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Introduction & Course Overview PROaction versus REaction “Well that’s an accident waiting to happen…” “Someone ought to do something…” That someone is.

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Presentation on theme: "Introduction & Course Overview PROaction versus REaction “Well that’s an accident waiting to happen…” “Someone ought to do something…” That someone is."— Presentation transcript:

1

2 Introduction & Course Overview

3 PROaction versus REaction “Well that’s an accident waiting to happen…” “Someone ought to do something…” That someone is YOU!

4

5 Accident Prevention

6 What Is An Accident?

7

8 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

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

10 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

11 Safety FREEDOM FROM DANGER OR HARM Nothing is Free of BUT - We can almost always make something SAFER

12 Safety Is Better Defined As…. A Judgement of the Acceptability of Risk

13 RATIOSRATIOS

14 OSHA METHOD 330 Incidents 29 Minor Injuries 1 Major or Loss-Time Accident

15 Candy Jar Example

16 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

17 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

18 Fatal Accidents - Workplace U.S. WORKPLACE FATALITIES - 2006 1. Vehicle Accidents2413 2. Contact With Objects and Equipment 983 3. Falls809 4. Assaults & Violent Acts754

19 Fatal Accidents - Workplace Washington State FATALITIES - 2006 1. Vehicle Accidents40 2. Contact With Objects and Equipment 13 3. Falls19 4. Assaults & Violent Acts4 NONOTE:If you wish to normalize or compare the Washington data with the Federal data, just multiply the Washington numbers by 47 (based on population)

20 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

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

22 Basic Causes Management Environment Equipment Human Behavior Systems & Procedures Natural & Man-made Design & Equipment

23 Management Systems & Procedures –Lack of systems & procedures –Availability –Lack of Supervision

24 Environment Physical –Lighting –Temperature Chemical –vapors –smoke Biological –Bacteria –Reptiles

25 Environment

26 Design and Equipment Design –Workplace layout –Design of tools & equipment –Maintenance

27 Design and Equipment Equipment –Suitability –Stability Guarding Ergonomic Accessibility

28 Human Behavior Common to all accidents Not limited to person involved in accident

29 Human Factors Omissions & Commissions Deviations from SOP –Lacking Authority –Short Cuts –Remove guards

30 Competencies (how it needs to be done) Human Behavior is a function of : Activators (what needs to be done) Consequences (what happens if it is/isn’t done)

31 ABC Model Antecedents (trigger behavior) Behavior (human performance) Consequences (either reinforce or punish behavior)

32 Positive Reinforcement (R+) ("Do this & you'll be rewarded") Negative Reinforcement (R-) ("Do this or else you'll be penalized") Only 4 Types of Consequences: Behavior Punishment (P) ("If you do this, you'll be penalized") Extinction (E) ("Ignore it and it'll go away")

33 Consequences Influence Behaviors Based Upon Individual Perceptions of:  Timing - immediate or future  Consistency - certain or uncertain Significance { Magnitude Impact positive or negative

34 Human Behavior Behaviors that have consequences that are: Soon Certain Positive Have a stronger effect on people’s behavior

35 Some examples of Consequences:

36 Why is one sign often ignored, the other one often followed?

37 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

38 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

39 Human Behavior Positive A positive consequence influences behavior more powerfully than a negative consequence Penalties and Punishment don’t work Speeding Ticket Analogy

40 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)

41 Deviations from SOP No Safe Procedure Employee Didn’t know Safe Procedure Employee knew, did not follow Safe Procedure Procedure encouraged risk-taking Employee changed approved procedure

42 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?

43 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

44 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

45 Human Behavior Some experts believe you can change worker’s safety behavior by changing their “Attitude” Accident Report – “Safety Attitude” A person’s “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”

46 A re inside a person’s head -therefore they are not observable nor measurable Attitudes can be changed by changing behaviors however Attitudes

47 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 can’t scare workers into a safety focus with “Pay Attention” campaigns

48 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

49 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

50 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

51 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

52 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?

53 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 didn’t 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 “I’ve always done it this way”?

54 Human Behavior TIME! “All this safety stuff takes time doesn’t it”? “I’m too busy”! “I can’t possibly do all this”! “The boss wants the job done now”!

55 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!!

56 Safety Intervention Strategies Approach # of Studies # of Subjects Reduction % Behavior Based 72,444 59.6% Ergonomics 3n/a 51.6% Engineering Change 4 n/a 29.0% Problem Solving 1 76 20.0% Gov’t. Action 2 2 18.3% Mgt. Audits 4n/a 17.0% Stress Management 21,300 15.0% Poster Campaign 26100 14.0% Personnel Selection 26 19,177 3.7% Near-miss Reports 2n/a 0%

57 OUTCOMES OF ACCIDENTS NEGATIVE OUTCOMES POSITIVE OUTCOMES

58 $ Direct Costs Medical Insurance Lost Time Fines

59 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

60 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

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

62 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

63 “REAL” Costs

64

65 OUTCOMES OF ACCIDENTS POSITIVE ASPECTS –Accident investigation –Prevent repeat of accident –Improved safety programs –Improved procedures –Improved equipment design

66 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

67 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

68 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

69 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

70 Safety Meeting You Must –Review inspection reports –Evaluate accident investigations –Evaluate APP and discuss recommendations –Document attendance and topics

71 Safety Committees

72 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 Proactive Safety

73 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

74 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.

