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Wilson-Simon
Accident
Prevention
What Is An Accident?
What Is An Accident?
An Accident is:
a. An unexpected and undesirable event, especially one resulting in damage or
harm: car accidents on icy roads.
b. An unforeseen incident: A series of happy accidents led to his promotion.
c. An instance of involuntary urination or defecation in one's clothing.
2. Lack of intention; chance: ran into an old friend by accident.
3. Logic A circumstance or attribute that is not essential to the nature of something.
http://www.thefreedictionary.com/accident
Hazard
Existing or Potential
Condition That Alone
or Interacting With
Other Factors Can
Cause Harm
A Spill on the Floor
Broken Equipment
Risk
A measure of the probability and
severity of a hazard to harm human
health, property, or the environment
A measure of how likely harm is to
occur and an indication of how serious
the harm might be
Risk 0
Safety
FREEDOM FROM DANGER OR HARM
Nothing is Free of
R
A
T
I
O
S
OSHA METHOD
330 Incidents
29 Minor Injuries
1 Major or Loss-Time Accident
Candy Jar
Example
Types of Accidents
FALL TO
same level
lower level
CAUGHT
in
on
between
CONTACT WITH
chemicals
electricity
heat/cold
radiation
BODILY
REACTION FROM
voluntary motion
involuntary motion
By
moving or flying
object
falling object
RUBBED OR
ABRADED BY
friction
pressure
vibration
Vehicle Accidents
Contact With Objects and Equipment
Falls
Assaults & Violent Acts
2413
983
809
754
Vehicle Accidents
Contact With Objects and Equipment
Falls
Assaults & Violent Acts
40
13
19
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)
Management
Environmental
Equipment
Human Behavior
Indirect Causes
Unsafe Acts
Unsafe Conditions
Direct Causes
Basic Causes
Unsafe
Acts
Direct Causes
Slip/Trip Fall
Energy Release
Pinched Between
ACCIDENT
Personal Injury
Property Damage
Potential/Actual
Unsafe
Conditions
Basic Causes
Management
Environment
Equipment
Human Behavior
Management
Systems &
Procedures
Lack of systems &
procedures
Availability
Lack of Supervision
Environment
Physical
Lighting
Temperature
Chemical
vapors
smoke
Biological
Bacteria
Reptiles
Environment
Guarding
Ergonomic
Accessibility
Human Behavior
Common to
all accidents
Human Factors
Omissions &
Commissions
Deviations from
SOP
Lacking Authority
Short Cuts
Remove guards
Consequences
(what happens if it is/isnt done)
ABC Model
Antecedents
(trigger behavior)
Behavior
(human performance)
Consequences
(either reinforce or punish behavior)
Only 4 Types of
Consequences:
Positive Reinforcement (R+)
("Do this & you'll be rewarded")
Behavior
Punishment (P)
("If you do this, you'll be penalized")
Extinction (E)
("Ignore it and it'll go away")
Consequences Influence
Behaviors Based Upon
Individual Perceptions of:
Impact
Significance
Magnitude
positive
or
negative
Human Behavior
Behaviors that have consequences that are:
Soon
Certain
Positive
Have a stronger effect on peoples behavior
Human Behavior
Soon
A consequence that follows soon after a
behavior has a stronger influence than
consequences that occur later
Silence is considered to be consent
Failure to correct unsafe behavior
influences employees to continue the
behavior
Human Behavior
Certain
A consequence that is certain to follow a
behavior has more influence than an
uncertain or unpredictable consequence
Corrective Action must be:
Prompt
Consistent
Persistent
Human Behavior
Positive
A positive consequence influences
behavior more powerfully than a
negative consequence
Penalties and Punishment dont work
Speeding Ticket Analogy
Human Behavior
Example: Smokers find it hard to stop smoking
because the consequences are:
A) Soon (immediate)
B) Certain (they happen every time)
C) Positive (a nicotine high)
The other consequences are:
A) Late (years later)
B) Uncertain (not all smokers get lung cancer)
C) Negative (lung cancer)
Human Behavior
Thought Question:
What would you do as a worker if you
had to take 10-15 minutes to don the
correct P.P.E. to enter an area to turn off
a control valve which took 10 seconds?
