Introduction & Course Overview

Introduction & Course Overview

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

Accident Prevention

What Is An Accident? Call an Ambulance "EVACUATE" F I R E "9 1 1"
CRASH F I R E Get Class Ideas as to what an “Accident” is. # # *% ! Call an Ambulance

What Is An Accident? L U C K Y "Just Missed !" Near Miss "Whhoooaaa!"
"That Was Close" "Just Missed !" "Whhoooaaa!" # # *% ! Near Miss Get Class Ideas as to what an “Accident” is. "Watch Out" Almost Hit L U C K Y

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.

Hazard Existing or Potential Condition That Alone or Interacting With Other Factors Can Cause Harm A Spill on the Floor Broken Equipment Unsafe Conditions – examples Poor housekeeping , Blocked walkways, Improper or damaged PPE Machine guards removed, Exposed electrical wires Slippery floors, Physical Factors – noise, vibration, illumination, temperature extremes Chemical Factors – exposures that may impair a worker’s skill, reactions, Judgment Ergonomic Factors –workstation design, habits,

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 More people are injured or killed each day while driving their automobiles. Driving a car is risky. We accept that risk, WHY? Rules in place to protect us (Engineering and Administrative) Equipment in place to protect us (Engineering and PPE) Training in place to protect us. (Administrative) Perceive the benefits outweigh the risks

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 CAUGHT CONTACT WITH BODILY REACTION FROM
same level lower level CAUGHT in on between CONTACT WITH chemicals electricity heat/cold radiation BODILY REACTION FROM voluntary motion involuntary motion

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

Fatal Accidents - Workplace
U.S. WORKPLACE FATALITIES 1. Vehicle Accidents 2. Contact With Objects and Equipment 983 3. Falls 4. Assaults & Violent Acts Some 6,023 fatal work injuries occurred during 1999, nearly the same as 1998’s total, though more people were employed in Decreases in job-related deaths from homicides and electrocutions in 1999 were offset by increases from workers struck by falling objects or caught in running machinery. Washington state Transportation Accidents (43%) Contact w/objects & Equipment (25%) Falls (10%) Homicide (10%) Homicides fell from the second-leading cause of fatal work injuries to the third, behind highway fatalities, which remained the number one occupational killer, and falls.

Fatal Accidents - Workplace
Washington State FATALITIES 1. Vehicle Accidents 2. Contact With Objects and Equipment 13 3. Falls 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) Some 6,023 fatal work injuries occurred during 1999, nearly the same as 1998’s total, though more people were employed in Decreases in job-related deaths from homicides and electrocutions in 1999 were offset by increases from workers struck by falling objects or caught in running machinery. Washington state Transportation Accidents (43%) Contact w/objects & Equipment (25%) Falls (10%) Homicide (10%) Homicides fell from the second-leading cause of fatal work injuries to the third, behind highway fatalities, which remained the number one occupational killer, and falls.

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 Normally three cause levels: Most accidents are preventable by eliminating one or more causes. At the lowest level, 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. Unsafe acts and conditions are the INDIRECT CAUSES or symptoms. In turn, indirect causes are usually traceable to poor management policies and decisions, or to personal or environmental factors. These are the BASIC CAUSES.

Unsafe Conditions Unsafe Acts ACCIDENT Policy & Procedures
Environmental Conditions Equipment/Plant Design Human Behavior Basic Causes Indirect Causes Unsafe Conditions Unsafe Acts Slip/Trip Fall Energy Release Pinched Between Direct Causes Accidents are usually complex. May have10 or more events that can be causes. ACCIDENT Personal Injury Property Damage Potential/Actual

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

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

Environment Physical Chemical Biological Lighting Temperature vapors
smoke Biological Bacteria Reptiles

