ACCIDENT PREVENTION

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Photo Tulalip Bay by Diane L. Wilson-Simon
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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)

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Introduction Course Overview
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PROaction versus REaction

• Well thats an accident waiting to happen
• Someone ought to do something
• That someone is YOU!

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What Is An Accident?
"9 1 1"
"EVACUATE"
CRASH
F I R E
! _at_ !
Call an Ambulance
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What Is An Accident?
"That Was Close"
"Just Missed !"
"Whhoooaaa!"
! _at_ !
Near Miss
"Watch Out"
Almost Hit
L U C K Y
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An Accident is

• a. An unexpected and undesirable event,
  especially one resulting in damage or harm car
  accidents on icy roads.
• b. An unforeseen incident A series of happy
  accidents led to his promotion.
• c. An instance of involuntary urination or
  defecation in one's clothing.
• 2. Lack of intention chance ran into an old
  friend by accident.
• 3. Logic A circumstance or attribute that is not
  essential to the nature of something.
• http//www.thefreedictionary.com/accident

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Hazard

• Existing or Potential Condition That Alone or
  Interacting With Other Factors Can Cause Harm
• A Spill on the Floor
• Broken Equipment

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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
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Safety

• FREEDOM FROM DANGER OR HARM

Nothing is Free of

• BUT - We can almost always make something SAFER

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Safety Is Better Defined As.

• A Judgement of the
• Acceptability of Risk

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RATIOS
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OSHA METHOD330 Incidents29 Minor Injuries1
Major or Loss-Time Accident
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Candy Jar Example
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Types of Accidents

• FALL TO
• same level
• lower level
• CAUGHT
• in
• on
• between

• CONTACT WITH
• chemicals
• electricity
• heat/cold
• radiation
• BODILY REACTION FROM
• voluntary motion
• involuntary motion

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Types of Accidents (continued)

• STRUCK
• Against
• stationary or moving object
• protruding object
• sharp or jagged edge
• By
• moving or flying object
• falling object

• RUBBED OR ABRADED BY
• friction
• pressure
• vibration

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Fatal Accidents - Workplace

• U.S. WORKPLACE FATALITIES - 2006
• 1. Vehicle Accidents 2413
• 2. Contact With Objects and Equipment 983
• 3. Falls 809
• 4. Assaults Violent Acts 754

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Fatal Accidents - Workplace

• Washington State FATALITIES - 2006
• 1. Vehicle Accidents 40
• 2. Contact With Objects and Equipment 13
• 3. Falls 19
• 4. Assaults Violent Acts 4
• NO NOTE If you wish to normalize or compare the
  Washington data with the Federal data, just
  multiply the Washington numbers by 47 (based on
  population)

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Accident Causing Factors

• Basic Causes
• Management
• Environmental
• Equipment
• Human Behavior
• Indirect Causes
• Unsafe Acts
• Unsafe Conditions

• Direct Causes
• Slips, Trips, Falls
• Caught In
• Run Over
• Chemical Exposure

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Policy Procedures Environmental Conditions
Equipment/Plant Design Human Behavior
Basic Causes
Unsafe Conditions
Indirect Causes
Unsafe Acts
Slip/Trip Fall Energy Release Pinched Between
Direct Causes
ACCIDENT Personal Injury Property
Damage Potential/Actual
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Basic Causes

• Management
• Environment
• Equipment
• Human Behavior

• Systems Procedures
• Natural Man-made
• Design Equipment

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Management

• Systems Procedures
• Lack of systems procedures
• Availability
• Lack of Supervision

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Environment

• Physical
• Lighting
• Temperature
• Chemical
• vapors
• smoke

• Biological
• Bacteria
• Reptiles

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Environment
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Design and Equipment

• Design
• Workplace layout
• Design of tools
• equipment
• Maintenance

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Design and Equipment

• Equipment
• Suitability
• Stability
• Guarding
• Ergonomic
• Accessibility

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Human Behavior

• Common to
• all accidents

Not limited to person involved in accident
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Human Factors

• Omissions Commissions
• Deviations from SOP
• Lacking Authority
• Short Cuts
• Remove guards

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Human Behavior is a function of
Activators (what needs to be done)
Competencies (how it needs to be done)
Consequences (what happens if it is/isnt done)
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ABC Model