Human Behavior
Punishment or threatening workers is a
behavioral method used by some Safety
Management programs
Punishment only works if:
It is immediate
Occurs every time there is an unsafe behavior
Human Behavior
The soon, certain, positive reinforcement
from unsafe behavior outweighs the
uncertain, late, negative reinforcement
from inconsistent punishment
People tend to respond more positively to
praise and social approval than any other
factors
Human Behavior
Some experts believe you can change 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
Attitudes
however
Human Behavior
Attention Behavioral Safety approach
Focuses on getting workers to pay
Attention
Inability to control Attention is a
contributing factor in many injuries
Human Behavior
Focusing on Awareness is a typical
educational approach to change safety
behavior
Example: You provide employees with a
persuasive rationale for wearing safety
glasses and hearing protection in certain
work areas
Human Behavior
Developing Personal Safety Awareness
A) Before starting, consider how to do job safely
B) Understand required P.P.E. and how to use it
C) Determine correct tools and ensure they are in good
condition
D) Scan work area know what is going on
E) As you work, check work position reduce any strain
F) Any unsafe act or condition should be corrected
G) Remain aware of any changes in your workplace people
coming, going, etc.
H) Talk to other workers about safety
I) Take safety home with you
Human Behavior
Some Thought Questions:
1. Do you want to work safely?
2. Do you want others to work safely?
3. Do you want to learn how to prevent
accidents/injuries?
4. How often do you think about safety as you
work?
5. How often do you look for actions that
could cause or prevent injuries?
Human Behavior
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!
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!!
# of Subjects Reduction %
2,444
59.6%
n/a
51.6%
n/a
29.0%
76
20.0%
2
18.3%
n/a
17.0%
1,300
15.0%
100
14.0%
19,177
3.7%
n/a
0%
OUTCOMES OF ACCIDENTS
NEGATIVE OUTCOMES
POSITIVE OUTCOMES
$ Direct Costs
Medical
Insurance
Lost Time
Fines
Compliance
Failure to develop and implement a
program may be cited as a SERIOUS
violation (by itself or "Grouped" with
other violations)
Penalties (as high as $ 2,000) may be
assessed
Compliance
Up to 35% of the penalty can be
deducted based upon an employer's
"good faith - Good faith is based
upon:
Awareness of the Law
Efforts to comply with the Law before the
inspection
Correction of hazards during the inspection
Cooperation & Attitude during the inspection
Overall safety and health efforts including the
Accident Prevention Program
Indirect Costs
Injured, Lost Time
Wages
Non-Injured, Lost
Time Wages
Overtime
Supervisor Wages
Lost Bonuses
Employee Morale
Need For
Counseling
Turn-over
Indirect Costs
Equipment Rental
Cancelled Contracts
Lost Orders
Equipment/Material
Damage
Investigation Team Time
Decreased Production
Light Duty
New Hire Learning Time
Administrative Time
Community Goodwill
Public/Customer Perception
3rd Party Lawsuits
REAL Costs
OUTCOMES OF ACCIDENTS
POSITIVE ASPECTS
Accident investigation
Prevent repeat of accident
Improved safety programs
Improved procedures
Improved equipment design
Minimum Elements
Safety Orientation Program
Safety and Health Committee
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
Safety Meeting
You Must
Safety Committees
Safety Committees
Proactive
Safety
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
From everyone
Partnership:
Between Management
and Employees
Participation:
An important part of
team working.
How effective
can a
Committee be?
Safety Committee
Policy Statement
A written and publicized statement is an
effective means of providing guidance and
demonstrating commitment
Select topics
Set & post the agenda
Schedule safety meeting
Prepare meeting site
Encourage participation
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
Emergency Plan
Anticipate What
Could Go Wrong
and Plan for
those Situations
Drill for
Emergency
Situations
Immediately Report:
Any accident that involves: 1. Injury 2. Illness 3.