Environment

Design and Equipment Design Workplace layout Design of tools &
Maintenance

Design and Equipment Equipment Guarding Ergonomic Accessibility
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 Unsafe Acts - examples Unauthorized operation or repair of equipment, Running - Horse Play, Not following procedures Improper use of chemicals By-passing safety devices, Not using protective equipment, influence of drugs or alcohol, Improper lifting, Not cleaning up spills immediately REAL CONCERN IS WHY THE DEVIATION OCCURRED. 1. No known standard for safe job procedure --Perform JSA and develop good JIT 2.Employee did not know the safe procedures --Train in the correct procedure 3.Employee knew, bud did not follow safe procedures;Work pressure, difficulty , time consuming, prior success Countermeasure: Employee performance evaluation, test validity of procedure, counsel employees/manager’s, change work procedures, job requirements, Train 4.Employee knew and followed safe procedures --Develop safe procedures - train 5.Procedure encouraged risk-taking (incentive pay) --Change unsafe job design, procedure or incentive program 6.Employee changed the approved procedure or bypassed safety equipment--Evaulate safety measures, change safety methods so they can not be bypassed 7.Individual Characteristics -- Counsel employees, consider change in work procedures, workstation design or job requirements, in-depth training. Unsafe Acts - system approach. Management and Worker Responsibility

Human Behavior is a function of :
Activators (what needs to be done) Competencies (how it needs to be done) management needs to understand the forces that drive human behavior. The three forces are: activators, competencies, and consequences. Activators precede behavior. If activators are effective then they get the right behaviors started. Competencies are the skills and abilities that people possess now or will need to posses in order to perform the desired functions. Competencies are demonstrated on the job in the form of behaviors. Consequences are the most powerful force. The consequences of a person’s actions determine whether he or she will continue or increase the desired behavior or discontinue or decrease it. The challenge is to use consequences in a strategic and honest way in order to create a win/win situation for everyone, not a win/win for some and a win/lose situation for others. Consequences (what happens if it is/isn’t done)

(either reinforce or punish behavior)
ABC Model Antecedents (trigger behavior) Behavior (human performance) Consequences (either reinforce or punish behavior) The ABC model of behavior change has 3 components that lend it it’s name: Antecedents (also frequently referred to as activators) are objects, people, sensory perceptions, or environmental stimuli that serve as the trigger for a particular behavior. For example, seeing a stop sign is a trigger for a driver to slow down and cover the brake before coming to a stop. Behavior, as we have already said, is anything that you are able to observe a person do - walk, sit, stand, grasp, lift, read, sleep, etc.. Consequences are what the person who performs the behavior perceives or actually receives when he/she demonstrates a particular behavior. Consequences can either reinforce behavior (leading to an increase in performance) or punish or work to make the behavior extinct (leading to a decrease in performance).

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") Key Concepts Extinction (essentially there’s no consequence). Seldom used in business to decrease undesired safety behaviors, but commonly (unknowingly) used to decrease desired safety behaviors. (Mgrs./Peers never saying thanks for cleaning up that spill/picking up that tool etc.) Crying Baby example. Punishment: Very effective & essential -- there always will be behaviors that cannot be tolerated. We need to understand how the punishment affects the person being punished. WHEN WOULD YOU USE PUNISHMENT? (Severe situations, repeated violations, knowingly disregard) Positive and Negative Reinforcement can both increase behavior, but Positive gives the benefit of discretionary effort. Positive Reinforcement is not necessarily always beneficial: it can increase undesired behavior as well (ex: peer support for violating safety rules, slack enforcement results in +reinforcement to continue bad behavior) Consequences are negative or positive based upon receiver’s perception, not sender’s intent

Consequences Influence Behaviors Based Upon Individual Perceptions of:
{ positive or negative Magnitude Significance Impact Timing - immediate or future Consistency - certain or uncertain Consequences influence behavior based upon three factors: timing, consistency, and significance. Significance is dependent on magnitude and impact. The different combinations of these factors will determine the likelihood of behavior increasing or decreasing in the future. Timing: Is the consequence immediate or does it happen in the future? For example, the consequence of putting your hand on a red hot burner on the stove is immediate - pain!! The consequence of not exercising for most of your adult life is not so immediate. Poor health in old age may come years down the road from now. More Timely the consequence the more influencing/effective. Consistency: Is the consequence certain to happen or is there uncertainty? For example, if everyone who smoked cigarettes was guaranteed that by the time they had smoked their third cigarette they would have developed lung cancer, you’d have a lot less smokers. Because of the high degree of uncertainty of contracting lung cancer due to smoking, many people still smoke. Significance refers to whether the consequence is viewed as positive or negative by the person who receives the consequence. If I find that a friendly pat on the back by my boss is a positive stroke, another female co-worker may see that hand on her shoulder as a sign of sexual harassment - very negative. Significance means is the consequence of large or small magnitude and what impact does it have on the person receiving it.