• Antecedents
• (trigger behavior)
• Behavior
• (human performance)
• Consequences
• (either reinforce or punish behavior)

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Only 4 Types of Consequences

• Positive Reinforcement (R)
• ("Do this you'll be rewarded")
• Negative Reinforcement (R-)
• ("Do this or else you'll be penalized")

Behavior

• Punishment (P)
• ("If you do this, you'll be penalized")
• Extinction (E)
• ("Ignore it and it'll go away")

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Consequences Influence Behaviors Based Upon
Individual Perceptions of

positive or negative
Magnitude

• Significance

Impact

• Timing - immediate or future
• Consistency - certain or uncertain

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Human Behavior

• Behaviors that have consequences that are
• Soon
• Certain
• Positive
• Have a stronger effect on peoples behavior

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Some examples of Consequences
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Why is one sign often ignored, the other one
often followed?
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Human Behavior

• Soon
• A consequence that follows soon after a behavior
  has a stronger influence than consequences that
  occur later
• Silence is considered to be consent
• Failure to correct unsafe behavior influences
  employees to continue the behavior

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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

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Human Behavior

• Positive
• A positive consequence influences behavior more
  powerfully than a negative consequence
• Penalties and Punishment dont 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)

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Deviations from SOP

• No Safe Procedure
• Employee Didnt know Safe Procedure
• Employee knew, did not follow Safe Procedure
• Procedure encouraged risk-taking
• Employee changed approved procedure

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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?

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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

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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

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Human Behavior

• Some experts believe you can change workers
  safety behavior by changing their Attitude
• Accident Report Safety Attitude
• A persons 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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Are inside a persons head -therefore they are
not observable nor measurableAttitudes can be
changed by changing behaviors
Attitudes
however
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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 cant scare workers into a safety focus with
  Pay Attention campaigns

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Reasons for Lack of Attention

• 1. Technology encourages short attention spans
  (TV remote, Computer Mouse)
• 2. Increased Job Stress caused by uncertainty
  (mergers downsizing)
• 3. Lean staffing and increased workloads require
  quick attention shifts between tasks
• 4. Fast pace of work little time to learn new
  tasks and do familiar ones safely

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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

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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

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Human Behavior

• Developing Personal Safety Awareness
• Before starting, consider how to do job safely
• Understand required P.P.E. and how to use it
• Determine correct tools and ensure they are in
  good condition
• Scan work area know what is going on
• As you work, check work position reduce any
  strain
• Any unsafe act or condition should be corrected
• Remain aware of any changes in your workplace
  people coming, going, etc.
• Talk to other workers about safety
• Take safety home with you

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Human Behavior

• Some Thought Questions
• Do you want to work safely?
• Do you want others to work safely?
• Do you want to learn how to prevent
  accidents/injuries?
• How often do you think about safety as you work?
• How often do you look for actions that could
  cause or prevent injuries?

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Human Behavior

• More Thought Questions
• Have you ever carried wood without wearing
  gloves?
• Have you ever left something in a walkway that
  was a tripping hazard?
• Have you ever carried a stack of boxes that
  blocked your view?
• Have you ever used a tool /equipment you didnt
  know how to operate?
• Have you ever left a desk or file drawer open
  while you worked in an area?
• Have you ever placed something on a stair Just
  for a minute?
• Have you ever done anything unsafe because Ive
  always done it this way?

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Human Behavior

• TIME!
• All this safety stuff takes time doesnt it?
• Im too busy!
• I cant possibly do all this!
• The boss wants the job done now!

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Human Behavior

• Does rushing through the job, working quickly
  without considering safety, really save time?
• Remember if an incident occurs, the job may not
  get done on time and someone could be injured
  and that someone could be YOU!!

