foot; worker was not wearing steel-toed shoes; worker examined on hospital emergency room and X ray revealed no fractures or other injuries; worker receives whirlpool therapy and goes home; worker reports back to his regular job on time next day and wears his company-issued safety shoes.

• File 11 August 9: Maintenance worker in the tool room incurs injury from foerign object in the eye; irrigation method to remove foreign object, which was not embedded in the eye; worker returns to regular job.

• File 12 September 11; Worker in final assembly diagnosed with carpal tunnel syndrome from repetitive work; surgery prescribed; worker misses 3 weeks of work before returning to regular job with engineering improvements to the worlstation.

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Classification of cost of accidentClassification of cost of accident

• Insured costs

• Uninsured costs

Insured costs of accidents is a simple matter of examining accounting records.

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• Which are the uninsured cost?

• Class 1: Lost workdays, permanent partial disabilities and temporary total disabilities.

• Class 2: Treatment by a physician outside the company’s facility.

• Class 3: Locally provided first aid, property damage of less than $100 or the loss of fewer than eight hours of work time.

• Class 4: Injuries that are so minor they do not require the attention of a physician, result in property damage of $100 or more, or cause eight or more work hours to be lost.

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• Average uninsured costs for each class of accident can be determined by pulling the

records of all accidents that occurred during a specified period and sorting the

records according to class.

• Some accident costs that might be overlooked:

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Other cost estimation MethodsOther cost estimation Methods

• Lost work hours• Medical costs• Insurance premiums and administration• Property damage • Fire losses• Indirect costs


Checklist forChecklist for

Estimating the hidden costs of accidentEstimating the hidden costs of accident

paid time to the injured employee on the day of the accident.paid time to the injured employee on the day of the accident. Paid time of any emergency-responder personnel involved Paid time of any emergency-responder personnel involved

(including ambulance driver).(including ambulance driver). Paid time of all employees who were interviewed as part of Paid time of all employees who were interviewed as part of

the accident investigation.the accident investigation. Paid time of the safety personnel who conducted the Paid time of the safety personnel who conducted the

accident investigation.accident investigation. Paid time of the supervisor involved in the accidentPaid time of the supervisor involved in the accident

investigation and accident response.investigation and accident response.

Paid time to employees near the accident working.Paid time to employees near the accident working. Paid time to employees who spent time talking about the Paid time to employees who spent time talking about the

accident as news of it spread through the co’s grapevine.accident as news of it spread through the co’s grapevine.

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High cost of PainHigh cost of Pain

When employees are in pain, they respond by

taking sick leave from work. Sick leave due to unspecified pain costs employers more

than $3 billion in lost workdays.

• Approximately 17 million employees in the USA take an average of three days of sick

leave per year to deal with unspecified pain (e.g., headaches, neck pain, back pain, and

menstrual pain).

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Hidden costsHidden costs

1. Cost of wages paid for time lost by workers who were not injured

2. Cost of damage to material or equipment3. Cost of wages paid for time lost by the

injured worker4. Extra cost of overtime work necessitated by

the accident 5. Cost of wages paid supervisors for time

required for activities necessitated by the accident

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Cont..Cont..

6. Wage cost by decreased output of injured worker and return to work

7. Cost of learning period of new worker8. Uninsured medical cost borne by the company9. Cost of time spent by higher supervision and clerical

workers on investigation or in the processing of compensation application forms

10.Miscellaneous usual cost – public liability claim cost, cost of renting equipment, loss of profit on contracts canceled or order losses..

Figure 2.8Figure 2.8 Direct costs of accidents (workers’ compensation premiums and medical insurance) represent only the “tip Direct costs of accidents (workers’ compensation premiums and medical insurance) represent only the “tip of the iceberg.”of the iceberg.”

