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OVERVIEW
Well thats an
accident waiting to
happen
Someone ought to
do something
PROACTION VERSUS
REACTION
That someone is YOU!
Accident
Prevention
WHAT IS AN ACCIDENT?
WHAT IS AN ACCIDENT?
a. An unexpected and undesirable event, especially one resulting in
damage or harm: car accidents on icy roads.
b. An unforeseen incident: A series of happy accidents led to his promotion.
c. An instance of involuntary urination or defecation in one's clothing.
2. Lack of intention; chance: ran into an old friend by accident.
3. Logic A circumstance or attribute that is not essential to the nature of
something.
http://www.thefreedictionary.com/accident
AN ACCIDENT IS:
HAZARD
Existing or Potential
Condition That Alone or
Interacting With Other
Factors Can Cause Harm
Risk 0
SAFETY
FREEDOM FROM DANGER OR
HARM
Nothing is Free of
A Judgement of
the
Acceptability of
Risk
R
A
T
I
O
S
OSHA METHOD
330 INCIDENTS
29 MINOR INJURIES
1 MAJOR OR LOSS-TIME
ACCIDENT
CANDY
JAR
EXAMPLE
CONTACT WITH
chemicals FALL TO
electricity same level
heat/cold lower level
radiation CAUGHT
BODILY REACTION in
FROM on
voluntary motion between
involuntary motion
TYPES OF ACCIDENTS
STRUCK
Against
RUBBED OR ABRADED stationary or moving
BY object
protruding object
friction
sharp or jagged edge
pressure
By
vibration
moving or flying
object
falling object
TYPES OF ACCIDENTS
(CONTINUED)
U.S. WORKPLACE FATALITIES - 2006
FATAL
NO NOTE:ACCIDENTS -
If you wish to normalize or compare the
Washington data with the Federal data, just
WORKPLACE
multiply the Washington numbers by 47 (based on
population)
Basic Causes
Direct Causes
Management
Slips, Trips, Falls
Environmental
Caught In
Equipment
Run Over
Human Behavior
Chemical Exposure
Indirect Causes
Unsafe Acts
Unsafe Conditions
ACCIDENT CAUSING
FACTORS
Policy & Procedures
Basic Causes Environmental Conditions
Equipment/Plant Design
Human Behavior
ACCIDENT
Personal Injury
Property Damage
Potential/Actual
Management
Systems & Procedures
Environment
MANAGEMENT
Physical
Lighting
Temperature
Chemical Biological
vapors Bacteria
smoke Reptiles
ENVIRONMENT
DESIGN AND EQUIPMENT
Design
Workplace layout
Design of tools &
equipment
Maintenance
DESIGN AND EQUIPMENT
Equipment
Suitability
Stability
Guarding
Ergonomic
Accessibility
HUMAN BEHAVIOR
Common
to
all
accident
s
Omissions &
Commissions
Consequences
(what happens if it is/isnt done)
ABC MODEL
Antecedents
(trigger behavior)
Behavior
(human performance)
Consequences
(either reinforce or punish behavior)
ONLY 4 TYPES OF
CONSEQUENCES:
Positive Reinforcement (R+)
("Do this & you'll be rewarded")
Extinction (E)
("Ignore it and it'll go away")
CONSEQUENCES
INFLUENCE BEHAVIORS
BASED UPON INDIVIDUAL
PERCEPTIONS OF:
Magnitude
{ positive
Significance or
Impact negative
Soon
Certain
Positive
HUMAN BEHAVIOR
SOME EXAMPLES OF
CONSEQUENCES:
WHY IS ONE SIGN OFTEN
IGNORED, THE OTHER ONE
OFTEN FOLLOWED?
HUMAN
Soon
BEHAVIOR
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
Certain BEHAVIOR
A consequence that is certain to follow a
behavior has more influence than an
uncertain or unpredictable consequence
Corrective Action must be:
Prompt
Consistent
Persistent
HUMAN BEHAVIOR
Positive
A positive consequence influences
behavior more powerfully than a negative
consequence
Penalties and Punishment dont work
Speeding Ticket Analogy
Example: Smokers find it hard to stop
HUMAN BEHAVIOR
smoking because
are:
the consequences
A) Soon (immediate)
B) Certain (they happen every time)
C) Positive (a nicotine high)
The other consequences are:
A) Late (years later)
B) Uncertain (not all smokers get lung
cancer)
C) Negative (lung cancer)
DEVIATIONS FROM SOP
No Safe Procedure
Employee Didnt know Safe
Procedure
Employee knew, did not follow
Safe Procedure
Procedure encouraged risk-taking
Employee changed approved
procedure
HUMAN BEHAVIOR
Thought Question:
Im too busy!