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Safety Intervention Strategies

• Approach of Studies of Subjects
  Reduction
• Behavior Based 7 2,444 59.6
• Ergonomics 3 n/a 51.6
• Engineering Change 4 n/a 29.0
  
• Problem Solving 1 76
  20.0
• Govt. Action 2 2
  18.3
• Mgt. Audits 4 n/a
  17.0
• Stress Management 2 1,300 15.0
• Poster Campaign 26 100 14.0
• Personnel Selection 26 19,177
  3.7
• Near-miss Reports 2 n/a
  0

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OUTCOMES OF ACCIDENTS

• NEGATIVE OUTCOMES
• POSITIVE OUTCOMES

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Direct Costs

• Medical
• Insurance
• Lost Time
• Fines

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Compliance

• Failure to develop and implement a program may be
  cited as a SERIOUS violation (by itself or
  "Grouped" with other violations) Penalties (as
  high as 2,000) may be assessed

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Compliance

• Up to 35 of the penalty can be deducted based
  upon an employer's "good faith - Good faith is
  based upon
• Awareness of the Law
• Efforts to comply with the Law before the
  inspection
• Correction of hazards during the inspection
• Cooperation Attitude during the inspection
• Overall safety and health efforts including the
  Accident Prevention Program

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Indirect Costs

• Injured, Lost Time Wages
• Non-Injured, Lost Time Wages
• Overtime
• Supervisor Wages
• Lost Bonuses
• Employee Morale
• Need For Counseling
• Turn-over

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Indirect Costs

• Equipment Rental
• Cancelled Contracts
• Lost Orders
• Equipment/Material Damage
• Investigation Team Time
• Decreased Production
• Light Duty
• New Hire Learning Time
• Administrative Time
• Community Goodwill
• Public/Customer Perception
• 3rd Party Lawsuits

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REAL Costs
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OUTCOMES OF ACCIDENTS

• POSITIVE ASPECTS
• Accident investigation
• Prevent repeat of accident
• Improved safety programs
• Improved procedures
• Improved equipment design

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Accident Prevention Program

• Must Be
• Written
• Tailored to particular hazards for a particular
  plant or operation
• Minimum Elements
• Safety Orientation Program
• Safety and Health Committee

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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

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Accident Prevention Program

• Designated Safety and Health Committee
• Management Representatives
• Employee Elected Representatives
• Max. 1 year
• Must be equal or more employee representatives
  than employer representatives
• Elected Chairperson
• Self-determine frequency of meetings
• 1 hour or less unless majority votes
• Minutes
• Keep for 1 Year
• Available for review by OSHA Personnel

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Accident Prevention Program

• Safety Meeting instead of Safety Committee
• If less than 11 employees
• Total
• Per shift
• Per location
• Meet at least once/month
• 1 Management Representative

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Safety Meeting

• You Must
• Review inspection reports
• Evaluate accident investigations
• Evaluate APP and discuss recommendations
• Document attendance and topics

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Safety Committees
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Safety Committees
Proactive Safety

• They should meet as often as necessary
• This will depend on volume of production and
  conditions such as
• Number of employees
• Size of workplace covered
• Nature of work undertaken on site
• Type of hazards and degree of risk
• Meetings should not be cancelled

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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
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Four points to Remember

• Communication Must be a loop system
• Dedication From everyone
• Partnership Between Management
• and Employees
• Participation An important part of
• team working.

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How effective can a Committee be?
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Safety CommitteePolicy Statement
A written and publicized statement is an
effective means of providing guidance and
demonstrating commitment
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Safety Committee Focus

• Long Term Goals
• Objectives to Achieve
• Time Frame
• Short Term Goals
• Assignments between Meetings
• Work toward achieving Long-Term Plan

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Planning the Safety Meeting

• Select topics
• Set post the agenda
• Schedule safety meeting
• Prepare meeting site
• Encourage participation

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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
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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
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Regular Agenda Item

• Review Policies Plans such as
• Hazard Communication Program
• Personal Protective Equipment
• Respiratory Protection
• Housekeeping
• Machine Safeguarding
• Safety Audits
• Record Keeping
• Emergency Response Plans

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Emergency Plan

• Anticipate What Could Go Wrong and Plan for those
  Situations
• Drill for Emergency Situations

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Emergency Action Plan

• The following minimum elements shall be
  included
• Alarm Systems
• Emergency escape procedures and route
  assignments
• Procedures for employees who remain to operate
  critical plant operations before evacuation
• Procedures to account for all employees
• Rescue and medical duties for those employees who
  are to perform them
• The preferred means of reporting fires and other
  emergencies
• Names / job titles of who can be contacted for
  further information or explanation of duties
  under the plan

