Occupational safety and health (OSH), also commonly referred to as occupational health and safety (OHS), occupational health, or occupational safety, is a multidisciplinary field concerned with the safety, health, and welfare of people at work (i.e. in an occupation). These terms also refer to the goals of this field, so their use in the sense of this article was originally an abbreviation of occupational safety and health program/department etc.
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L3- Accident investigation.ppt
1. OCCUPATIONAL SAFETY & HEALTH
ACCIDENT INVESTIGATION
ASSISTANT PROFESSOR PRACHI DESSAI, DON BOSCO COLLEGE OF ENGINEERING
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 1
2. IMPORTANT TERMS
Safety
being free from harm, danger, injury or damage.
Safety Engineering
application of engineering principles and practices to the recognition,
evaluation and control of hazards that can lead to accidents and incidents.
Hazard
potential or inherent characteristics of an activity, condition, or circumstance
which can produce adverse or harmful events and consequences.
Risk
chance or likelihood of an adverse event and the potential severity that may
result.
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 2
3. IMPORTANT TERMS
Accident
A happening or event that is not expected, foreseen or intended.
An accident is an unintended, unplanned, single or multiple event
sequence that results from hazards and may result in immediate or
delayed undesirable effects.
Injury
Injury is physical harm or damage to the body resulting from an
exchange, usually acute, of mechanical, chemical, thermal, or other
environmental energy that exceeds the body’s tolerance.
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 3
4. IMPORTANT TERMS
Occupational Injury
An occupational injury is any injury, such as a cut, fracture, sprain,
amputation, or other injury, which results from a work accident or
from a single instantaneous exposure in the work environment.
Occupational Illness
An occupational illness is any abnormal condition or disorder other
than one resulting from an occupational injury caused by exposure
to environmental factors associated with employment. It includes
acute and chronic illnesses or diseases that may result from
inhalation, absorption, ingestion, or direct contact.
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 4
5. 300 INCIDENTS
1
ACCIDENT
For each accident,
• 300 incidents occurred, or you lost 300 chances to prevent
the accident!
If we are going to
prevent accidents,
we have to investigate the
accidents and the incidents!
WHAT IS THE PYRAMID SAYING?
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 5
6. COST OF AN ACCIDENT
Direct Costs
Medical expenses;
Compensation
time away from work
sick leave
long-term disability payments
Repair or replacement of damaged equipment,
buildings, and other items.
Indirect Costs
Time lost
by other employees to help injured co-worker
supervisor to help injured worker,
investigate, prepare reports, adjust work and staffing.
Damage to tools, equipment, materials or property.
Losses due to late or unfilled orders, loss of bonuses or
payment of penalties.
Losses due to reductions in productivity
Overhead costs that continue during lost work.
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 6
7. CAUSES OF ACCIDENTS
Unsafe Acts
Conduct work operations without prior training
Block or remove safety devices.
Clean, lubricate, or repair equipment while its in
operation.
Working without protection in hazardous places.
Unsafe Conditions
Poorly maintained machinery or equipment.
Defective or missing personal protective
equipment.
Missing or inadequate warnings or safety and
health signs.
Lack of housekeeping.
Unguarded machinery
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 7
8. ACCIDENT CAUSATION
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 8
9. DOMINO THEORY
1932 First Scientific Approach to Accident/Prevention - H.W. Heinrich
“Industrial Accident Prevention”
Social Environment
and Ancestry
Fault of the
Person (Carelessness)
Unsafe Act
or
Condition
Accident Injury
MISTAKES OF PEOPLE
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 9
10. CONSTRUCTION PRODUCTS COMPANY
COMPANY PROFILE
• Distributor of lumber, pipe, and concrete products.
• Orders are also relatively small and can be loaded by
hand.
• Personal protection gear - hard hats, padded gloves,
steel-toed boots, and lower-back-support belts.
• Summer months – increase in Injuries
• Minor cuts, scrapes, bruises.