NEGATIVE OUTCOMES
POSITIVE OUTCOMES
$ DIRECT COSTS
Medical
Insurance
Lost Time
Fines
Failure to develop and implement a program may
be cited as a SERIOUS violation (by itself or
"Grouped" with other violations)
COMPLIANCE
COMPLIANCE
OF ACCIDENTS
POSITIVE ASPECTS
Accident investigation
Prevent repeat of accident
Improved safety programs
Improved procedures
Improved equipment design
ACCIDENT PREVENTION PROGRAM
Must Be
Written
Tailored to particular hazards for a particular plant or
operation
Minimum Elements
Safety Orientation Program
Safety and Health Committee
ACCIDENT PREVENTION PROGRAM
Safety Orientation
Description of Total Safety Program
Safe Practices for Initial Job Assignment
How and When to Report Injuries
Location of First Aid Facilities in Workplace
How to Report Unsafe Conditions & Practices
Use and Care of PPE
Emergency Actions
Identification of hazardous materials
ACCIDENT PREVENTION
PROGRAM
SAFETY MEETING
SAFETY
COMMITTEES
Proactive
SAFETY Safety
COMMITTEES
Select topics
Set & post the agenda
Schedule safety meeting
Prepare meeting site
Encourage participation
CONDUCTING A SAFETY MEETING
Anticipate
What Could
Go Wrong and
Plan for those
Situations
Drill for
Emergency
Situations
EMERGENCY ACTION PLAN
The following minimum elements shall be
included :
Alarm Systems
Emergency escape procedures and route
assignments;
Procedures for employees who remain to operate
critical plant operations before evacuation
Procedures to account for all employees
Rescue and medical duties for those employees who
are to perform them
The preferred means of reporting fires and other
emergencies
Names / job titles of who can be contacted for further
information or explanation of duties under the plan
Record 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
RECORD KEEPING &
work or motion
This information in posted every year
UPDATING
from February 1 to April 30 in the
OSHA 300A Summary
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
HAZARD ANALYSIS
STEP 1: IDENTIFY HAZARDS
HAZARD
condition with
the potential
to cause
personal
injury, death
and property
damage
Review Records
Talk to Personnel
Accident Investigations
Follow Process Flow
Write a Job Safety Analysis
Use Inspection Checklists
HAZARD IDENTIFICATION
STEP 2: ASSESS HAZARDS
Substitution
Engineering controls
Administrative Controls
Personal Protective
Equipment
Source
Path
Receiver
HAZARD CONTROLS
HAZARD CONTROL
Administrative
Engineering
Protective Equipment/Clothing
ENGINEERING
Ventilation
Hazard Elimination
Add-On Safety Design
Design/Layout
Active vs. Passive Safety Devices
User Instructions (Manual)
Safety Rules
Disciplinary Policy - Accountability
Preventative Maintenance
Training
Proficiency/Knowledge Demonstrations
ADMINISTRATIVE
STEP 5: SUPERVISE
New Jobs
Potential of Severe Injuries
History of Disabling Injuries
Frequency of Accidents
OBSERVATION OF THE
Select experienced worker(s) to
ACTUAL
WORK
participate in the JSA process
Explain purpose of JSA
Observe the employee perform the job
and write down basic steps
Completely describe each step
Note any deviations (Very Important!)
IDENTIFY HAZARDS &
POTENTIAL
Search for HazardsACCIDENTS
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
Park car
Take off flat tire
Put on spare tire
Drive away
KEY JOB STEPS JUST RIGHT
CHANGING A FLAT TIRE
Steps Hazards
Park & set Hit by
brake traffic
Loosen lugs
Shoulde
r strain
JOB SAFETY ANALYSIS
Steps Hazards
Prevention
Park & set Hit by Far off road as
brake traffic possible
Remove Spare Back Pull items close
& Jack Strain before lift
Foot/Toe Lift in increments
impact Lift and lower
using leg power
Wide leg stance
Loosen lugs Use full body, not
Shoulder arm/shoulder
strain
DEVELOP SOLUTIONS
Change No off-road
physical
conditions that driving
create hazards
Change the
work Buy self-sealing
procedure
Reduce tires
frequency Maintenance /
Change-out
program
JSA EXERCISE
INSPECTIONS
Fact-Finding vs. Fault Finding
Sound knowledge of the plant
Knowledge of relevant standards & codes
Systematic inspection steps
Method of evaluating data
INSPECTIONS
Blinder affect
Rote inspections
All Check - No action
Who is inspecting?