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Record Keeping Updating

• Record each Recordable Injury Illness on OSHA
  300 Log w/in 6 Days
• Recordable
• Occupational fatalities
• Lost workday
• 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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Record Keeping and Updating

• First Aid - one-time treatment that could be
  expected to be given by a person trained in basic
  first-aid using supplies from a first-aid kit and
  any follow-up visit or visits for the purpose of
  observation of the extent of treatment
• NOTE The new OSHA Recordkeeping Rule lists the
  specific First Aid Treatments

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Immediately Report

• Any accident that involves 1. Injury 2. Illness
  3. Equipment or property damage
• Any near-misses. A near miss is an event that,
  strictly by chance, does not result in actual or
  observable injury, illness, death, or property
  damage. Examples slips, trips falls,
  compressed gas cylinder falling, overexposures
  to a chemical
• Any hazards such as Exposed electrical wires,
  Damaged PPE, Improper material storage, Improper
  chemical use, Horseplay, Damaged equipment,
  Missing or loose machine guards

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HAZARD ANALYSIS
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Hazard Analysis

• Orderly process used to determine if a hazard
  exists in the workplace
• Uncover hazards overlooked in design
• Locate hazards developed in-process
• Determine essential steps of a job
• Identify hazards that result from the performance
  of the actual job

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Step 1 Identify Hazards

• HAZARD condition with the potential to
  cause personal injury, death and property damage

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Hazard Identification

• Review Records
• Talk to Personnel
• Accident Investigations
• Follow Process Flow
• Write a Job Safety Analysis
• Use Inspection Checklists

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STEP 2 Assess Hazards

• Probability - How likely is the hazard?
• Likely
• Not likely
• Severity - What will happen if encountered?
• Death
• Serious Injury
• Damage to property

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Levels of Risk Awareness

• Unaware Doesnt realize at-risk
• Post-Awareness Realizes Risk After Task
  Completion
• Engaged-Awareness Recognizes Risk While
  Performing Task(s) and corrects the situation
• Proactive-Awareness Foresee Hazards and Begins
  Task Only When Safe to Proceed

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Who is at Risk?

• Contractors
• Janitorial
• Maintenance
• Others
• Members of Public
• Passers-by
• Neighbors

• Workers
• Visitors
• Invited
• Customers
• Emergency services
• Delivery drivers
• Uninvited
• Trespassers
• Burglars

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STEP 3 Make Risk Decisions
What can we do to reduce the risk? Does the
benefit outweigh the risk?
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STEP 4 Implement Controls

• Substitution
• Engineering controls
• Administrative Controls
• Personal Protective Equipment

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Hazard Controls

• Source
• Path
• Receiver

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Hazard Control

• Administrative Engineering
• Protective Equipment/Clothing

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Engineering

• Hazard Elimination
• Add-On Safety Design
• Active vs. Passive
• User Instructions (Manual)

Ventilation Design/Layout Safety Devices
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Administrative

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

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Step 5 Supervise

• Ensure risk control measures are implemented
• Track progress
• Feedback

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JOB SAFETY ANALYSIS
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Job Safety Analysis

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

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Job Safety Analysis
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Job Safety Analysis Priorities

• New Jobs
• Potential of Severe Injuries
• History of Disabling Injuries
• Frequency of Accidents

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Observation of the Actual Work

• Select experienced worker(s) to participate in
  the JSA process
• Explain purpose of JSA
• Observe the employee perform the job and write
  down basic steps
• Completely describe each step
• Note any deviations (Very Important!)

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Identify Hazards Potential Accidents

• Search for Hazards
• Produced by Work
• Produced by Environment
• Repeat job observation as many times as necessary
  to identify all hazards

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Key Steps TOO MUCHChanging a Flat Tire

• Pull off road
• Put car in park
• Set brake
• Activate emergency flashers
• Open door
• Get out of car
• Walk to trunk
• Put key in lock
• Open trunk
• Remove jack
• Remove Spare tire

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Key Steps NOT ENOUGHChanging a Flat Tire

• Park car
• Take off flat tire
• Put on spare tire
• Drive away

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Key Job Steps JUST RIGHTChanging a Flat Tire