75 How effective can a Committee be?

76 Safety Committee Policy Statement A written and publicized statement is an effective means of providing guidance and demonstrating commitment

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

78 Planning the Safety Meeting Select topics Set & post the agenda Schedule safety meeting Prepare meeting site Encourage participation

79 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

80 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

81 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

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

83 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

84 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

85 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

86 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

87 HAZARD ANALYSIS

88 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

89 Step 1: Identify Hazards HAZARD – condition with the potential to cause personal injury, death and property damage

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

91 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

92 Levels of Risk Awareness Unaware: Doesn’t 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

93 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

94 STEP 3: Make Risk Decisions What can we do to reduce the risk? Does the benefit outweigh the risk?

95 STEP 4: Implement Controls Substitution Engineering controls Administrative Controls Personal Protective Equipment

96 Hazard Controls Source Path Receiver

97 Hazard Control Administrative Engineering Protective Equipment/Clothing

98 Engineering Hazard Elimination Add-On Safety Design “Active” vs. “Passive” User Instructions (Manual) Ventilation Design/Layout Safety Devices

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

100 Step 5: Supervise Ensure risk control measures are implemented Track progress Feedback

101 JOB SAFETY ANALYSIS

102 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

103 Job Safety Analysis

104 Job Safety Analysis Priorities New Jobs New Jobs Potential of Severe Injuries Potential of Severe Injuries History of Disabling Injuries History of Disabling Injuries Frequency of Accidents Frequency of Accidents

105 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!)

106 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

107 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

108 Key Steps NOT ENOUGH Changing a Flat Tire Park car Take off flat tire Put on spare tire Drive away

109 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

110 Job Safety Analysis Steps –Park & set brake –Remove Spare & Jack –Loosen lugs

111 Job Safety Analysis Hazards –Hit by traffic –Back Strain –Foot/Toe impact –Shoulder strain Steps –Park & set brake –Remove Spare & Jack –Loosen lugs

112 Job Safety Analysis Hazards –Hit by traffic –Back Strain –Foot/Toe impact –Shoulder strain Steps –Park & set brake –Remove Spare & Jack –Loosen lugs 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

113 Develop Solutions Find a new way to do job Change physical conditions that create hazards Change the work procedure Reduce frequency Fix-A-Flat No off-road driving Buy self-sealing tires Maintenance / Change-out program

114 JSA EXERCISE

115 INSPECTIONS

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

117 Inspection Limitations “Blinder affect” Rote inspections All Check - No action Who is inspecting?

118 Outcomes Improve Safety –New Way to Do Job –Change Physical Conditions –Change Work Procedures –Reduce Frequency of Dangerous Job

119 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

120 Change in Physical Conditions Tools, materials, equipment layout or location Study change carefully for other benefits (costs, time savings)

121 Change in Work Procedures What should the worker do to eliminate the hazard? How should it be done? Document changes in detail

122 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

123 Performing Safety Audits

124 Guide for Personal Audits The guide has five steps Audit React Communicate Follow up Raise standards

125 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

126 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…

127 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

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

129 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

130 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

131 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

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

133 Inspections and Field Observations Use a checklist Ask questions Take notes Respect lines of communication Draw conclusions

134 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

135 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

136 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

137

138 Management Commitment Should Management Consider Safety as a Priority in Conducting Business ??

139 Management Commitment NO !

140 PRIORITIES CHANGE SAFETY MUST BE A VALUE!!

141 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.

142 SHARED VISION EXERCISE

143 AVAILABLE RESOURCES OSHA Website: www.osha.gov Washington State Labor & Industries Website: www.lni.wa.gov

144 ACCIDENT INVESTIGATION

145 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

146 THE ACCIDENT WHAT IS AN ACCIDENT?

147 THE ACCIDENT An unplanned and unwelcome event that interrupts normal activity

148 Accidents are What Happens to Somebody Else BUT REMEMBER: YOU are somebody else to somebody else

149 THE ACCIDENT MINOR ACCIDENTS: Such as paper cuts to fingers or dropping a box of materials

150 THE ACCIDENT MORE SERIOUS ACCIDENTS Such as a forklift dropping a load or someone falling off a ladder

151 THE ACCIDENT Accidents that occur over an extended time frame: –Such as hearing loss or an illness resulting from exposure to chemicals

152 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!

153 THE ACCIDENT ACCIDENTS HAVE TWO THINGS IN COMMON

154 THE ACCIDENT They all have outcomes from the accident

155 THE ACCIDENT They all have contributory factors that cause the accident

156

157 OUTCOMES OF ACCIDENTS NEGATIVE Results – Injury & possible death – Disease – Damage to equipment & property – Litigation costs, possible citations – Lost productivity – Morale

158 OUTCOMES OF ACCIDENTS POSITIVE Results – Accident investigation – Prevent repeat of accident – Change to safety programs – Change to procedures – Change to equipment design

159 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

160 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

161 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

162 ACCIDENT INVESTIGATION Conduct a preliminary investigation for: –serious injuries with immediate symptoms Document the investigation findings You Must:

163 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

164 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)

165 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

166 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

167 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?