INSPECTION LIMITATIONS
Improve Safety
New Way to Do Job
Change Physical Conditions
Change Work Procedures
Reduce Frequency of Dangerous Job
OUTCOMES
NEW WAY TO DO THE JOB
CHANGE IN WORK
PROCEDURES
REDUCE FREQUENCY OF
DANGEROUS JOB
AUDIT
Take notes
REACT
FOLLOW UP
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
RAISE STANDARDS
KEY POINTS: BECOMING A GOOD
OBSERVER
OBSERVATION TECHNIQUES
Observe activity -- do not avoid the action
Remember ABBI -- look Above,
Below, Behind, Inside
Develop a questioning attitude
Use a checklist
Ask questions
Take notes
Respect lines of communication
Draw conclusions
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 ACTS
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
UNSAFE CONDITIONS
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
AUDIT
PRACTICES
Auditing contractors
MANAGEMENT COMMITMENT
??
Should Management Consider Safety
as a Priority in Conducting Business
MANAGEMENT COMMITMENT
NO !
PRIORITIES CHANGE
SAFETY
MUST BE A
VALUE!!
EMPLOYEE PARTICIPATION
Crew-Leader
Meetings
SHARED VISION
EXERCISE
OSHA Website: www.osha.gov
AVAILABLE RESOURCES
ACCIDENT INVESTIGATION
Thousands of accidents occur
throughout the United States
INTRODUCTION
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?
An
unplanned and unwelcome
event
that interrupts normal
THE ACCIDENTactivity
BUT REMEMBER:
YOU
are somebody else
ACCIDENTS ARE WHAT
HAPPENS TO
to SOMEBODY ELSE
somebody else
MINOR ACCIDENTS:
THE ACCIDENT
MORE SERIOUS ACCIDENTS
THE ACCIDENT
Accidents that occur over an extended
time frame:
Such as hearing loss or an illness resulting
from exposure to chemicals
THE ACCIDENT
THE ACCIDENT
Also know as a Near Hit
NEAR-MISS
An accident that does not quite result in
injury or damage (but could have)
THE ACCIDENT
They all have outcomes from the accident
THE ACCIDENT
They all have contributory factors that
cause the accident
THE ACCIDENT
OUTCOMES OF ACCIDENTS
NEGATIVE Results
Accident investigation
Prevent repeat of accident
Change to safety programs
Change to procedures
Change to equipment design
ACCIDENT INVESTIGATION
DIRECT CAUSE
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 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:
Focus On
Culpability
Minor Accidents
Not Investigated
PREVENTION
Protect Company
Interests
OSHA
Requirements
INVESTIGATING
ACCIDENTS
WHYProtect company
INVESTIGATE
interests
ACCIDENTS?
At which level do we investigate?
Death
Lost Time
Injury
Reportable Injury
Minor Injuries
Near Misses
Acts Conditions
Maintenance
Knowledge
Motivation
Design
Ability
Others
Action
of
INVESTIGATION STRATEGY
Need For Investigation
Gather Facts
Analyze Data
Establish Causes
Write Report
THE AIM
Defend OF THE
a position for legal argument
INVESTIGATION
Or, to assign blame
IS NOT TO:
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10 2
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10 2
9 3
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10 2
9 3
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7 5
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COMPANY ACCIDENT FORMS
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!
BENEFITS OF ACCIDENT
INVESTIGATION
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
Assess the scene
CALL 911
Activate In-House Response
Scene Safety
Provide Aid to Injured
Provide Assistance to Affected
Secure the Scene of Accident
**IMMEDIATE ACTIONS
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
Unbiased Recording
Keep Log of Photos
Overall to Close-up
Color if possible
Supplement with Video
Data includes:
Persons involved
Date, time, location
Activities at time of accident
Equipment involved
List of witnesses
GATHER DATA
REVIEW RECORDS
Repeat
Repeat
Repeat
It.
ISOLATE FACT FROM FICTION
Objective
Not an Interpretation -
Subjective
Based on a factual Interpretations - Based on
description. personal
Observable - Based on interpretations/biases.
what is seen or heard. Non-observable - Based on
Reliable - Two or more events not directly
people independently observed.
agree on what they Unreliable - Two or more
observed. people dont agree on
Measurable - A number is what they observed.
used to describe behavior Non-Measurable - A
or situation. number isnt used.