• Park set brake
• Remove jack tire from trunk
• Loosen lug nuts
• Jack up car
• Remove tire
• Set new tire
• Jack down car
• Tighten lug nuts
• Store tire jack

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Job Safety Analysis

• Steps
• Park set brake
• Remove Spare Jack
• Loosen lugs

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Job Safety Analysis

• Steps
• Park set brake
• Remove Spare Jack
• Loosen lugs

• Hazards
• Hit by traffic
• Back Strain
• Foot/Toe impact
• Shoulder strain

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Job Safety Analysis

• Steps
• Park set brake
• Remove Spare Jack
• Loosen lugs

• Hazards
• Hit by traffic
• Back Strain
• Foot/Toe impact
• Shoulder strain

• Prevention
• Far off road as possible
• Pull items close before lift
• Lift in increments
• Lift and lower using leg power
• Wide leg stance
• Use full body, not arm/shoulder

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Develop Solutions

• Fix-A-Flat
• No off-road driving
• Buy self-sealing tires
• Maintenance / Change-out program

• Find a new way to do job
• Change physical conditions that create hazards
• Change the work procedure
• Reduce frequency

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JSA EXERCISE
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INSPECTIONS
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Inspections

• Fact-Finding vs. Fault Finding
• Sound knowledge of the plant
• Knowledge of relevant standards codes
• Systematic inspection steps
• Method of evaluating data

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Inspection Limitations

• Blinder affect
• Rote inspections
• 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

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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

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Change in Physical Conditions

• Tools, materials, equipment layout or location
• Study change carefully for other benefits (costs,
  time savings)

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Change in Work Procedures

• What should the worker do to eliminate the
  hazard?
• How should it be done?
• Document changes in detail

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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

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Performing Safety Audits
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Guide for Personal Audits

• The guide has five steps
• Audit
• React
• Communicate
• Follow up
• Raise standards

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Audit

• Get into one of the work areas on a regular basis
• Develop your own system
• Do not combine a safety audit with other visits
• Audit must be designed to evaluate safety
• Take notes

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React

• How you react is the strongest element in
  improving the safety culture
• Your reaction tells what is acceptable and not
  acceptable
• You must come away from each inspection with a
  reaction
• Acceptable because...
• Not acceptable because...
• Deteriorated because...
• Improved because

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Communicate

• In order for the contact to be productive, your
  subordinate/co-worker must understand that
• You inspected his or her area
• You are pleased (or displeased) with what you saw
  because of
• You expect him or her to react to your comments
  and to improve
• You will audit the area again in a specified
  number of days

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Follow Up

• Critical for success of the safety program
• Allows you to demonstrate that it is important
• Must communicate your assessment to the employees

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Raise Standards

• Will see improvement if the first four steps are
  followed
• Keep raising your expectations and help provide
  leadership
• Solve the obvious problems then fine tune the
  safety and housekeeping efforts

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Key Points Becoming a Good Observer

• Effective observation includes
• Be selective
• Know what to look for
• Practice
• Keep an open mind
• Guard against habit and familiarity
• Do not be satisfied with general impressions
• Record observations systematically

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Observation Techniques

• To become a good observer, a person must
• Stop for 10 to 30 seconds before entering an area
  to ascertain where employees are working
• Be alert for unsafe practices
• Observe activity -- do not avoid the action

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Observation Techniques

• Remember ABBI -- look Above, Below, Behind,
  Inside
• Develop a questioning attitude
• Use all senses
• sight
• hearing
• smell
• touch

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Inspections and Field Observations

• Use a checklist
• Ask questions
• Take notes
• Respect lines of communication
• Draw conclusions

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Unsafe Acts

• Conduct that unnecessarily increases the
  likelihood of injury
• All safety rule and procedure violations are
  unsafe acts
• All unsafe acts should be corrected immediately

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Unsafe Conditions

• An unsafe condition is a situation, not directly
  caused by the action or inaction of one or more
  employees, in an area that may lead to an
  incident or injury if uncorrected
• Unsafe conditions are normally beyond the direct
  control of employees in the area where the
  condition is observed

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Audit Practices

• Concentrate on people and their actions because
  actions of people account for more than 96
  percent of all injuries
• When to audit
• Where to audit
• How much to audit
• Auditing contractors

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Management Commitment

• Should Management Consider Safety as a Priority
  in Conducting Business

??
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Management Commitment

• NO !