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Recordkeeping

- important

- to observe trends

1.Traditional indexes – statistical measures used :• frequency – measures the number of cases per

standard quantity of workhours• severity – measures the total impact of these cases

in terms of ‘lost workdays’ per standard quantity hours

• seriousness – ratio of severity to frequency

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2.Incidence rates2.Incidence rates

total injury – illness incident rate =

# of injuries and illnesses including fatalities X 200,000

total hours worked by all employees during the period covered

200,000 is based on the number of hours a full-time worker typically work is ~ 50 weeks per year at 40 hours per week (40 x 50 = 2000) x 100 workers = 200000 hrs/yr

• The total injury-illness rate represents the number of injuries by a 100- employee firm in a full year

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The total injury-illness incidence rate includes :The total injury-illness incidence rate includes :

i. Injury incidence rate

ii. Illness incidence rate

iii.Fatality incidence rate

iv.Lost-workday-cases incidence rate (LWDI)

v. Number –of-lost-workdays rate

vi.Specific-hazard incidence rate

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LWDILWDI

• Lost Workday-cases incidence rate (LWDI),

– does not include the date of injury or the onset of illness, use

calendar days not workdays

- LWDI – most recognized, consider only injury not illnesses and fatalities

- one or more work days lost or days in which the worker is

transferred to another job

- consider only injuries

- based on clear evidence-more precise and robust measure of firms

overall effectiveness of s & H programs

- only consider lost-time injuries-where restricted work activity

cases are considered as lost-time cases

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RECORDKEEPING FORMSRECORDKEEPING FORMS

Standardized formats to keep records of injury and illness a. Log of work-Related Injuries and illnesses- Basic Form OSHAs

Form 300b. Summary of Work-Related Injuries and illnesses OSHAs Form

300A - to be displayed and posted in a prominent place so that employees can see what injuries and illnesses have been recorded for the year - employer’s responsibility to enter data correctly into the log and summary - General records are required to be saved for a period of 5 years - person completing the form must be able to distinguish between occupational injuries and illnesses.

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• Occupational injuries : lacerations, fractures, Occupational injuries : lacerations, fractures, sprains, and amputations that are the result of a sprains, and amputations that are the result of a work accident or an exposure involving a single work accident or an exposure involving a single incident in the work environment (including animal incident in the work environment (including animal bites, chemical exposure) bites, chemical exposure)

• Illnesses : any abnormal condition or disorder not classified as an injury and caused by exposure to environmental factors associated with employment

c. Injury and Illness Report (OSHAs Form 301)- Each page of the report corresponds to a single –line entry in the log

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Case Study :Case Study :

• A worker was struck in the head and killed by the sudden movement of a large wrench used or releasing gates on the bottom of railroad hopper cars. The worker used a powerful, 3-to-4-foot long wrench to trip a mechanical latch on the bottom gate of the car. The wrench was supposed to be of a ratchet type, so that when the gate was tripped, the tremendous weight of the bulk of material in the hopper car would not suddenly force the wrench back on the worker. But for some reason the ratchet wrench was not available, and workers had been using an ordinary rigid wrench to release the latch. Only a week before the fatality occurred, another worker had narrowly escaped the same injury when he lost control of the same wrench in the same operation.

• How would you go about investigating the accident? What is the root cause?

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Class exercise 2.28Class exercise 2.28

Top management has set a safety and health objective for the year for a plant employing 135 employees. The objective is to reduce LWDI of the firm to a level lower than the national average: 3.6. By May 1, the safety and health manager has logged 12 first aid cases, 3 lost time injuries, and 2 illnesses, both of which resulted in hospitalization. Based on these preliminary results, does it appear that the firm will meet top management’s objective for the year? Show calculations to justify your conclusion.

Figure 2.9Figure 2.9 OSHA Form 300 for Exercises 2.30 and 2.33. (This form is available in larger format on the Companion OSHA Form 300 for Exercises 2.30 and 2.33. (This form is available in larger format on the Companion Website.)Website.)

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Class exercise 2.30Class exercise 2.30

On February 1, a 50-employee firm posts its annual OSHA log as shown in figure 2.9. Complete the table and calculate the following:

1. Total injury incidence rate

2. Total illness incidence rate

3. Number-of-lost-workdays rates

4. LWDI

accident+investigation+week2

Documents

accident investigation

accident site

isolate accident scene

pertinent evidence

injured persons

injured worker

injured person proficient

companys safety