168 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

169 Why Not Rely On OSHA & Police To Investigate? Focus On Culpability Minor Accidents Not Investigated PREVENTION Protect Company Interests OSHA Requirements

170 Investigating Accidents How to find out what really happened

171 Why Investigate Accidents? Find the cause Prevent similar accidents Protect company interests

172 At which level do we investigate?

173 Investigation Strategy Need For InvestigationNeed For Investigation Control the SceneControl the Scene Gather FactsGather Facts Analyze DataAnalyze Data Establish CausesEstablish Causes Write ReportWrite Report Take Corrective ActionTake Corrective Action

174 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

175 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?

176 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

177 121 2 5 4 7 8 6 39 10 11

178 121 2 5 4 7 8 6 39 10 11

179 121 2 5 4 7 8 6 39 10 11

180 COMPANY ACCIDENT FORMS Must be filled out completely by the employee and employee’s immediate supervisor (this includes foremen) Must be turned in to Safety within 24 hours of incident

181 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

182 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!

183 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

184 **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

185 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

186 Provide Care to the Injured Ensure that medical care is provided to the injured people before proceeding with the investigation

187 Secure the Scene for Safety Eliminate the hazards: –Control chemicals –De-energize –De-pressurize –Light it up –Shore it up –Ventilate

188 Fact Finding Gather evidence from many sources during an investigation Get information from witnesses and reports as well as by observation Don’t try to analyze data as evidence is gathered

189 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

190 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)

191 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

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

193 Gather Data Data includes: –Persons involved –Date, time, location –Activities at time of accident –Equipment involved –List of witnesses

194 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?

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

196 Those who do not know the past are destined to: Repeat It.

197 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

198 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 don’t agree on what they observed. Non-Measurable - A number isn’t used. General - Based on non- detailed descriptions.

199 INVESTIGATION TRAPS Put your emotions aside! –Don’t 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

200 Record Evidence Keep All Notes in Bound Notebook Include Date - Time - Place – Vantage Point Keep Originals Rewrite in Report Form

201 Samples Collect Perishables First Fluids Open Containers Filings Chemicals Air

202 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

203 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

204 Interviews Excellent Source of first hand knowledge May Present Pitfalls in form of: –Bias –Perspective –Embellishment –Omissions

205 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

206 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

207 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

208 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

209 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?”

210 The Interview Don’t 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

211 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

212 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

213 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?

214 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?

215 Witness Interviews DO Separate Witnesses Written Statements Open ended questions Provide Diagrams Encourage Details Show Concern Record w/permission DON’T Suggest Answers Interrogate Focus on Blame Dismiss Details Bar Emotions Make Judgments

216 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 didn’t they do that? Why did the unsafe condition exist? Why wasn’t it corrected?

217 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

218 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?

219 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

220 Indirect Causes Unsafe conditions – what material conditions, environmental conditions and equipment conditions contributed to the accident Unsafe Acts – what activities contributed to the accident

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

222 Breakdown of Unsafe Conditions Housekeeping Hazardous environmental conditions Improper ventilation Improper illumination Unsafe dress or apparel

223 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

224 Basic Causes Management Environment Equipment Human Behavior Systems & Procedures Design & Equipment

225 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?

226 FIND ROOT CAUSES When you have determined the contributing factors, dig deeper! –If employee error, what caused that behavior? –If defective machine, why wasn’t it fixed? –If poor lighting, why not corrected? –If no training, why not?

227 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.

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

229 What controls worked? List any controls that prevented a more serious accident or minimized collateral damage or injuries

230 Determine What was not normal before the accident Where the abnormality occurred When it was first noted How it occurred

231 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)

232 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

233 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

234 PREPARE A REPORT, (CONT.) Be objective! –State facts –Assign cause(s), not blame –If referring to an individual’s actions, don’t use names in the recommendation Good: All employees should……. Bad: George should……..

235 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?

236 Recommendations Consider -Effectiveness -Cost -Feasibility -Effect on Productivity -Time to Implement -Employee Acceptance -Management Acceptance

237 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

238 Common Problems Accidents not reported Unable to identify basic causes Accepting inadequate reports Neglecting to implement corrective actions

239 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

240 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

241 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

242 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?

243 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

244 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

245 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

246 Other Accident Investigation Tools

247 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

248 Problem Solving Fault Tree

249

250 ISHIKAWA “FISHBONE” DIAGRAM Machinery Methods Materials People Environment EFFECT

251 FIVE WHYs DIAGRAM Undesired Event Why? Direct Cause Why? Contributing Cause Why? Contributing Cause Why? Contributing Cause Why? Root Cause

252

253 ACCIDENT ANALYSIS AND REPORT (Handout)

254 TEST


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