Equipment or property damage
Any near-misses.
HAZARD ANALYSIS
Hazard Analysis
Orderly process used to determine if a
hazard exists in the workplace
Hazard Identification
Review Records
Talk to Personnel
Accident Investigations
Follow Process Flow
Write a Job Safety Analysis
Use Inspection Checklists
Who is at Risk?
Workers
Visitors
Invited
Customers
Emergency services
Delivery drivers
Uninvited
Trespassers
Burglars
Contractors
Janitorial
Maintenance
Others
Members of Public
Passers-by
Neighbors
Substitution
Engineering controls
Administrative Controls
Personal Protective Equipment
Hazard Controls
Source
Path
Receiver
Hazard Control
Administrative
Engineering
Protective Equipment/Clothing
Engineering
Hazard Elimination
Add-On Safety Design
Active vs. Passive
User Instructions
(Manual)
Ventilation
Design/Layout
Safety Devices
Administrative
Safety Rules
Disciplinary Policy - Accountability
Preventative Maintenance
Training
Proficiency/Knowledge Demonstrations
Step 5: Supervise
Ensure risk control
measures are
implemented
Track progress
Feedback
JOB SAFETY
ANALYSIS
Hazards
Hit by
traffic
Remove Spare
& Jack
Back
Strain
Foot/Toe
impact
Loosen lugs
Shoulder
strain
Hazards
Hit by
traffic
Back Strain
Foot/Toe
impact
Loosen lugs
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
Develop Solutions
Find a new way
to do job
Fix-A-Flat
Change physical
conditions that
create hazards
Change the work
procedure
Reduce
frequency
No off-road
driving
Buy self-sealing
tires
Maintenance /
Change-out
program
JSA EXERCISE
INSPECTIONS
Inspections
Fact-Finding vs. Fault Finding
Inspection Limitations
Blinder affect
Rote inspections
All Check - No action
Who is inspecting?
Outcomes
Improve Safety
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
Audit
Get into one of the work areas on a
regular basis
Develop your own system
Do not combine a safety audit with other
visits
Audit must be designed to evaluate safety
Take notes
React
Communicate
In order for the contact to be productive, your
subordinate/co-worker must understand that:
You inspected his or her area
You are pleased (or displeased) with what you saw because
of
You expect him or her to react to your comments and to
improve
You will audit the area again in a specified number of days
Follow Up
Critical for success of the safety program
Allows you to demonstrate that it is
important
Must communicate your assessment to the
employees
Raise Standards
Will see improvement if the first four
steps are followed
Keep raising your expectations and help
provide leadership
Solve the obvious problems then fine
tune the safety and housekeeping efforts
Observation Techniques
To become a good observer, a person
must:
Stop for 10 to 30 seconds before entering an
area to ascertain where employees are
working
Be alert for unsafe practices
Observe activity -- do not avoid the action
Observation Techniques
Remember ABBI -- look Above, Below,
Behind, Inside
Develop a questioning attitude
Use all senses
sight
hearing
smell
touch
Unsafe Acts
Conduct that unnecessarily increases the
likelihood of injury
All safety rule and procedure violations
are unsafe acts
All unsafe acts should be corrected
immediately
Unsafe Conditions
An unsafe condition is a situation, not
directly caused by the action or inaction
of one or more employees, in an area that
may lead to an incident or injury if
uncorrected
Unsafe conditions are normally beyond
the direct control of employees in the
area where the condition is observed
Audit Practices
Concentrate on people and their actions
because actions of people account for more
than 96 percent of all injuries
When to audit
Where to audit
How much to audit
Auditing contractors
Management Commitment
Should Management Consider Safety as a Priority
in Conducting Business
??
Management Commitment
NO !
PRIORITIES CHANGE
SAFETY
MUST BE A
VALUE!!
