Photo: Tulalip Bay by Diane L.

Wilson-Simon
 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)
Introduction & Course Overview
 PROaction versus REaction

Well thats an accident

waiting to happen
Someone ought to do
something

That someone is YOU!

 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

BUT - We can almost always make

something SAFER
 Safety Is Better Defined As.

A Judgement of the
Acceptability of Risk
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 CONTACT WITH
same level chemicals
lower level electricity
CAUGHT heat/cold
in radiation
on BODILY
between REACTION FROM
voluntary motion
involuntary motion
Types of Accidents (continued)
STRUCK RUBBED OR
Against ABRADED BY
stationary or moving friction
object
pressure
protruding object
sharp or jagged edge vibration
By
moving or flying
object
falling object
 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
 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)
 Accident Causing Factors
Basic Causes Direct Causes
Management Slips, Trips, Falls
Environmental Caught In
Equipment Run Over
Human Behavior Chemical Exposure
Indirect Causes
Unsafe Acts
Unsafe Conditions
 Policy & Procedures
Basic Causes Environmental Conditions
Equipment/Plant Design
Human Behavior

Unsafe Indirect Causes Unsafe

Conditions
Acts
Slip/Trip Fall
Direct Causes Energy Release
Pinched Between

ACCIDENT
Personal Injury
Property Damage
Potential/Actual
 Basic Causes
Management Systems & Procedures

Environment Natural & Man-made

Equipment Design & Equipment

Human Behavior
 Management

Systems &
Procedures
Lack of systems &
procedures
Availability
Lack of Supervision
 Environment

Physical
Lighting
Temperature

Chemical Biological
vapors Bacteria
smoke Reptiles
Environment
 Design and Equipment

Design

Workplace layout
Design of tools &
equipment
Maintenance
Design and Equipment
Equipment
Suitability
Stability
Guarding

Ergonomic

Accessibility
 Human Behavior
Common to
all accidents

Not limited to person

involved in accident
 Human Factors
Omissions &
Commissions

Deviations from
SOP
Lacking Authority
Short Cuts
Remove guards
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)
 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")

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")
 Consequences Influence
Behaviors Based Upon
Individual Perceptions of:
Magnitude
{ positive
Significance or
Impact negative

Timing - immediate or future

Consistency - certain or uncertain

 Human Behavior
Behaviors that have consequences that are:

Soon
Certain
Positive

Have a stronger effect on peoples behavior

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

Thought Question:

What would you do as a worker if you

had to take 10-15 minutes to don the
correct P.P.E. to enter an area to turn off
a control valve which took 10 seconds?
 Human Behavior

Punishment or threatening workers is a

behavioral method used by some Safety
Management programs
Punishment only works if:
It is immediate
Occurs every time there is an unsafe behavior
This is very hard to do
 Human Behavior

The soon, certain, positive reinforcement

from unsafe behavior outweighs the
uncertain, late, negative reinforcement
from inconsistent punishment

People tend to respond more positively to

praise and social approval than any other
factors
 Human Behavior
Some experts believe you can change 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

Are inside a persons head -therefore they

are not observable nor measurable

Attitudes can be changed by

changing behaviors
 Human Behavior

Attention Behavioral Safety approach

Focuses on getting workers to pay
Attention
Inability to control Attention is a
contributing factor in many injuries

You cant scare workers into a safety

focus with Pay Attention campaigns
 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
 Reasons for Lack of Attention
5. Work repetition can lull workers into a loss of
attention
6. Low level of loyalty shown to employees by an
ever reorganizing employer may lead to:
a) Disinterested workers
b) Detached workers (no connection to employer)
c) Inattentive workers
 Human Behavior

