tajuk 5 _jabatan keselamatan dan kesihatan pekerjaan( prosedur penyiasatan di tempat kerja)
TRANSCRIPT
ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION
OSHA 1994 - Regulation -SHC Section 13(1)Section 13(1)
A safety and health committee shall inspect theA safety and health committee shall inspect the place of work, as soon as it is safe to do so, after any accident, dangerous occurrence, occupational
i i i l di h dpoisoning or occupational disease has occurred at the place of work
ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION
POLICYObjective of incident investigation should notObjective of incident investigation should not
be to apportion blame or fault finding but to determine the cause(s) in order to prevent recurrence of accident
All i id t t b t d d dAll incidents must be report, recorded and investigated by competent
ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION
POLICYAll staff must give their full cooperation andAll staff must give their full cooperation and
assistance when requested, to the investigation team
All recommendations arising from incident i ti ti t b di d d dinvestigation must be discussed, agreed and executed by the relevant action parties
ACCIDENT INVESTIGATIONACCIDENT INVESTIGATIONDefinition
Incidentan unplanned event or chain of event, which has or could
h d i j ill l d/ d (l )have caused injury or illness to people and/or damage (loss) to assets, the enviroment e.g near miss, accident, fire
Accident an event which resulted injuries or illness to people and/or
damage (loss) to assets and the enviroments
Near missan event which did not result in injuries or illness to people j p p
and/or damage (loss) to assets and the enviroment
ACCIDENT INVESTIGATIONACCIDENT INVESTIGATIONACCIDENT - THE CONSEQUENCES
Immediate• Death
Short Term• Medical
T
Long Term•Suffering
• Injury• Pain
Di
Treatment• Repairs• Replacement
•Disability•Lost Income
• Disease• Damage• Loss
• Replacement• Lost
Production
•Insurance•Compensation
iLoss• Fear • Increased
CostDi i li
•Mistrust•Profitability
• Discipline• Low Morale
ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION
Safety IcebergSafety Iceberg
1 Fatality1
100
y
Lost Time InjuriesMi I j i /P t
1,000
10 000
Minor Injuries/Property damage
N Mi10,000
100,000
Near Misses
Unsafe Acts / Conditions,
ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION
INCIDENT INVESTIGATIONPurpose
Law (OSHA 1994) and Company requirementsPrevent recurrenceEssential element in Safety & Health ManagementContribute to good morale and overall safety
awarenessawarenessGeared towards continuous OSH improvement thus
increased productivity and improved work enviroment
ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION
AIMTo find the root cause and to prevent recurrenceTo find the root cause and to prevent recurrence
Not to apportion or assign blame, satisfyNot to apportion or assign blame, satisfy insurance claims or defend against liabilities
ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION
TYPES OF INCIDENTS
Injurious accident
Non-injurious incident with asset damage
Occupational illness or disease
Near missNear miss
ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION
INVESTIGATION PARTIESMinor accidentMinor accident
Relevant individual staff and/or line supervisor
Major accidentTeam comparising mixed discpline and expertise including safety personel and led by line manager
ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION
INVESTIGATION PARTIES
Be objective and be impartial
Gather the facts and information
Isolate the contributor factors
Determine corrective actions and action partiesDetermine corrective actions and action parties
Implement corrective actions with target dates
ACCIDENT INVESTIGATIONACCIDENT INVESTIGATIONMETHODOLOGY
Gather safety rules/procedures of the site and information on plant, machinery or facilitiesp , y
Isolate the scene of accident and do not disturb evidence
Take photos, sketch, diagrams of the accident site/facilities
Interview witnesses, affected or involed parties and obtain facts but not opinions or assumptions
Isolate key contributory factors
ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION
OUTCOMES OF THE INCIDENT
Negative results like death, injuries, production
loss, property damage
Positive results like rehabilitation, change in
safety procedures, improvement in processessafety procedures, improvement in processes
ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION
CONTRIBUTORY FACTORS
Environment e.g. noise, heat, light, fumes, bad weather
Design e.g. worksite layout, tools/equipment
Systems and procedures e.g. not present or inapproprite
H b h i f t h tHuman behaviour e.g unsafes acts, purchase wrong type
of equipment
ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION
CAUSES OF INCIDENTS
Immediate e.g. Unsafe act, using unsafe tools/equipment,
incorrect procedures, poor housekeeping, unsafe
condition
Uderlying e.g. Poor training, poor maintenance, lowUderlying e.g. Poor training, poor maintenance, low