Specific - Based on detailed General - Based on non-
definitions of what detailed descriptions.
happened.
INVESTIGATION TRAPS
Keep Originals
RECORD EVIDENCE
SAMPLES
Collect
Perishables
First
Fluids
Open Containers
Filings
Chemicals
Air
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
INTERVIEWS
THE INTERVIEW
Use closed-ended questions later to gain
more detail
After the person has provided their
explanation, these type of questions can
be used to clarify
Where were you standing?
What time did it happen?
THE INTERVIEW
Dont ask leading questions
Bad: Why was the forklift operator
driving recklessly?
Good: How was the forklift operator
driving?
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
THE INTERVIEW
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?
DO DONT
Separate Witnesses Suggest Answers
Written Statements Interrogate
Open ended
questions Focus on Blame
Provide Diagrams Dismiss Details
Encourage Details Bar Emotions
Show Concern Make Judgments
Record w/permission
ANALYSIS OF ACCIDENT CAUSES
Immediate Causes
What was done?
What was not done?
What hazardous condition existed?
Root Causes
Why did they do this?
Why didnt they do that?
Why did the unsafe condition exist?
Why wasnt it corrected?
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
ANALYZE DATA
CONTRIBUTING FACTORS
INVESTIGATION STRATEGY
INVESTIGATION TEAM
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
Unsafe conditions what material
conditions, environmental conditions and
equipment conditions contributed to the
accident
INDIRECT CAUSES
Inadequately guarded or unguarded
equipment
Defective tools, equipment or materials
Fire and explosion hazard
Unexpected movement hazard
BREAKDOWN
Projection hazards OF
UNSAFE CONDITIONS
Housekeeping
Hazardous environmental conditions
Improper ventilation
Improper illumination
Unsafe dress or apparel
BREAKDOWN OF
UNSAFE CONDITIONS
BREAKDOWN OF UNSAFE
ACTS
Environment
Equipment
Design & Equipment
Human Behavior
BASIC CAUSES
MANAGEMENT
FIND ROOT CAUSES
WHAT CONTROLS
WORKED?
What was not normal before the accident
Where the abnormality occurred
When it was first noted
How it occurred
DETERMINE
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)
REPORT CAUSES
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
State facts
Assign cause(s), not blame
If referring to an individuals actions, dont
use names in the recommendation
Good: All employees should.
Bad: George should..
Action to remedy
Basic causes
Indirect causes
Direct causes
RECOMMENDATIONS
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
ACCEPTING INADEQUATE
REPORTS
Accidents not reported
Unable to identify basic causes
Accepting inadequate reports
Neglecting to implement corrective actions
COMMON PROBLEMS
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
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
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
COMBAT REPORTING
PROBLEMS
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 of
Insist on reporting QUALITY OF
all injuries
ACCIDENT INVESTIGATION
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
P I T H it s W a ll
F a ilu r e T o S t o p
E n v ir o n m e n ta l E q u ip m e n t P ro c e d u ra l Hum an
W e t F lo o r B r a k e s F a il S t e e r in g F a ils N o T r a in in g N o In s p e c t io n
N o F lu id D id N o t K n o w In te n t io n a l O m is s io n
B r e a k L in e L e a k N o T r a in in g
S u d d e n R e le a s e S lo w L e a k
N o P r e s h if t In s p e c tio n
PROBLEM SOLVING
FAULT TREE
P I T H i t s W a ll
F a ilu r e T o S to p
E q u ip m e n t P ro c e d u ra l H um an
D id n o t C o n d u c t I n s p e c t io n
B r a k e s F a il T r a i n i n g R e q 'd
N o F lu id S u p .R e s p . D id N o t K n o w In t e n t io n a l O m is s io n
B r e a k L in e L e a k S u p v . s ic k T r a in i n g N o t R e c e iv e d T im e lt d .
S u d d e n R e le a s e S lo w L e a k N O T R A IN IN G
N o P r e s h if t In s p e c t io n
ISHIKAWA FISHBONE
DIAGRAM
Machinery Methods
EFFECT
Undesired Event
Why?
Direct Cause
Why?
Contributing Cause
Why?
Contributing Cause
Why?
Contributing Cause
Why?
Root Cause
ACCIDENT
ANALYSIS AND
REPORT
(HANDOUT)
TEST