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PRIORITIES CHANGE

• SAFETY MUST BE A VALUE!!

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Employee Participation

• Accident Prevention Plan Development
• Safety Committee
• Safety Bulletin Board
• Crew-Leader Meetings

• Day-to-Day Knowledge comes from where the work
  is actually done and hazards actually exist.

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SHARED VISION EXERCISE
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AVAILABLE RESOURCES

• OSHA Website www.osha.gov
• Washington State Labor Industries Website
  www.lni.wa.gov

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ACCIDENT INVESTIGATION
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INTRODUCTION

• Thousands of accidents occur throughout the
  United States every day
• Accident investigations determine how and why
  these failures occur
• Conduct accident investigations with accident
  prevention in mind - Investigations are NOT to
  place blame
• Investigate all accidents regardless of the
  extent of injury or damage

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THE ACCIDENT

• WHAT IS AN ACCIDENT?

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THE ACCIDENT

• An
• unplanned and unwelcome event
• that interrupts normal activity

149
Accidents are What Happens to Somebody Else

• BUT REMEMBER
• YOU
• are somebody else
• to somebody else

150
THE ACCIDENT

• MINOR ACCIDENTS
• Such as paper cuts to fingers or dropping a box
  of materials

151
THE ACCIDENT

• MORE SERIOUS ACCIDENTS
• Such as a forklift dropping a load or someone
  falling off a ladder

152
THE ACCIDENT

• Accidents that occur over an extended time frame
• Such as hearing loss or an illness resulting from
  exposure to chemicals

153
THE ACCIDENTNEAR-MISS

• Also know as a Near Hit
• An accident that does not quite result in injury
  or damage (but could have)
• Remember, a near-miss is just as serious as an
  accident!

154
THE ACCIDENT

• ACCIDENTS HAVE TWO THINGS IN COMMON

155
THE ACCIDENT

• They all have outcomes from the accident

156
THE ACCIDENT

• They all have contributory factors that cause
  the accident

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OUTCOMES OF ACCIDENTS

• NEGATIVE Results
• Injury possible death
• Disease
• Damage to equipment property
• Litigation costs, possible citations
• Lost productivity
• Morale

159
OUTCOMES OF ACCIDENTS

• POSITIVE Results
• Accident investigation
• Prevent repeat of accident
• Change to safety programs
• Change to procedures
• Change to equipment design

160
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

161
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
162
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

163
ACCIDENT INVESTIGATION
You Must

• Conduct a preliminary investigation for
• serious injuries with immediate symptoms
• Document the investigation findings

164
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

165
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)

166
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

167
ACCIDENT INVESTIGATION

• Make sure your preliminary investigation is
  conducted by the following people
• A person designated by the employer
• The immediate supervisor
• Witnesses
• An employee representative
• Other persons with experience and skills to
  evaluate the facts

168
ACCIDENT INVESTIGATION

• A preliminary investigation includes noting
  information such as the following
• Where did the accident or incident occur?
• What time did it occur?
• What people were present?
• What was the employee doing at the time?
• What happened during the accident or incident?

169
ACCIDENT INVESTIGATION

• Provide the following information to OSHA within
  30 days concerning any accident involving a
  fatality or hospitalization of 3 or more
  employees
• Name of the work place
• Location of the incident
• Time and date of the incident
• Number of fatalities or hospitalized employees
• Contact person
• Phone number
• Brief description of the incident

170
Why Not Rely On OSHA Police To Investigate?

• Focus On Culpability
• Minor Accidents Not Investigated
• PREVENTION
• Protect Company Interests
• OSHA Requirements

171
Investigating Accidents

• How to find out what really happened

172
Why Investigate Accidents?

• Find the cause
• Prevent similar accidents
• Protect company interests

173
At which level do we investigate?
174
Investigation Strategy

• Need For Investigation
• Control the Scene
• Gather Facts
• Analyze Data
• Establish Causes
• Write Report
• Take Corrective Action

175
Investigative Procedures

• The actual procedures used in a particular
  investigation depend on the nature and results of
  the accident
• All investigations start with a collection of
  data and are followed by analysis of that data
• An investigation is not complete until all data
  is analyzed and a final report is completed

176
The Aim of the Investigation

• The key result should be to prevent a repeat of
  the same accident
• Fact finding
• What happened?
• What was the root cause?
• What should be done to prevent repeat of the
  accident?

