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- 2. Safety Committees 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 Proactive Safety
- 3. 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
- 4. 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.
- 5. How effective can a Committee be?
- 6. Safety Committee Policy Statement A written and publicized statement is an effective means of providing guidance and demonstrating commitment
- 7. Safety Committee Focus Long Term Goals Objectives to Achieve Time Frame Short Term Goals Assignments between Meetings Work toward achieving Long-Term Plan
- 8. Planning the Safety Meeting • SELECT TOPICS • SET & POST THE AGENDA • SCHEDULE SAFETY MEETING • PREPARE MEETING SITE • ENCOURAGE PARTICIPATION
- 9. 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
- 10. 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
- 11. 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
- 12. Emergency Plan Anticipate What Could Go Wrong and Plan for those Situations Drill for Emergency Situations
- 13. 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
- 14. Record Keeping & Updating Record each Recordable Injury & Illness on ISM DOCS 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
- 15. 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
- 16. 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
- 17. HAZARD ANALYSIS
- 18. 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
- 19. Step 1: Identify Hazards HAZARD – condition with the potential to cause personal injury, death and property damage
- 20. Hazard Identification Review Records Talk to Personnel Accident Investigations Follow Process Flow Write a Job Safety Analysis Use Inspection Checklists
- 21. 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
- 22. 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
- 23. 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
- 24. STEP 3: Make Risk Decisions What can we do to reduce the risk? Does the benefit outweigh the risk?
- 25. STEP 4: Implement Controls Substitution Engineering controls Administrative Controls Personal Protective Equipment
- 27. Hazard Control Administrative Engineering Protective Equipment/Clothing
- 28. Engineering Hazard Elimination Add-On Safety Design “Active” vs. “Passive” User Instructions (Manual) Ventilation Design/Layout Safety Devices
- 29. Administrative Safety Rules Disciplinary Policy - Accountability Preventative Maintenance Training Proficiency/Knowledge Demonstrations
- 30. Step 5: Supervise Ensure risk control measures are implemented Track progress Feedback
- 32. 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
- 34. Job Safety Analysis Priorities New Jobs Potential of Severe Injuries History of Disabling Injuries Frequency of Accidents
- 35. 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!)
- 36. 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
- 37. 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
- 38. Key Steps NOT ENOUGH Changing a Flat Tire Park car Take off flat tire Put on spare tire Drive away
- 39. 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
- 40. Job Safety Analysis • Steps – Park & set brake – Remove Spare & Jack – Loosen lugs
- 41. Job Safety Analysis Hazards Hit by traffic Back Strain Foot/Toe impact Shoulder strain • Steps – Park & set brake – Remove Spare & Jack – Loosen lugs
- 42. 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
- 43. 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
- 44. INSPECTIONS
- 45. Inspections Fact-Finding vs. Fault Finding Sound knowledge of the plant Knowledge of relevant standards & codes Systematic inspection steps Method of evaluating data
- 46. Inspection Limitations “Blinder affect” Rote inspections All Check - No action Who is inspecting?
- 47. Outcomes Improve Safety New Way to Do Job Change Physical Conditions Change Work Procedures Reduce Frequency of Dangerous Job
- 48. 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
- 49. Change in Physical Conditions Tools, materials, equipment layout or location Study change carefully for other benefits (costs, time savings)
- 50. Change in Work Procedures What should the worker do to eliminate the hazard? How should it be done? Document changes in detail
- 51. 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
- 53. Guide for Personal Audits The guide has five steps • Audit • React • Communicate • Follow up • Raise standards
- 54. 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
- 55. 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…
- 56. 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
- 57. Follow Up Critical for success of the safety program Allows you to demonstrate that it is important Must communicate your assessment to the employees
- 58. 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
- 59. 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
- 60. 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
- 61. Observation Techniques Remember ABBI -- look Above, Below, Behind, Inside Develop a questioning attitude Use all senses • sight • hearing • smell • touch
- 62. Inspections and Field Observations Use a checklist Ask questions Take notes Respect lines of communication Draw conclusions
- 63. 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
- 64. 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
- 65. 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
- 67. Management Commitment Should Management Consider Safety as a Priority in Conducting Business
- 69. PRIORITIES CHANGE SAFETY MUST BE A VALUE!!
- 70. 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.
- 72. AVAILABLE RESOURCES OSHA Website: www.osha.gov Washington State Labor & Industries Website: www.lni.wa.gov
- 74. 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
- 75. THE ACCIDENT WHAT IS AN ACCIDENT?
- 76. THE ACCIDENT An unplanned and unwelcome event that interrupts normal activity
- 77. Accidents are What Happens to Somebody Else BUT REMEMBER: YOU are somebody else to somebody else
- 78. THE ACCIDENT MINOR ACCIDENTS: Such as paper cuts to fingers or dropping a box of materials
- 79. THE ACCIDENT MORE SERIOUS ACCIDENTS Such as a forklift dropping a load or someone falling off a ladder
- 80. THE ACCIDENT Accidents that occur over an extended time frame: Such as hearing loss or an illness resulting from exposure to chemicals
- 81. 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!