Employee Participation
Day-to-Day Knowledge
comes from where the
work is actually done
and hazards actually
exist.
Accident Prevention
Plan Development
Safety Committee
Safety Bulletin Board
Crew-Leader
Meetings
SHARED VISION
EXERCISE
AVAILABLE RESOURCES
OSHA Website: www.osha.gov
Washington State Labor & Industries
Website: www.lni.wa.gov
ACCIDENT
INVESTIGATION
INTRODUCTION
Thousands of accidents occur throughout the
United States every day
Accident investigations determine how and why
these failures occur
Conduct accident investigations with accident
prevention in mind - Investigations are NOT to
place blame
Investigate all accidents regardless of the extent
of injury or damage
THE ACCIDENT
WHAT IS AN ACCIDENT?
THE ACCIDENT
An
unplanned and unwelcome event
that interrupts normal activity
THE ACCIDENT
MINOR ACCIDENTS:
Such as paper cuts to fingers or dropping
a box of materials
THE ACCIDENT
MORE SERIOUS ACCIDENTS
Such as a forklift dropping a load or
someone falling off a ladder
THE ACCIDENT
Accidents that occur over an extended
time frame:
Such as hearing loss or an illness resulting
from exposure to chemicals
THE ACCIDENT
NEAR-MISS
Also know as a Near Hit
An accident that does not quite result in
injury or damage (but could have)
Remember, a near-miss is just as serious
as an accident!
THE ACCIDENT
THE ACCIDENT
They all have outcomes from the accident
THE ACCIDENT
They all have contributory factors that
cause the accident
OUTCOMES OF ACCIDENTS
NEGATIVE Results
OUTCOMES OF ACCIDENTS
POSITIVE Results
Accident investigation
Prevent repeat of accident
Change to safety programs
Change to procedures
Change to equipment design
ACCIDENT INVESTIGATION
Accidents are usually complex
An accident may have 10 or more events
that can be causes
A detailed analysis of an accident will
normally reveal three cause levels:
direct
indirect
root
Direct Cause
An accident results only when a person
or object receives an amount of energy
or hazardous material that cannot be
absorbed safely - This energy or
hazardous material is the DIRECT
CAUSE of the accident
The direct cause is usually the result of one or
more unsafe acts or unsafe conditions or both
ACCIDENT INVESTIGATION
You Must:
Conduct a preliminary
investigation for:
serious injuries with immediate
symptoms
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)
ACCIDENT INVESTIGATION
Within 8 hours of a work-related incident or
accident you must contact the nearest
office of the OSHA in person or by phone to
report
A death
A probable death
3 or more employees are sent to the hospital
(WISHA -2)
(OSHA) 1-800-321-6742
WISHA 1-800-4BE-SAFE (423-7233)
ACCIDENT INVESTIGATION
Assign witnesses and other employees
to assist OSHA personnel who arrive to
investigate the incident
Include:
The immediate supervisor
Employees who were witnesses to the
incident
Other employees the investigator feels are
necessary to complete the investigation
ACCIDENT INVESTIGATION
Make sure your preliminary
investigation is conducted by the
following people:
ACCIDENT INVESTIGATION
A preliminary investigation includes
noting information such as the following:
Where did the accident or incident
occur?
What time did it occur?
What people were present?
What was the employee doing at the
time?
What happened during the accident or
incident?
ACCIDENT INVESTIGATION
Provide the following information to OSHA
within 30 days concerning any accident
involving a fatality or hospitalization of 3 or
more employees:
Investigating Accidents
O
thers
of
A
ction
M
aintenance
M
otivation
A
bility
K
now
ledge
D
esign
Conditions
Acts
Investigation Strategy
Need For Investigation
Control the Scene
Gather Facts
Analyze Data
Establish Causes
Write Report
Take Corrective Action
Investigative Procedures
The actual procedures used in a particular
investigation depend on the nature and results
of the accident
All investigations start with a collection of data
and are followed by analysis of that data
An investigation is not complete until all data
is analyzed and a final report is completed
11
12
10
3
8
4
7
11
12
10
3
8
4
7
11
12
10
3
8
4
7
BENEFITS OF ACCIDENT
INVESTIGATION
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!