Focusing on Awareness is a typical

educational approach to change safety
behavior

Example: You provide employees with a

persuasive rationale for wearing safety
glasses and hearing protection in certain
work areas
 Human Behavior
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
More Thought Questions:
a) Have you ever carried wood without wearing gloves?
b) Have you ever left something in a walkway that was a
tripping hazard?
c) Have you ever carried a stack of boxes that blocked your
view?
d) Have you ever used a tool /equipment you didnt know how
to operate?
e) Have you ever left a desk or file drawer open while you
worked in an area?
f) Have you ever placed something on a stair Just for a
minute?
g) Have you ever done anything unsafe because Ive always
done it this way?
 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!!
 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%
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
 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
 Accident Prevention Program
Safety Orientation
Description of Total Safety Program
Safe Practices for Initial Job Assignment
How and When to Report Injuries
Location of First Aid Facilities in Workplace
How to Report Unsafe Conditions & Practices
Use and Care of PPE
Emergency Actions
Identification of hazardous materials
 Accident Prevention Program
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
 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
 Safety Meeting
You Must
Review inspection reports
Evaluate accident investigations
Evaluate APP and discuss recommendations
Document attendance and topics
Safety Committees
 Proactive
Safety Committees 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

 Safety Committees
The Goal of the committee is to facilitate a safe
workplace
Objectives that guide a committee towards the goal include:
Motivate, educate and train at all levels to ID, Reduce, &
Avoid Hazards
Incorporate safety into every aspect of the organization
Create a culture where each person is responsible for
safety of self and others
Encourage and utilize ideas from all sources
 Four points to Remember:
Communication: Must be a loop system

Dedication: From everyone

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
 Safety Committee Focus
Long Term Goals
Objectives to Achieve
Time Frame
Short Term Goals
Assignments between Meetings
Work toward achieving Long-Term Plan
Planning the Safety Meeting

Select topics
Set & post the agenda
Schedule safety meeting
Prepare meeting site
Encourage participation
 Conducting A Safety Meeting
Provide an attendance list or sign in sheet
Provide a meeting agenda
Call meeting to order and review meeting topics
Cover any old business
Primary meeting topic
Future agendas
Close meeting and document
Components of an Agenda
Opening statement including reason for
attendance, objective, and time
commitment
Items to be discussed
Generate alternative solutions
Decide among the alternatives
Develop a plan to solve the problem
Assign task to carry out plan
Establish follow-up procedures
Summarize and adjourn
 Regular Agenda Item
Review Policies & Plans such as:
Hazard Communication Program
Personal Protective Equipment
Respiratory Protection
Housekeeping
Machine Safeguarding
Safety Audits
Record Keeping
Emergency Response Plans
 Emergency Plan

Anticipate What
Could Go Wrong
and Plan for
those Situations

Drill for
Emergency
Situations
 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
 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
 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
 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
HAZARD ANALYSIS
 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
 Step 1: Identify Hazards

HAZARD
condition with
the potential to
cause personal
injury, death and
property damage
 Hazard Identification
Review Records
Talk to Personnel
Accident Investigations
Follow Process Flow
Write a Job Safety Analysis
Use Inspection Checklists
 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
 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
 Who is at Risk?
Workers Contractors
Janitorial
Visitors
Maintenance
Invited
Customers
Emergency services Others
Delivery drivers Members of Public
Uninvited Passers-by
Trespassers
Neighbors
Burglars
STEP 3: Make Risk Decisions

What can we do to reduce the risk?

Does the benefit outweigh the risk?
STEP 4: Implement Controls

Substitution
Engineering controls
Administrative Controls
Personal Protective Equipment
Hazard Controls
Source

Path

Receiver
 Hazard Control
Administrative Engineering

Protective Equipment/Clothing
 Engineering
Hazard Elimination Ventilation
Add-On Safety Design Design/Layout
Active vs. Passive Safety Devices
User Instructions
(Manual)
 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
 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
Job Safety Analysis
 Job Safety Analysis Priorities
New Jobs
Potential of Severe Injuries
History of Disabling Injuries
Frequency of Accidents
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!)
 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
 Key Steps TOO MUCH
Changing 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
 Key Steps NOT ENOUGH
Changing a Flat Tire
Park car
Take off flat
tire
Put on spare
tire
Drive away
 Key Job Steps JUST RIGHT
Changing 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
 Job Safety Analysis
Steps
Park & set
brake
Remove
Spare &
Jack
Loosen lugs
 Job Safety Analysis
Steps Hazards
Park & set Hit by
brake traffic