Human Behavior Behaviors that have consequences that are: Soon Certain
Positive Have a stronger effect on people’s 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 don’t 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 Didn’t know Safe Procedure Employee knew, did not follow Safe Procedure Procedure encouraged risk-taking Employee changed approved procedure 1. No known standard for safe job procedure --Perform JSA and develop good JIT 2.Employee did not know the safe procedures --Train in the correct procedure 3.Employee knew, bud did not follow safe procedures;Work pressure, difficulty , time consuming, prior success Countermeasure: Employee performance evaluation, test validity of procedure, counsel employees/manager’s, change work procedures, job requirements, Train 4.Employee knew and followed safe procedures --Develop safe procedures - train 5.Procedure encouraged risk-taking (incentive pay) --Change unsafe job design, procedure or incentive program 6.Employee changed the approved procedure or bypassed safety equipment--Evaulate safety measures, change safety methods so they can not be bypassed 7.Individual Characteristics -- Counsel employees, consider change in work procedures, workstation design or job requirements, in-depth training.

Human Behavior Thought Question:
What would you do as a worker if you had to take 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 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”

Attitudes however Are inside a person’s head -therefore they are not observable nor measurable Attitudes can be changed by changing behaviors We often hear managers talk about an employee having a “bad attitude towards safety” or a “bad attitude about work in general” or that an employee “has a good attitude towards his/her job.” These statements reflect an overall perception that has been formed by observing a series of behaviors over time. Unfortunately they are not precise enough statements to allow us to pinpoint the specific behaviors that were being observed over time that led to this perception. You cannot see a person’s attitude. You can see his/her behaviors and form an opinion on what is causing that “attitude” but you can never be 100% certain that you are right. If our perception of a person’s attitude is based on our observation of his/her behaviors, remember that we just said that we can manage behaviors. If we can manage behaviors effectively enough we can get people to perform differently. If they perform differently long enough and are provided with positive reinforcement for their behavior changes, their attitude towards a particular work task will begin to change. How we manage behaviors will determine if that attitude change takes place quickly or slowly. If we use the technique of positive reinforcement we are likely to see the most rapid change. If we use mostly negative reinforcement and punishment we will probably see a slow change in attitude or perhaps very little change at all.

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

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

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

Human Behavior More Thought Questions:
Have you ever carried wood without wearing gloves? Have you ever left something in a walkway that was a tripping hazard? Have you ever carried a stack of boxes that blocked your view? Have you ever used a tool /equipment you didn’t know how to operate? Have you ever left a desk or file drawer open while you worked in an area? Have you ever placed something on a stair “Just for a minute”? Have you ever done anything unsafe because “I’ve always done it this way”?

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”!

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 , % Ergonomics n/a % Engineering Change n/a % Problem Solving % Gov’t. Action % Mgt. Audits n/a % Stress Management , % Poster Campaign % Personnel Selection , % Near-miss Reports n/a % National Safety Council

OUTCOMES OF ACCIDENTS NEGATIVE OUTCOMES POSITIVE OUTCOMES

$ Direct Costs Medical Insurance Lost Time Fines
National Safe Workplace Institute - FATALITIES

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 On a $2500 base penalty, that's up to $875 dollars per serious violation. Taken from

Indirect Costs Injured, Lost Time Wages Non-Injured, Lost Time Wages
Overtime Supervisor Wages Lost Bonuses Employee Morale Need For Counseling Turn-over From the perspective of the witness/victim and their families, the ramifications of WorkPlace acccidents is devastating. The loss of human life (co-workers, friends, and supervisors) can never be replaced. The emotional trauma of being involved and witnessing a serious/fatal accident cannot be described in words. After a fatality has occurred, many valuable employees may not return to work – Especially in cases of violence.

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 . Compare $4.4 Million sanctioned against Equilon by L&I to $45M in out-of-court settlement with families of 6 deceased employees.

“REAL” Costs

Pneumatic nailer. Reached around board and nailed in his own direction
Pneumatic nailer. Reached around board and nailed in his own direction. Nail went through the board and into his eye. Dr. Hsushi Yeh (Tacoma)

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

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

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 11 or more employees (one work location) shall have a designated safety committee. Fewer than 11 employees may have safety meetings. MONTHLY

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 McGill University Office of Safety Phone Dialog.