• Past summer - Two warehouse workers had sustained
serious back injuries.
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 10
11. CONSTRUCTION PRODUCTS COMPANY
Investigation
CPC’s warehouses became so hot during the summer months
Personal protection gear was uncomfortable.
Warehouse personnel simply discarded it
Lead to an increase in injuries.
Recommendations:
training on the importance and proper use of personal protection gear
Monitoring - warehouse supervisors
company policy - disciplinary measures for failure to use required personal
protection gear
implement several heat reduction measures to make warehouses cooler
during the summer months.
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 11
12. HUMAN FACTORS THEORY
Overload
•Environmental Factors
(noise, distractions
•Internal Factors (personal
problems, emotional stress)
•Situational Factors (unclear
instructions, risk level)
Inappropriate Response
•Detecting a hazard but
not correcting it
•Removing safeguards
from machines and
equipment
•Ignoring safety
Inappropriate
Activities
•Performing tasks without
the requisite training
•Misjudging the degree of
risk involved with a given
task
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 12
13. KITCHENWARE MANUFACTURING INCORPORATED (KMI)
COMPANY PROFILE
• Produces aluminum kitchenware for commercial settings(10 years)
• Sudden sales triple in less than six months.
Response
• by adding a second shift of production personnel
• approving unlimited overtime for highly skilled personnel.
Effect - Increase in accidents and injuries.
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 13
14. KITCHENWARE MANUFACTURING INCORPORATED (KMI)
Investigation:
Overload - rush to fill orders was pushing production personnel beyond
their personal limits in some cases, and beyond their capabilities in others.
Stress, insufficient training of new employees, and fatigue all contributed
to the overload.
Inappropriate response - removed safeguards from their machines in an
attempt to speed up production.
Inappropriate activities - new employees weren’t yet fully trained.
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 14
15. PETERSEN’S ACCIDENT/INCIDENT THEORY
Overload
•Pressure
•Fatigue
•Motivation
•Drugs
•Alcohol
•Worry
Ergonomic Traps
•Incompatible
workstation (i.e. size,
force, reach, feel)
•Incompatible
expectations
Decision to Err
•Misjudgment of the
risk
•Unconscious desire
to err
•Logical decision
based on the situation
Systems Failure
Policy Inspection
Responsibility Correction
Training Standards
Human Error
Accident
Injury/Damage
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 15
16. POULTRY PROCESSING CORPORATION (PPC)
COMPANY PROFILE
• JOB - processes chickens and turkeys for grocery chains
• labor-intensive enterprise involving a great deal of handwork
• Work is monotonous and repetitive.
• Safety Measures - ensure that workstations are Ergonomically sound
• appropriate personal protection gear
• adequate precautions are taken to prevent illness and injuries
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 16
17. POULTRY PROCESSING CORPORATION (PPC)
• PPC is an award-winning company in the area of workplace safety and health.
Poultry-processing industry was shocked when a class action lawsuit was filed against PPC on behalf of over 50
employees
Investigation:
Safety Manager Huttle - worked seven days a week, two weeks at a time on the road
In office he either on the telephone or doing paperwork for the safety organization.
Stress at home due to continuous travelling
Duties at PPC were badly neglected.
Measurement of individual and group safety performance had come to a standstill. During time of neglect
- increased incidence of CTS occurred.
Safety precautions that Huttle had instituted to guard against this particular problem were no longer
observed properly once the workers realized that he had stopped observing and correcting them.
Measurement and inspection may also have prevented the injuries had Huttle maintained his normal
schedule of these activities.
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 17
18. EPIDEMIOLOGICAL THEORY
Predisposition Characteristics
•Susceptibility of people
•Perceptions
•Environmental factors
Situational Characteristics
•Risk assessment by individuals
•Peer pressure
•Priorities of the supervisor
•Attitude
Can cause or prevent accident
conditions
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 18
19. PARCEL DELIVERY SERVICES
CASE
Jane Andrews - newest member, loading unit
Responsible for loading 50 trucks every morning.