Remove Spare Back

& Jack Strain
Foot/Toe
impact

Loosen lugs Shoulder

strain
 Job Safety Analysis
Steps Hazards Prevention
Park & set Hit by Far off road as
brake traffic possible
Remove Spare Back Strain Pull items close
& Jack before lift
Foot/Toe Lift in increments
impact Lift and lower
using leg power
Wide leg stance
Loosen lugs Shoulder Use full body, not
strain arm/shoulder
 Develop Solutions
Find a new way Fix-A-Flat
to do job

Change physical No off-road

conditions that driving
create hazards
Change the work
procedure Buy self-sealing
Reduce tires
frequency Maintenance /
Change-out
program
JSA EXERCISE
INSPECTIONS
 Inspections
Fact-Finding vs. Fault Finding
Sound knowledge of the plant
Knowledge of relevant standards & codes
Systematic inspection steps
Method of evaluating data
 Inspection Limitations
Blinder affect
Rote inspections
All Check - No action
Who is inspecting?
 Outcomes
Improve Safety
New Way to Do Job
Change Physical Conditions
Change Work Procedures
Reduce Frequency of Dangerous Job
 New Way To Do The Job
Determine the work goal of the job, and
then analyze the various ways of reaching
this goal to see which way is safest
Consider work saving tools and
equipment
Change in Physical Conditions

Tools, materials, equipment layout or

location
Study change carefully for other benefits
(costs, time savings)
 Change in Work Procedures
What should the worker do to eliminate
the hazard?
How should it be done?
Document changes in detail
 Reduce Frequency of
Dangerous Job
What can be done to reduce the
frequency of the job??
Identify parts that cause frequent repairs
- change
Reduce vibration save machine parts
Performing Safety Audits
Guide for Personal Audits

The guide has five steps

Audit
React
Communicate
Follow up
Raise standards
 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
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:
1. Acceptable because...
2. Not acceptable because...
3. Deteriorated because...
4. Improved because
 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
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
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
 Inspections and Field
Observations

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

Plan Development
comes from where the
work is actually done
Safety Committee
and hazards actually
exist.
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
Accidents are What Happens to
Somebody Else

BUT REMEMBER:
YOU
are somebody else
to somebody else
 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

ACCIDENTS HAVE TWO THINGS IN

COMMON
 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
Injury & possible death
Disease
Damage to equipment & property
Litigation costs, possible citations
Lost productivity
Morale
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
 Indirect and Root Causes
Unsafe acts and conditions are the indirect
causes or symptoms of accidents
Indirect causes are usually traceable to:
poor management policies and decisions
personal or environmental factors
Root causes are the actual policies and
decisions by management and the actual
personal and environmental factors of the
workplace
ACCIDENT INVESTIGATION

You Must:
Conduct a preliminary
investigation for:
serious injuries with immediate
symptoms

Document the investigation

findings
 ACCIDENT INVESTIGATION
Do Not move equipment involved in a work
or work related accident or incident if :
A death
A probable death
3 or more employees are sent to the hospital
(WISHA -2)
Unless, Moving the equipment is necessary
to:
Remove any victims
Prevent further incidents and injuries
 ACCIDENT INVESTIGATION
Within 8 hours of a work-related incident or
accident you must contact the nearest
office of the OSHA in person or by phone to
report
A death
A probable death
3 or more employees are sent to the hospital
(WISHA -2)
(OSHA) 1-800-321-6742
WISHA 1-800-4BE-SAFE (423-7233)
 ACCIDENT INVESTIGATION
Assign witnesses and other employees
to assist OSHA personnel who arrive to
investigate the incident
Include:
The immediate supervisor
Employees who were witnesses to the
incident
Other employees the investigator feels are
necessary to complete the investigation
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
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:
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
 Why Not Rely On OSHA &
Police To Investigate?
Focus On Culpability
Minor Accidents Not
Investigated
PREVENTION
Protect Company
Interests
OSHA Requirements
 Investigating Accidents

How to find out what really happened

 Why Investigate Accidents?
Find the cause
Prevent similar accidents
Protect company interests
At which level do we investigate?