Safety Committees Proactive Safety Meetings should not be cancelled
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 Safety controls must be designed into every aspect of an organization. Must be a company vision - a value. Goal is to invoke desired change. Intervention. Positive Reinforcement. Action.

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?
Depends on the way they function within the organisation – DOES MANAGEMENT SUPPORT! Adequate time and $. Motivation level of committee members -Dedication to being effective (not just serving time). Encouraging proactive measures from all personnel System for communicating with personnel

Safety Committee Policy Statement
A written and publicized statement is an effective means of providing guidance and demonstrating commitment Keeps committee focused, Identifies to employees what your intent and purpose are.

Safety Committee Focus
Long Term Goals Objectives to Achieve Time Frame Short Term Goals Assignments between Meetings Work toward achieving Long-Term Plan Long Term - THEME (0 ACCIDENTS, 50% staff trained in CPR/1st Aid, Replace X Equipment, Short Term – Identify where accidents occur through record review, interview, investigate etc. FOCUS on problem areas

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 Be Prepared. Keep it professional and productive.

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 “The proper actions to take in event of emergencies including the routes of exiting from areas during emergencies”. WAC Employee emergency plans and fire prevention plans.

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 Facilities with Highly hazardous chemicals and others

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 WAC through 070 Recordables - OSHA 200 Log Supplemental OSHA 101 Form or L&I Form F

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?
Not likely Severity - What will happen if encountered? Death Serious Injury Damage to property

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

Who is at Risk? Contractors Workers Visitors Others Janitorial
Maintenance Others Members of Public Passers-by Neighbors Workers Visitors Invited Customers Emergency services Delivery drivers Uninvited Trespassers 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 Source:
Substitute less harmful substance (halogenated solvents -Citrus cleaner) Path: Use a paint-brush applicator rather than spray applications Receiver: Respirator, Gloves, Splash Goggles

Protective Equipment/Clothing
Hazard Control Administrative Engineering Protective Equipment/Clothing ENGINEERING CONTROLS - engineered safeguards to: 1. protect employees 2. prevent exposure to hazards Examples: machine guards, safety controls, isolation of hazardous areas, monitoring devices ADMINISTRATIVE CONTROLS - use of procedures to 1. monitor safe practices and environments 2. identify & correct new hazards 3. Safety Committee Examples: periodic inspections, equipment operating procedures , maintenance procedures, JHA selection & assignment of personal protective equipment, TRAINING Training Controls - used to ensure employees are fully and adequately trained to safely perform all tasks to which they are assigned 1. Safety Training is mandatory 2. No employee is to attempt any task without proper training in the equipment used, required personal protective equipment, specific hazards and control & emergency procedures. periodic refresher training PROTECTIVE CLOTHING/EQUIPMENT - Used when Engineering & Administrative controls not adequate protection.

Engineering Hazard Elimination Ventilation Add-On Safety Design
“Active” vs. “Passive” User Instructions (Manual) Ventilation Design/Layout Safety Devices The first cardinal rule of hazard control (safe design) is "hazard elimination" or "inherent safety." That is, if practical, one should control (eliminate or minimize) potential hazards by designing them out of products and facilities "on the drawing board." This is accomplished through the use of such interrelated techniques as "hazard removal, hazard substitution, and/or hazard attenuation," through the use of the principles and techniques of system and product safety engineering, system and product safety management, and human factors engineering, beginning with the concept and initial planning stages of the system design process. The second cardinal rule of hazard control (safe design) is the minimization of system hazards through the use of add-on "safety devices" or "safety features" engineered or designed into products or facilities "on the drawing board" to prevent the exposure of product or facility users to inherent potential hazards or dangerous combinations of hazards; called "extrinsic safety." A sample of such devices would include shields or barriers that guard or enclose hazards, component interlocks, pressure relief valves, stairway handrails, and passive vehicle occupant restraint and crashworthiness systems. Passive vs. Active Hazard Controls. A principle that applies equally to the first two cardinal rules of safe design is that of "passive vs. active" hazard control. Simply, a passive control is a control that works without requiring the continuous or periodic involvement or action of system users. An active control, in contrast, requires the system operator or user to "do something" before system use, continuously or periodically during system operation in order for the control to work and avoid injury. Passive controls are "automatic" controls, whereas active controls can be thought of as "manual" controls. Passive controls are unquestionably more effective than active controls. The third cardinal rule of hazard control (safe design) is the control of hazards through the development of warnings and instructions; that is, through the development and effective communication of safe system use (and maintenance) methods and procedures that first warn persons of the associated system dangers that may potentially be encountered under reasonably foreseeable conditions of system use, misuse, or service, and then instruct them regarding the precise steps that must be followed to cope with or avoid such dangers. This third approach must only be used after all reasonably feasible design and safeguarding opportunities (first and second rule applications) have been exhausted. Further, it must be recognized that the (attempted) control of system hazards through the use of warnings and instructions, the least effective method of hazard control, requires the development of a variety of state-of-the-art communication methods and materials to assure that such warnings and instructions are received and understood by system users. Among other things, the methods and materials used to communicate required safe use or operating methods and procedures must give adequate attention to the nature and potential severity of the hazards involved, as well as reasonably anticipated user capabilities and limitations (human factors). Briefly stated, the cardinal rules of hazard control involve system design, the use of physical safeguards, and user training. Further, it must be thoroughly understood that no safety device equals the elimination of a hazard on the drawing board, and no safety procedure equals the use of an effective safety device. This approach has been advocated by the safety literature and successfully practiced by safety professionals for decades.