177
The Aim of the InvestigationIS NOT TO

• Exonerate individuals or management
• Satisfy insurance requirements
• Defend a position for legal argument
• Or, to assign blame

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181
COMPANY ACCIDENT FORMS

• Must be filled out completely by the employee
  and employees immediate supervisor (this
  includes foremen)
• Must be turned in to Safety within 24 hours of
  incident

182
BENEFITS OF ACCIDENT INVESTIGATION

• Prevent repeat of the accident
• Identifying outmoded procedures
• Improvements to the work environment
• Increased productivity
• Improvement of operational safety procedures
• Raise safety awareness level

183
BENEFITS OF ACCIDENT INVESTIGATION

• WHEN AN ORGANIZATION REACTS SWIFTLY AND
  POSITIVELY TO ACCIDENTS AND INJURIES, ITS ACTIONS
  REAFFIRM ITS COMMITMENT TO THE SAFETY AND
  WELL-BEING OF ITS EMPLOYEES!

184
Who Should Investigate?

• Investigation TEAM
• Employer Designee (Management)
• Immediate Supervisor of affected area/personnel
• Experts (if needed)
• Employee Representative (one of the following)
• Employee selected representative
• Employee representative of safety committee
• Union representative or shop steward

185
Immediate Actions

• Assess the scene
• CALL 911
• Activate In-House Response
• Scene Safety
• Provide Aid to Injured
• Provide Assistance to Affected
• Secure the Scene of Accident

186
Isolate the Scene

• Barricade the area of the accident, and keep
  everyone out!
• The only persons allowed inside the barricade
  should be Rescue/EMS, law enforcement, and
  investigators
• Protect the evidence until investigation is
  complete

187
Provide Care to the Injured

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

188
Secure the Scene for Safety

• Eliminate the hazards
• Control chemicals
• De-energize
• De-pressurize
• Light it up
• Shore it up
• Ventilate

189
Fact Finding

• Gather evidence from many sources during an
  investigation
• Get information from witnesses and reports as
  well as by observation
• Dont try to analyze data as evidence is gathered

190
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

191
Gather Evidence

• Diagram the scene
• Use blank paper or graph paper. Mark the location
  of all pertinent items equipment, parts, spills,
  persons, etc.
• Note distances and sizes, pressures and
  temperatures
• Note direction (mark north on the map)

192
Gather Evidence

• Take photographs
• Photograph any items or scenes which may provide
  an understanding of what happened to anyone who
  was not there
• Photograph any items which will not remain, or
  which will be cleaned up (spills, tire tracks,
  footprints, etc.)
• 35mm cameras, Polaroids, and video cameras are
  all acceptable
• Digital cameras are not recommended - digital
  images can be easily altered

193
Photographs

• Unbiased Recording
• Keep Log of Photos
• Overall to Close-up
• Color if possible
• Supplement with Video

194
Gather Data

• Data includes
• Persons involved
• Date, time, location
• Activities at time of accident
• Equipment involved
• List of witnesses

195
Review Records

• Check training records
• Was appropriate training provided?
• When was training provided?
• Check equipment maintenance records
• Is regular PM or service provided?
• Is there a recurring type of failure?
• Check accident records
• Have there been similar incidents or injuries
  involving other employees?

196
Documents

• Collect All Related Documents
• Inspection Logs
• Policy Procedures Manual
• JSA (Job Safety Analysis)
• Equipment Operations Manuals
• Insurance Records
• Employee Records
• Police Reports

197
Those who do not know the past are destined to

• Repeat
• Repeat
• Repeat
• Repeat
• Repeat
• Repeat
• It.

198
ISOLATE FACT FROM FICTION

• Use NORMS-based analysis of information
• Not an interpretation
• Observable
• Reliable
• Measurable
• Specific
• If an item meets all five of above, it is a fact

199
NORMS OF OBJECTIVITY

• Objective
• Not an Interpretation - Based on a factual
  description.
• Observable - Based on what is seen or heard.
• Reliable - Two or more people independently agree
  on what they observed.
• Measurable - A number is used to describe
  behavior or situation.
• Specific - Based on detailed definitions of what
  happened.