Death
Lost Time
Injury
Reportable Injury

Minor Injuries

Near Misses

Acts Conditions

aintenance
ledge

otivation

esign
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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
 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?
 The Aim of the Investigation
IS NOT TO:
Exonerate individuals or management

Satisfy insurance requirements

Defend a position for legal argument

Or, to assign blame

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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
 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
 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!
 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
 **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
 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
 Provide Care to the Injured
Ensure that medical care is provided to
the injured people before proceeding
with the investigation
 Secure the Scene for Safety
Eliminate the hazards:
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:
Dents, cracks, scrapes, splits, etc. in equipment
Tire tracks, footprints, etc.
Spills or leaks
Scattered or broken parts
Any other possible evidence
 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
Digital cameras are not recommended -
digital images can be easily altered
 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?
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?
 Documents
Collect All Related Documents
Inspection Logs
Policy & Procedures Manual
JSA (Job Safety Analysis)
Equipment Operations Manuals
Insurance Records
Employee Records
Police Reports
Those who do not know the
past are destined to:
Repeat
Repeat
Repeat
Repeat
Repeat
Repeat

It.
 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
 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.
 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
 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
 Ask What Happened
Get a brief overview of
the situation from
witnesses and victims
Not a detailed report
yet, just enough to
understand the basics
of what happened
Interview Victims & Witnesses
Interview as soon as possible
after the incident
Do not interrupt medical care
to interview
Interview each person
separately
Do not allow witnesses to
confer prior to interview
 The Interview
Put the person at ease
People may be reluctant to
discuss the incident, particularly
if they think someone will get in
trouble

Reassure them that this is a

fact-finding process only
Remind them that these facts
will be used to prevent a
recurrence of the incident
 The Interview
Take Notes!
Ask open-ended questions
What did you see?
What happened?
Do not make suggestions
If the person is stumbling over a word or
concept, do not help them out
 The Interview
Use closed-ended questions later to gain
more detail
After the person has provided their
explanation, these type of questions can be
used to clarify
Where were you standing?
What time did it happen?
 The Interview
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
 The Interview
Summarize what you have been told
Correct misunderstandings of the events
between you and the witness

Ask the witness/victim for

recommendations to prevent recurrence
These people will often have the best
solutions to the problem
 The Interview
Get a written, signed statement from the
witness
It is best if the witness writes their own
statement; interview notes signed by the
witness may be used if the witness refuses to
write a statement
 Ask All Witnesses
Name, address, phone number
What did you see?
What did you hear?
Where were you standing/sitting?
What do you think caused the accident?
Was there anything different today?
 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
DO DONT
Separate Witnesses Suggest Answers
Written Statements Interrogate
Open ended questions Focus on Blame
Provide Diagrams Dismiss Details
Encourage Details
Bar Emotions
Show Concern
Make Judgments
Record w/permission
 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?
 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

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?
 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
 Breakdown of Unsafe Conditions

Inadequately guarded or
unguarded equipment
Defective tools, equipment or
materials
Fire and explosion hazard
Unexpected movement hazard
Projection hazards
 Breakdown of Unsafe Conditions

Housekeeping
Hazardous environmental conditions
Improper ventilation
Improper illumination
Unsafe dress or apparel
 Breakdown of Unsafe Acts
Operating without authority
Operating or working at unsafe speeds
Making safety devices inoperative
Using unsafe equipment
Neglecting to wear PPE
Unsafe loading, placing, mixing, combining
Taking unsafe position or posture
 Basic Causes
Management Systems & Procedures