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!) Purpose is not to evaluate the worker, Purpose is to evaluate the Process, System, Job, Equipment, Procedure

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 AVOID making the breakdown so detailed That an unnecessarily large number of steps results

Key Steps NOT ENOUGH Changing a Flat Tire
Park car Take off flat tire Put on spare tire Drive away AVOID making the job breakdown so general that basic steps are not recorded

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 brake Hit by traffic
Remove Spare & Jack Loosen lugs Hazards Hit by traffic Back Strain Foot/Toe impact Shoulder strain

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

Develop Solutions Fix-A-Flat Find a new way to do job
No off-road driving Buy self-sealing tires Maintenance / Change-out program Find a new way to do job Change physical conditions that create hazards Change the work procedure Reduce frequency NEW WAY TO DO 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 CONDITIONS. Tools, materials, equipment layout or location Study change carefully for other benefits (costs, time savings) CHANGE PROCEDURE. What should the worker do to eliminate the hazard How should it be done? Document changes in detail. REDUCE FREQUENCY. What can be done to reduce the frequency of the job?? Identify parts that cause frequent repairs - change Reduce vibration save machine parts

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: Acceptable because... Not acceptable because... Deteriorated because... 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 !

SAFETY MUST BE A VALUE!! PRIORITIES CHANGE
Safety Culture. Safety must be considered as part of the process

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. The Single Most Powerful Source of Motivation Is Employee Ownership of The Safety Process Ed Blair, Professor of Safety Education, Indiana University Employees are already motivated to improve safety. Their motivation is a natural instinct; they have seen what can happen when safety is compromised and they don’t want it. --Thomas R. Krause, Ph.D., Behavioral Science Technology, Inc.®

SHARED VISION EXERCISE

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

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?

unplanned and unwelcome event that interrupts normal activity
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

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

You Must: Conduct a preliminary investigation for: serious injuries with immediate symptoms Document the investigation findings WAC Conduct a preliminary investigation to determine cause(s) of work or work-related incident or accident that causes an employee serious injury A serious injury is one that: •Requires medical treatment beyond first-aid •Usually requires treatment by a medical doctor: –Makes part of the body of the injured useless or substantially reduced in efficiency –May be permanent or temporary –May be chronic or acute –May involve loss of consciousness –May cause death WAC Document the investigation findings You must: •Document the investigation findings for reference following any formal 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 •WAC DO Not move the equipment until a representative of the Department of Labor and Industries investigates the incident and releases the equipment

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) WISHA BE-SAFE ( ) WAC Report the death or probable death of any employee,or the in-patient hospitalization of 2 or more employees within 8 hours If you do not learn about the incident at the time it occurs,you must report the incident within 8 hours of the time it was reported to you,your agent,or employee.

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 WAC Assign people to assist the Department of Labor and Industries

•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 WAC Assign people to conduct the preliminary investigation If the employee representative is the business agent of the employee bargaining unit and is unavailable to participate without delaying the investigation group,you may proceed,by using one of the following: –The shop steward –An employee representative member of your safety committee –A person selected by all employees to represent them

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? Where did the accident occur When Who was present How

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?
Investigate ALL incidents. Level of involvement should be consistent with POTENTIAL damage.