**Immediate Actions
Assess the scene
CALL 911
Control chemicals
De-energize
De-pressurize
Light it up
Shore it up
Ventilate
Fact Finding
Gather evidence from
many sources during an
investigation
Get information from
witnesses and reports as
well as by observation
Dont try to analyze data
as evidence is gathered
Gather Evidence
Examine the accident scene - Look for things
that will help you understand what happened:
Gather Evidence
Diagram the scene:
Use blank paper or graph
paper. Mark the location of
all pertinent items;
equipment, parts, spills,
persons, etc.
Note distances and sizes,
pressures and temperatures
Note direction (mark north
on the map)
Gather Evidence
Take photographs
Photograph any items or scenes which may provide an
understanding of what happened to anyone who was
not there
Photograph any items which will not remain, or which
will be cleaned up (spills, tire tracks, footprints, etc.)
35mm cameras, Polaroids, and video cameras are all
acceptable
Photographs
Unbiased Recording
Keep Log of Photos
Overall to Close-up
Color if possible
Supplement with Video
Gather Data
Data includes:
Persons involved
Date, time, location
Activities at time of accident
Equipment involved
List of witnesses
Review Records
Check training records
Was appropriate training provided?
When was training provided?
Documents
Collect All Related Documents
Inspection Logs
Policy & Procedures Manual
JSA (Job Safety Analysis)
Equipment Operations Manuals
Insurance Records
Employee Records
Police Reports
It.
Not an interpretation
Observable
Reliable
Measurable
Specific
NORMS OF OBJECTIVITY
Objective
Not an Interpretation - Based on
a factual description.
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 nondetailed descriptions.
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
Record Evidence
Keep All Notes in Bound Notebook
Include Date - Time - Place Vantage Point
Keep Originals
Rewrite in Report Form
Samples
Collect Perishables
First
Fluids
Open Containers
Filings
Chemicals
Air
Interviews
Experienced personnel should conduct
interviews
If possible the team assigned to this task
should include an individual with a legal
background
After interviewing all witnesses, the team
should analyze each witness' statement
Interviews
Analyze this information along with data
from the accident site
Not all people react in the same manner
to a particular stimulus
A witness who has had a traumatic
experience may not be able to recall the
details of the accident
A witness who has a vested interest in the
results of the investigation may offer
biased testimony
Interviews
Excellent Source of first hand knowledge
May Present Pitfalls in form of:
Bias
Perspective
Embellishment
Omissions
The Interview
Put the person at ease
People may be reluctant to
discuss the incident, particularly
if they think someone will get in
trouble
The Interview
Take Notes!
Ask open-ended questions
What did you see?
What happened?
The Interview
Use closed-ended questions later to gain
more detail
After the person has provided their
explanation, these type of questions can be
used to clarify
Where were you standing?
What time did it happen?
The Interview
Dont ask leading questions
Bad: Why was the forklift operator driving
recklessly?
Good: How was the forklift operator driving?
The Interview
Summarize what you have been told
Correct misunderstandings of the events
between you and the witness
The Interview
Get a written, signed statement from the
witness
It is best if the witness writes their own
statement; interview notes signed by the
witness may be used if the witness refuses to
write a statement
Ask Supervisors
What is normal procedure for activities
involved in the accident?
What type of training persons involved in
accident have had?
What, if anything was different today?
What they think caused the accident?
What could have prevented the accident?