safety morale, lack of enforcement of safety rules
ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION
INVESTIGATION INTERVIEWINVESTIGATION INTERVIEW TECHNIQUES
InprivateInprivate
Put them at ease
S bj i f id iState objective for accident prevention
Blame - free environment
Establish facts only
No leading question
Give appreciation
ACCIDENT INVESTIGATION
1. Event leading to the accident
• System of work• Work instruction
2. Facts of the Incident itself
• State of system• Parties involed
3. Relevant facts of what happened immediately after the incident
• Direct resultant injuries • Variations from safe
practice/instruction• Workplace condition• Environment condition
• Material/Equipment/Tool/fixtures in direct involement
jto people damage to assets or environment
• Event leading to ti l i j i
• Exact location of incident• Material/Equipment/Tool
used or handled
consequential injuries or assets/environment damage
• Parties involed including emergency respons or recovery
• Effectiveness of emergency respons or recovery
CHECKLIST TO ESTABLISHCHECKLIST TO ESTABLISH FACTS OF INCIDENTWHO
• was injured• saw incident
WHAT• is the injury• is the damaged or loss
• working with injured• assigned job to injured• else was involved• has information leading to the incident
• is the injured doing• had the injured been instruced to do• tools were being used• machine/plant/equipment was in use• has information leading to the incident • machine/plant/equipment was in use• previous similar accident or near misses
and whether action had been taken to prevent recurrencedid th i j d d it• did the injured and witnesses see
• safety rules were violated• safe system of work, permit/procedures• were the contributory causes of the
accident• communication system was in use
CHECKLIST TO ESTABLISHCHECKLIST TO ESTABLISH FACTS OF INCIDENT
WHERE
• did accident occur
HOW
• did the injury occur• did the damage occur• was the supervisor at that time• were the witnesses at that time
• was the medical response• could the accident been avoided• could better design help• could the supervisor have prevented the• could the supervisor have prevented the
accident
CHECKLIST TO ESTABLISH FACTS OF INCIDENTFACTS OF INCIDENT
WHEN• did the accident occur
WHY• did the injury occur• did the accident occur
• did the comunication fail• did the injured start the job• was hazards explained
• did the injury occur • did communication fail• was training not given• were the unsafe condition permitted
• did the supervisor last see the injured• as something observed to be wrong
• were the hazard not evaluated• was PPE not given or not worn• was there no safe system of work,
permitted or proceduresp p• were specific instructions not given• was there no safety inspection or audit• was the level of safety awareness and
commitment lowcommitment low• was there no safety program• was the injured there• was supervisor not notified when things
went wrong• was the supervisor not there at the time
ACCIDENT INVESTIGATIONACCIDENT INVESTIGATIONACCIDENT CAUSATION
Over 90% of all accident are caused by the action or inaction’s of people which are unsafe acts or unsafe conditionsR i tt f id tRecognise patterns of accident
people - any particular group or individualbehaviour - poor safety attitudetime- particular time, day, start/end week, shiftplace - particular place, type of place, indoor/outdooractivity - during a particular task, type of task, boring job, high y g p , yp , g j , gspeed, during difficult or complex tasksystem or procedures - any particular operations, system or procedurespequipment - specific type, old or new
ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION
1. Unsafe Actsfailure to wear PPE
i f l hiwearing unsafe clothinghorseplayimproper use of hands and other parts of the bodyimproper use of hands and other parts of the bodybypassing safety devicesunsafe position or posturep pdriving errorsunsafe operation acts
ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION
2. Unsafe Conditionsdefective tools and equipmentd f i d idefective designunsafe clothing or PPEunsafe workplaceunsafe workplaceinadequate layout and storageunsafe guardingg gpublic hazards
BENEFIT OF ACCIDENT INVESTIGATION
Prevent recurrenceIdentify out-moded operartion methodsI d k iImproved work environmentIncreased productivity due to upgrading of process systemsystemRaising of safety awareness and moraleLower medical costs due to fewer accidentsAvoid lawsuits or liabilities due to accidentsGreater efficiency due to no work stoppages
ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION
ACCIDENT REPORTING FORM(refer to handout)
DOSH - Accident Reporting Form
Company - Accident Reporting Form
Witness Interview FormWitness Interview Form
ACCIDENT INVESTIGATIONACCIDENT INVESTIGATION
PRINCIPLES OF ACCIDENT PREVENTION
The identification of hazards, risk assessment and risk
control
OSH promotion and communication to influence
behaviour and encourage safe attitudesbehaviour and encourage safe attitudes