- 82. THE ACCIDENT ACCIDENTS HAVE TWO THINGS IN COMMON
- 83. THE ACCIDENT They all have outcomes from the accident
- 84. THE ACCIDENT They all have contributory factors that cause the accident
- 86. OUTCOMES OF ACCIDENTS NEGATIVE Results Injury & possible death Disease Damage to equipment & property Litigation costs, possible citations Lost productivity Morale
- 87. OUTCOMES OF ACCIDENTS POSITIVE Results Accident investigation Prevent repeat of accident Change to safety programs Change to procedures Change to equipment design
- 88. 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
- 89. 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
- 90. 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
- 91. ACCIDENT INVESTIGATION Conduct a preliminary investigation for: serious injuries with immediate symptoms Document the investigation findings You Must:
- 92. 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
- 93. 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)
- 94. 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
- 95. 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
- 96. 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?
- 97. 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
- 98. Why Not Rely On OSHA & Police To Investigate? Focus On Culpability Minor Accidents Not Investigated PREVENTION Protect Company Interests OSHA Requirements
- 99. Accidents HOW TO FIND OUT WHAT REALLY HAPPENED
- 100. Why Investigate Accidents? Find the cause Prevent similar accidents Protect company interests
- 101. Acts Conditions Near Misses Minor Injuries Reportable Injury Lost Time Injury Death Knowledge Ability Motivation Design Maintenance Action of Others At which level do we investigate?
- 102. Investigation Strategy Need For Investigation Control the Scene Gather Facts Analyze Data Establish Causes Write Report Take Corrective Action
- 103. 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
- 104. 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?
- 105. 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
- 109. 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
- 110. 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
- 111. 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!
- 112. 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
- 113. **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
- 114. 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
- 115. Provide Care to the Injured Ensure that medical care is provided to the injured people before proceeding with the investigation
- 116. Secure the Scene for Safety Eliminate the hazards: Control chemicals De-energize De-pressurize Light it up Shore it up Ventilate
- 117. 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
- 118. 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
- 119. 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)
- 120. 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
- 121. Photographs Unbiased Recording Keep Log of Photos Overall to Close-up Color if possible Supplement with Video
- 122. Gather Data Data includes: Persons involved Date, time, location Activities at time of accident Equipment involved List of witnesses
- 123. 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?
- 124. Documents Collect All Related Documents Inspection Logs Policy & Procedures Manual JSA (Job Safety Analysis) Equipment Operations Manuals Insurance Records Employee Records Police Reports
- 125. Those who do not know the past are destined to: Repeat Repeat Repeat Repeat Repeat Repeat It.
- 126. 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
- 127. 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.
- 128. 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
- 129. Record Evidence Keep All Notes in Bound Notebook Include Date - Time - Place – Vantage Point Keep Originals Rewrite in Report Form
- 130. Samples Collect Perishables First Fluids Open Containers Filings Chemicals Air
- 131. 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
- 132. 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
- 133. Interviews Excellent Source of first hand knowledge May Present Pitfalls in form of: Bias Perspective Embellishment Omissions
- 134. 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
- 135. 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
- 136. 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
- 137. 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
- 138. 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?”
- 139. 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
- 140. 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
- 141. 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
- 142. 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?
- 143. 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?
- 144. 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
- 145. 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?
- 146. 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
- 147. 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?
- 148. 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
- 149. Indirect Causes Unsafe conditions – what material conditions, environmental conditions and equipment conditions contributed to the accident Unsafe Acts – what activities contributed to the accident
- 150. Breakdown of Unsafe Conditions Inadequately guarded or unguarded equipment Defective tools, equipment or materials Fire and explosion hazard Unexpected movement hazard Projection hazards
- 151. Breakdown of Unsafe Conditions Housekeeping Hazardous environmental conditions Improper ventilation Improper illumination Unsafe dress or apparel
- 152. 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
- 153. Basic Causes Management Environment Equipment Human Behavior Systems & Procedures Design & Equipment
- 154. 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?
- 155. 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?
- 156. 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.
- 157. What controls failed? List the specific engineering, administrative and training controls that failed and how these failures contributed to the accident
- 158. What controls worked? List any controls that prevented a more serious accident or minimized collateral damage or injuries
- 159. Determine What was not normal before the accident Where the abnormality occurred When it was first noted How it occurred
- 160. 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)
- 161. 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
- 162. 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
- 163. 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……..
- 164. 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?
- 165. Recommendations Consider -Effectiveness -Cost -Feasibility -Effect on Productivity -Time to Implement -Employee Acceptance -Management Acceptance
- 166. 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
- 167. Common Problems Accidents not reported Unable to identify basic causes Accepting inadequate reports Neglecting to implement corrective actions
- 168. 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
- 169. 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
- 170. 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
- 171. 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?
- 172. 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
- 173. 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
- 174. 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
- 175. Other Accident Investigation Tools
- 176. 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
- 177. Problem Solving Fault Tree Wet Floor Environmental Sudden Release No Preshift Inspection Slow Leak Break Line Leak No Fluid Brakes Fail Steering Fails Equipment No Training Procedural NoTraining Did Not Know Intentional Omission No Inspection Human Failure To Stop PIT Hits Wall
- 178. Problem Solving Fault Tree Sudden Release No Preshift Inspection Slow Leak Break Line Leak No Fluid Brakes Fail Equipment NO TRAINING Supv. sick Sup.Resp. Training Req'd Procedural Training Not Received Did Not Know Time ltd. Intentional Omission Did not Conduct Inspection Human Failure To Stop PIT Hits Wall
- 179. FIVE WHYs DIAGRAM Undesired Event Why? Direct Cause Why? Contributing Cause Why? Contributing Cause Why? Contributing Cause Why? Root Cause