Witness Interviews
DONT
DO
Separate Witnesses
Written Statements
Open ended questions
Provide Diagrams
Encourage Details
Show Concern
Record w/permission
Suggest Answers
Interrogate
Focus on Blame
Dismiss Details
Bar Emotions
Make Judgments
Root Causes
Analyze Data
Gather all photos, drawings, interview
material and other information collected
at the scene
Determine a clear picture of what
happened
Formally document sequence of events
CONTRIBUTING FACTORS
INVESTIGATION STRATEGY
INVESTIGATION TEAM
DETERMINE CAUSES
Employee actions
Safe behavior, at-risk behavior
Environmental conditions
Lighting, heat/cold, moisture/humidity, dust, vapors,
etc.
Equipment condition
Defective/operational, guards, leaks, broken parts,
etc.
Procedures
Existing (or not), followed (or not), appropriate (or
not)
Training
Was employee trained - when, by whom,
documentation
Indirect Causes
Unsafe conditions what material
conditions, environmental conditions and
equipment conditions contributed to the
accident
Unsafe Acts what activities contributed
to the accident
Basic Causes
Management
Environment
Equipment
Human Behavior
Management
Determine
What was not normal before the
accident
Where the abnormality occurred
When it was first noted
How it occurred
Report Causes
Analysis of the Accident HOW &
WHY
a. Direct causes (energy sources;
hazardous materials)
b. Indirect causes (unsafe acts and
conditions)
c. Basic causes (management policies;
personal or environmental factors)
Timeliness
Poor development of information
Reluctance to accept responsibility
Narrow interpretations of
environmental causes
Erroneous emphasis on a single cause
Allowing solutions to determine causes
Wrong person(s) investigating
PREPARE A REPORT
Accident Reports should contain
the following:
Description of incident and injuries
Sequence of events
Pertinent facts discovered during
investigation
Conclusions of the investigator(s)
Recommendations for correcting
problems
Recommendations
Action to remedy
Basic causes
Indirect causes
Direct causes
Recommendations
Consider
-Effectiveness
-Cost
-Feasibility
-Effect on Productivity
-Time to Implement
-Employee Acceptance
-Management Acceptance
Common Problems
Accidents not reported
Unable to identify basic causes
Accepting inadequate reports
Neglecting to implement corrective
actions
Neglecting to Implement
Corrective Action
The whole purpose of the investigation
process is negated if management fails to
remedy the causes
Here again, management sends a signal
to subordinates that it's not important,
and subordinates develop the attitude
that it's an exercise in futility and "why
bother?
Summary
Most accident investigations follow
formal procedures
An investigation is not concluded until
completion of a final report
A successful accident investigation
determines what happened and how and
why the accident occurred
Investigations are an effort to prevent a
similar or perhaps more disastrous
sequence of events
Problem Solving
Fault Tree
Problem Solving
Fault Tree
P IT H its W a ll
F a ilu r e T o S t o p
E n v ir o n m e n ta l
W e t F lo o r
E q u ip m e n t
B r a k e s F a il
S te e r in g F a ils
P ro c e d u ra l
Hum an
N o T r a in in g
N o In s p e c tio n
N o F lu id
D id N o t K n o w
B r e a k L in e L e a k
N o T r a in in g
S u d d e n R e le a s e
S lo w L e a k
N o P r e s h ift In s p e c tio n
In te n tio n a l O m is s io n
Problem Solving
Fault Tree
P IT H its W a ll
F a ilu r e T o S to p
E q u ip m e n t
P ro c e d u ra l
Hum an
B r a k e s F a il
T r a in in g R e q 'd
D id n o t C o n d u c t In s p e c tio n
N o F lu id
S u p .R e s p .
D id N o t K n o w
In te n tio n a l O m is s io n
B r e a k L in e L e a k
S u p v . s ic k
T r a in in g N o t R e c e iv e d
T im e ltd .
S u d d e n R e le a s e
S lo w L e a k
N o P r e s h ift In s p e c tio n
N O T R A IN IN G
Machinery
Materials
ISHIKAWA FISHBONE
DIAGRAM
Methods
EFFECT
People
Environment
ACCIDENT
ANALYSIS AND
REPORT
(Handout)
TEST