Physically demanding work - the first woman ever selected by PDS
to work in the loading unit.
Anxious to do well.
If she failed, other women might not get a chance to try in the future.
TRAINING
Two days of training -proper lifting techniques, use of back-support
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 19
20. PARCEL DELIVERY SERVICES
CAUSE
Supervisor called her aside on her first day in the unit and told her to forget what she had learned in training.
“Jane, nobody wants a back injury, so be careful. But the key to success in this unit is speed. The lifting techniques
they teach you in that workshop will just slow you down. You’ve got the job, and I’m glad you’re here. But you
won’t last long if you can’t keep up.”
CONSEQUENCE
Follow safety procedures OR make a good impression on her new supervisor??
Several of her co-workers complained that she wasn’t keeping up
Supervisor WARNED - “keep up or get out of the way.”
Taking the same shortcuts she had seen her co-workers use.
Positive results were immediate, nods of approval from fellow workers and a “good job” from the supervisor.
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 20
21. PARCEL DELIVERY SERVICES
Two months Later
She began to experience persistent lower back pain.
Her hurried lifting techniques were to blame, but she valued the
approval of her supervisor and fellow workers too much to do
anything that might slow her down
Finally, one day , she fell to the pavement in pain and could not
get up.
Back throbbed with intense pain, and her legs were numb.
Rushed to the emergency room – FOUND two ruptured disc.
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 21
23. PRECISION TOOLING COMPANY (PTC) - SYSTEMS THEORY
COMPANY PROFILE
• Making corrections to parts
• Uses several manually operated machines
PROBLEM
• machines are so old that they frequently break down.
CASE
• Johnson’s manufacturing division incorrectly produced 10,000 copies of a critical part before noticing the
problem.
• PTC could perform well then even more lucrative contracts were sure to follow.
• PTC CEO explained to the employees that the contract was a great opportunity
• BUT the parts that needed reworking would have to go through several manual operations in the beginning
of the process.
• The parts have to be ready in 90 days.
• PTC didn’t perform on this contract - MACHINIST fault.
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 23
24. SYSTEMS THEORY
• Used their old machines and got to work.
• The processes was complicated
• Special effort on every single part.
REASON/ CAUSE
manual machining unit was behind schedule, and management was
getting nervous.
Continual breakdowns and equipment failures experienced.
Unit supervisor pushed HARDER - more stressed the employees and
machines became.
Safety procedures were forgotten ,Pressure from management, the
inexperience of the apprentice machinists, and the constant
equipment failures
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS
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25. SYSTEMS THEORY
In a hurry - One machinist got careless and ran his hand into the cutter
on his milling machine.
By the time the machine had been shut down, his hand was badly
mutilated.
In the aftershock of this accident, PTC was unable to meet the agreed-
upon completion schedule. Unfortunately, PTC did not make the kind
of impression on H. R. Johnson’s management team that it had hoped.
This accident can be explained by the systems theory.
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 25
26. SYSTEMS THEORY
The person-machine-environment chain has a direct application in this case.
The person involved was relatively inexperienced.
The machine involved was old and prone to breakdowns.
The environment was especially stressful and pressure packed.
These three factors, taken together, resulted in this serious and tragic accident.
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 26
27. COMBINATION THEORY
• For some accidents, a given model may be very accurate, for others less so Often the cause of an accident
cannot be adequately explained by just one model/theory
• Actual cause may combine parts of several different models
HUMAN + PETERSONS +SYSTEMS + EPIDEMILOGICAL + DOMINO = COMBINATION THEORY
PETERSONS +SYSTEMS + EPIDEMILOGICAL + DOMINO = COMBINATION THEORY
SYSTEMS + EPIDEMILOGICAL + DOMINO = COMBINATION THEORY
EPIDEMILOGICAL + DOMINO = COMBINATION THEORY
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 27
28. CRESTVIEW GRAIN CORPORATION (CGC)
PROFILE
• maintains ten large silos for storing corn, rice, wheat, barley, and various
other grains.