• Subjective
• Interpretations - Based on personal
  interpretations/biases.
• Non-observable - Based on events not directly
  observed.
• Unreliable - Two or more people dont agree on
  what they observed.
• Non-Measurable - A number isnt used.
• General - Based on non-detailed descriptions.

200
INVESTIGATION TRAPS

• Put your emotions aside!
• Dont let your feelings interfere - stick to the
  facts!
• Do not pre-judge
• Find out the what really happened
• Do not let your beliefs cloud the facts
• Never assume anything
• Do not make any judgements

201
Record Evidence

• Keep All Notes in Bound Notebook
• Include Date - Time - Place Vantage Point
• Keep Originals
• Rewrite in Report Form

202
Samples

• Collect Perishables First
• Fluids
• Open Containers
• Filings
• Chemicals
• Air

203
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

204
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

205
Interviews

• Excellent Source of first hand knowledge
• May Present Pitfalls in form of
• Bias
• Perspective
• Embellishment
• Omissions

206
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

207
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

208
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

209
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

210
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?

211
The Interview

• Dont 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

212
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

213
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

214
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?

215
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?

216
Witness Interviews

• DO
• Separate Witnesses
• Written Statements
• Open ended questions
• Provide Diagrams
• Encourage Details
• Show Concern
• Record w/permission

• DONT
• Suggest Answers
• Interrogate
• Focus on Blame
• Dismiss Details
• Bar Emotions
• Make Judgments

217
Analysis of Accident Causes

• Immediate Causes
• What was done?
• What was not done?
• What hazardous condition existed?
• Root Causes
• Why did they do this?
• Why didnt they do that?
• Why did the unsafe condition exist?
• Why wasnt it corrected?

218
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

219
CONTRIBUTING FACTORS INVESTIGATION STRATEGY

• INVESTIGATION TEAM
• EVALUATES ALL FACTORS CONCERNED
• ISOLATES THE KEY FACTOR(S) BY ASKING THE
  FOLLOWING QUESTION....
• WOULD THE ACCIDENT HAVE HAPPENED IF THIS
  PARTICULAR FACTOR WAS NOT PRESENT?

220
DETERMINE CAUSES

• Employee actions
• Safe behavior, at-risk behavior
• Environmental conditions
• Lighting, heat/cold, moisture/humidity, dust,
  vapors, etc.
• Equipment condition
• Defective/operational, guards, leaks, broken
  parts, etc.
• Procedures
• Existing (or not), followed (or not), appropriate
  (or not)
• Training
• Was employee trained - when, by whom,
  documentation

221
Indirect Causes

• Unsafe conditions what material conditions,
  environmental conditions and equipment conditions
  contributed to the accident
• Unsafe Acts what activities contributed to the
  accident

222
Breakdown of Unsafe Conditions

• Inadequately guarded or unguarded equipment
• Defective tools, equipment or materials
• Fire and explosion hazard
• Unexpected movement hazard
• Projection hazards

223
Breakdown of Unsafe Conditions

• Housekeeping
• Hazardous environmental conditions
• Improper ventilation
• Improper illumination
• Unsafe dress or apparel

224
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

225
Basic Causes

• Management
• Environment
• Equipment
• Human Behavior

• Systems Procedures
• Design Equipment

226
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?

227
FIND ROOT CAUSES

• When you have determined the contributing
  factors, dig deeper!
• If employee error, what caused that behavior?
• If defective machine, why wasnt it fixed?
• If poor lighting, why not corrected?
• If no training, why not?

228
Contribution of Safety Controls such as

• Engineering Controls - machine guards, safety
  controls, isolation of hazardous areas,
  monitoring devices, etc.
• Administrative Controls - procedures,
  assessments, inspection, records to monitor and
  ensure safe practices and environments are
  maintained.
• Training Controls - initial new hire safety
  orientation, job specific safety training and
  periodic refresher training.

229
What controls failed?

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

230
What controls worked?

• List any controls that prevented a more serious
  accident or minimized collateral damage or
  injuries