Environment

Equipment Design & Equipment

Human Behavior
 Management
Was a hazard assessment conducted?
Were the hazards recognized?
Was control of the hazards addressed?
Were employees trained?
Did supervision detect/correct deviations?
Was Supervisor trained in job/accident
prevention?
What were the production rates?
 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?
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.
 What controls failed?
List the specific engineering,
administrative and training controls that
failed and how these failures contributed
to the accident
 What controls worked?
List any controls that prevented a
more serious accident or
minimized collateral damage or
injuries
 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)
 Unable to Identify Root Causes
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
PREPARE A REPORT, (CONT.)
Be objective!
State facts
Assign cause(s), not blame
If referring to an individuals actions, dont
use names in the recommendation
Good: All employees should.
Bad: George should..
 Recommendations
Action to remedy
Basic causes
Indirect causes
Direct causes

Recommendations - as a result of the finding is

there a need to make changes to:
Employee training?
Work Stations Design?
Policies or procedures?
 Recommendations
Consider
-Effectiveness -Cost
-Feasibility -Effect on Productivity
-Time to Implement -Employee Acceptance
-Management Acceptance
Accepting Inadequate Reports
There is no surer way to destroy a
program's effectiveness than to accept
substandard work
This immediately sends a signal to
subordinates that accident investigation
is not a high priority and does not receive
significant attention from management
 Common Problems
Accidents not reported
Unable to identify basic causes
Accepting inadequate reports
Neglecting to implement corrective
actions
 Accidents Not Reported
Nothing is learned from unreported
accidents
Accident causes are left uncorrected
Infections and injury aggravations result
Neglecting to report tends to spread and
become a common practice
 Why Workers Fail to Report
Fear of discipline
Concern for reputation
Fear of medical treatment
Desire to keep personal record clean
Avoidance of red tape
Concern about attitudes of others
Poor understanding of importance
 Combat Reporting Problems
Indoctrinate new employees
Encourage workers to report minor accidents
Focus on accident prevention and loss control
Be positive
Discuss past accidents
Take corrective action promptly
 Neglecting to Implement
Corrective Action
The whole purpose of the investigation
process is negated if management fails to
remedy the causes
Here again, management sends a signal
to subordinates that it's not important,
and subordinates develop the attitude
that it's an exercise in futility and "why
bother?
 Improving the Quality of
Accident Investigation
Insist on reporting of all injuries
Adopt a well-designed accident report form
Train all levels of management
Insist on the investigation of all accidents
Participate actively in serious accident
investigations
 Improving the Quality of
Accident Investigation
Review and comment
Refuse to accept inadequate reports
Establish controls to follow up on corrective
actions
Be responsive to recommendations
Hold responsible persons accountable
Emphasize that accident investigations are
FACT-finding, not FAULT-finding
Encourage investigators to challenge the system
 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
Other Accident Investigation Tools
 Problem Solving
Fault Tree

Deductive, top-down method of analyzing

Identify all elements that could cause
Accident
Performed graphically using AND and OR
gates
Create symbolic representation of events
resulting in the Accident
Entire system and human interactions are
analyzed
 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 E q u ip m e n t P ro c e d u ra l Hum an

W e t F lo o r B r a k e s F a il S te e r in g F a ils 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 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 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
 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

D id n o t C o n d u c t In s p e c tio n
B r a k e s F a il T r a in in g R e q 'd

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 T R A IN IN G

N o P r e s h ift In s p e c tio n
 ISHIKAWA FISHBONE
DIAGRAM
Machinery Methods

EFFECT

Materials People Environment

 FIVE WHYs DIAGRAM
Undesired Event
Why?
Direct Cause
Why?
Contributing Cause
Why?
Contributing Cause
Why?
Contributing Cause
Why?
Root Cause
 ACCIDENT
ANALYSIS AND
REPORT
(Handout)
TEST