• Generates fine dust and gases, ventilation of the silos is important.
• Silos have several large vents- WHICH uses a filter - changed periodically.
HAZARDS
• Unvented dust and gases that can make breathing difficult, or even
dangerous.
• Each silo has a catwalk that runs around its inside circumference near the
top.
• 100 feet above ground level
• Fall - probably be fatal.
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS
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29. CRESTVIEW GRAIN CORPORATION (CGC)
TRAINING
• Well-defined rules that employees are to follow when changing filters.
• Rules are strictly enforced, there had never been an accident in one of
CGC’s silos
TRAGEDY
Juan Perez -not new (five years)
New to the job of silo maintenance
Time to change the vent filters in silo number 4.
Perez had never changed vent filters himself.
He hadn’t been in the job long enough.
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 29
30. CRESTVIEW GRAIN CORPORATION (CGC)
TRAGEDY
Served as the required “second man” when his supervisor, Bao Chu Lai, had changed the filters in silos 1,
2, and 3.
Chu Lai was at home recuperating from heart surgery and would be out for another four weeks
Perez decided to change the filters himself.
collected his safety harness, respirator, and four new vent filters.
Climbed the external ladder to the entrance/exit platform near the top of silo number 4.
Respirator and strapped on his safety harness.
Opening the hatch cover, he stepped inside the silo onto the catwalk.
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 30
31. CRESTVIEW GRAIN CORPORATION (CGC)
• Perez attached a lifeline to his safety harness, picked up the new vent filters, and headed for the first vent.
• He changed the first two filters without incident.
• The filter in the third vent was wedged in tightly.
• After several attempts to pull it out, Perez became frustrated and gave the filter a good jerk.
• When the filter suddenly broke loose, the momentum propelled him backwards and he toppled off the catwalk.
• At first it appeared that his lifeline would hold, but without a second person to pull him up or call for help, Perez was suspended
by only the lifeline for over 20 minutes.
• He finally panicked, and in his struggle to pull himself up, knocked the buckle of his safety harness open.
• The buckle gave way, and he fell over 50 feet into the grain below.
• The impact knocked his respirator off, the grain quickly enveloped him, and he was asphyxiate
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS
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32. CRESTVIEW GRAIN CORPORATION (CGC)
• The accident investigation that followed revealed that several factors
combined to cause the fatal accident—the combination theory. The most
critical of these factors were as follows:
• Absence of the supervisor
• Inexperience of Perez
• A conscious decision by Perez to disregard CGC’s safety procedures
• A faulty buckling mechanism on the safety harness
• An unsafe design (only a knee-high guardrail on the catwalk)
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 32
33. BEHAVIORAL THEORY
Often referred to as behavior-based safety (BBS)
7 basic principles of BBS
Intervention
Identification of internal factors
Motivation to behave in the desired manner
Focus on the positive consequences of appropriate behavior
Application of the scientific method
Integration of information
Planned interventions
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS 33
34. EXCELLO CORPORATION
Mark Potter - Safety manager
He became concerned because employees seemed to have developed a lax attitude toward wearing hard hats.
There is more than the usual potential for head injuries because of the type of work done in Excello’s plant,
and he had personally witnessed two near misses in less than a week.
Remove all of the old “Hard Hat Area” signs from the plant and replace them with newer, more noticeable
signs.
Seminar - Head injuries (Two-week period)
It told a story of two employees. One was in a hospital bed surrounded by family members he did not
even recognize. The other was shown enjoying a family outing with happy family members.
Within days, employees were once again disciplining themselves to wear their hard hats (the desired
behavior).
D. L. GOETSCH; OCCUPATIONAL SAFETY AND HEALTH FOR TECHNOLOGISTS; ENGINEERS AND MANAGERS
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