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

12 1 2 5 4 7 8 6 3 9 10 11 Divide a Watch/Clock into 4 Sections. Each section must equal 15. YOU WILL HAVE TO LOOK AT THINGS WITH A NEW PERSPECTIVE! I know of 2 possible solutions. There may be more

12 1 2 5 4 7 8 6 3 9 10 11 =15 5+10=15 9+6=15 7+8=15

12 1 2 5 4 7 8 6 3 9 10 11 =15 6+9=15 7+8=15 =15

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

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 CALL 911 Assess the scene
Activate In-House Response Scene Safety Provide Aid to Injured Provide Assistance to Affected Secure the Scene of Accident Depending on the nature of the injury/accident should be your first response along with alerting those in the area. 1) They need to be on the way 2) Don’t know the extent of injuries and shock always a potential. Scene safety: DO NOT enter an unsecured area. Fools rush in….multiple victims REMEMBER. #1most important person=YOU, #2=Teammates, #3Employees/Public, #4 Injured. De-energize, de-pressurize, shore, ventilate etc. When it is safe to do so, provide aid, to the extent of your training. Very valuable to: talk calmly with them, provide blankets, distract them from their wounds, reassure that help is on the way. Remember to protect yourself (bbp etc.) Ask for on-lookers to leave area, assign useful things for others to do. Be aware of shock in others involved, not just the injured. Direct medical personnel to site, contact HR, etc. Securing accident scene, not for safety but for preservation of evidence. Again, clear all non-useful persons from the area. Leave tools, lights, exhaust etc., exactly where it is (unless unsafe to do so). Take meter readings, arrange for BAC, protect open containers & sample and spilled material etc.

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 Don’t 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 Cameras in kits. Start with big picture, work towards finest detail Black and white can be best for close, technical detail (ie., scratches on metal, frayed wires etc.) So keep one B&W camera available too

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 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 Subjective 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.

INVESTIGATION TRAPS Put your emotions aside! Do not pre-judge
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

Record Evidence Keep All Notes in Bound Notebook
Include Date - Time - Place – Vantage Point Keep Originals Rewrite in Report Form Bound notebook-use pages sequentially. Will provide evidence of when you entered information. Not a loose leaf book that pages can be added/deleted without evidence. Personal Observations. YOUR observations when first on scene. Use all senses.

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 GET All pertinent contact information. Locate position of each witness on a master chart (include vantage) Let each witness speak freely and take notes without distracting the witness. Tape record only with consent. Use sketches and diagrams to assist witness emphasize area of direct observation and label hearsay accordingly. Record exact words used by a witness to describe each observation. Word each question carefully….do not lead or suggest, but funnel Yes….Did anything seem different to you, think of the scene with all your senses - hearing, smelling-seeing-feeling-tasting. You state the motor sounded funny, can you describe the sound for us. Is that the first time you noticed the funny sound? Do you know what the sound might indicate? NO….so did you hear any funny sounds that might indicate the there might be a short in the electric motor? Identify

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 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

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 DON’T Separate Witnesses Suggest Answers
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

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?

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 Environmental conditions
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 Environment Equipment Human Behavior
Systems & Procedures Design & Equipment

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 wasn’t 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 individual’s actions, don’t 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 A fault tree analysis (FTA) is a deductive, top-down method of analyzing system design and performance. It involves specifying a top event to analyze (such as a fire), followed by identifying all of the associated elements in the system that could cause that top event to occur. Fault trees provide a convenient symbolic representation of the combination of events in the occurrence of the top event. Events and gates in fault tree analysis are represented by symbols. Fault tree analyses are generally performed graphically using a logical structure of AND and OR gates. Sometimes certain elements, or basic events, may need to occur together in order for that top event to occur. In this case, these events would be arranged under an AND gate, meaning that all of the basic events would need to occur to trigger the top event. If the basic events alone would trigger the top event, then they would be grouped under an OR gate. The entire system as well as human interactions would be analyzed when performing a fault tree analysis.

ADVANTAGES: Limited verbage Identify causes Graphic communication, Miscommunications limited Linkage between basic factors easily illustrated

ISHIKAWA “FISHBONE” DIAGRAM
Machinery Methods Materials People Environment EFFECT

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

ACCIDENT ANALYSIS AND REPORT (Handout)

Introduction & Course Overview

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