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Accident Investigation

Accident Investigation - ACCIDENT INVESTIGATION What's your...

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Unformatted text preview: ACCIDENT INVESTIGATION What's your Favorite Hobby? Is it dangerous ? Objectives Types of accidents Causes or contributing factors of accidents How to perform an accident investigation What documentation should be completed Accident and Safety at work place Reducing Injury Risk avoid mismatch between worker's physical capabilities and limits with job demands worker's injury compensation claims and costs to employer and insurance companies personal, physical, emotional, social, financial, and career costs and losses for injured employee e.g. Canada (year 2000): $5.7 billion in worker injury and associated costs e.g. Ontario (year 2000): $ 2.3 billion in worker injury and associated costs Canada (2000) W orker Injury Costs O ther 9% Long-term D is ability 37% R ehab 3% Health C are 18% W age Los s C om pens ation 13% Total = $ 5.7 Billion Short-term D is ability 20% [Institute for Work and Health, www.iwh.on.ca] Ontario (2000) W orker Injury C osts Surv iv or Benef its 5% Medic al & Rehab Cos ts 13% Wage Los s Compens ation 75% Labour Market Re-entry 7% Total = $ 2.3 Billion [Institute for Work and Health, www.iwh.on.ca] Performance Are there minimum strength, agility, speed, or other physical levels required for execution of task? What is the minimum level of "skill" or "excellence" needed for a successful performance of task? Are potential workers able to perform as well as seasoned workers? How much training or re-training may be required? Are there several potential "job postings" that the newly hired worker can fill successfully? Legal Cases Case 1: female applicant to police force, but could not scale 6 foot walls. City allows 6 foot walls/fences. Ruling 1: reasonable for police to be required to scale 6 foot walls. Case 2: police applicants required to run 1 mile track Ruling 2: job analysis showed that foot chases were usually only for short distances Case 3: fire-fighters tests included carrying a dummy and showing agility Ruling 3: tests did not arise from systematic analysis of work [adapted from Callaghan, 2002] Leading Causes of Workplace Deaths Miscellaneous 11% Caught Between Object/Equipment 5% Airplanes 5% Gunshot Wounds 8% Slips and Falls 8% Motor Vehicles 32% Heart Attacks/Strokes 13% Struck by Moving, Falling or Stationary Objects 18% What is the aim of an investigation EXONERATE INDIVIDUALS OR MANAGEMENT SATISFY INSURANCE REQUIREMENTS DEFEND A POSITION FOR LEGAL ARGUEMENT OR, TO ASSIGN BLAME The Aim of the Investigation THE MAIN GOAL SHOULD BE TO PREVENT A RECURRENCE OF THE SAME ACCIDENT WE SHOULD LEARN FROM OUR MISTAKES THE ACCIDENT WHAT IS AN ACCIDENT? THE ACCIDENT AN UNPLANNED AND UNWELCOMED EVENT WHICH INTERRUPTS NORMAL ACTIVITY. THE ACCIDENT THREE BASIC TYPES OF ACCIDENTS THE ACCIDENT MINOR ACCIDENTS: SUCH AS PAPER CUTS TO FINGERS OR DROPPING A BOX OF MATERIALS Example The Basic Causes Poor Management Safety Policy & Decisions Personal Factors Environmental Factors Basic Causes Unsafe Act Indirect Causes Unplanned release of energy and/or Hazardous material Unsafe Condition D t ec ir C ses au ACCIDENT Personal Injury Property Damage THE ACCIDENT MORE SERIOUS ACCIDENTS THAT CAUSE INJURY OR DAMAGE TO EQUIPMENT OR PROPERTY: SUCH AS A FORKLIFT DROPPING A LOAD OR SOMEONE FALLING OFF A LADDER We sometime invite accidents by becoming complacent or simply acting stupid THE ACCIDENT ACCIDENTS THAT OCCUR OVER AN EXTENDED TIME FRAME: SUCH AS HEARING LOSS OR AN ILLNESS RESULTING FROM EXPOSURE TO CHEMICALS, NOISE, VIBRATION 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 ASPECTS DEATH & INJURY DISEASE DAMAGE TO EQUIPMENT & PROPERTY LITIGATION COSTS LOST PRODUCTIVITY DEMORALIZING THE WORKFORCE You can seriously harm yourself as well as others OUTCOMES OF ACCIDENTS POSITIVE ASPECTS ACCIDENT INVESTIGATION CHANGE TO SAFETY PROGRAMS increase productivity, improve operations, raise awareness and prevent recurrence CONTRIBUTING FACTORS MATERIAL ENVIRONMENT TASK MANAGEMENT PERSONAL (1) Task Ergonomics Safety work procedures Condition changes Process Materials Workers Appropriate tools/materials Safety devices (including lockout) (2) Material Equipment failure Machinery design/guarding Hazardous substances Substandard material WORKPLACE LAYOUT DESIGN OF TOOLS & EQUIPMENT (3) Environment Weather conditions Housekeeping Temperature Lighting Air contaminants Personal protective equipment NOISE VAPORS, FUMES, DUST LIGHT HEAT ANIMALS (4) Human Factor Level of experience Level of training Physical capability Health Fatigue Stress Specific Task Training E.g. "LIFTING" Training Should Specifically Cover ... 1. Risks to health of unskilled lifting 2. Basic biomechanics of lifting 3. Effects of lifting on the body 4. Individual's awareness of their strengths and weaknesses using trials from moderate to heavy 5. How to avoid the unexpected shifting loads 6. Lifting skills posture, leverage, timing 7. Lifting aids back belts, dollies, hoists, gloves, pads 8. Warnings when to have individual vs. team lifting [source: NIOSH, 1981] Lifting Posture Lifting Distance [Chaffin et al, 1999] Lifting Speed "Free-style" lift Squat "leg" lift Stooped "back" lift Lifting Cycle Workers Safety Accident Theories Accident Proneness Theory some people more prone to accidents due to peculiar set of constitutional characteristics (e.g. age, job experience, etc.) e.g. Age: young workers more prone due to inattention, lack of discipline, impulsiveness, recklessness, misjudgment, overestimation of capacity, pride e.g. Age: older workers more prone due to deterioration of motor skills, sensory functions, mental agility Accident Theories accident liability increases when job requirements exceeds worker capacities and skills psychological stress or physiological stress exceeds worker endurance e.g. noise, poor lighting, anxiety, lack of sleep, anger, etc. accidents more likely to occur when job stimulation is too low (e.g. underloaded or bored) or too high (e.g. overloaded or overly motivated) Job Demand vs. Worker Capability Theory Adjustment-to-Stress Theory Arousal-Alertness Theory Accident Theories Goals-Freedom-Alertness Theory less freedom for workers to set job goals yields lower-quality job performance and more accidents Psychoanalytic Theory Some accidents are self-punitive actions due to anger, guilt, or aggression Account for isolated incidents but of no really value explaining typical accidents Accident Factors 19 % 15 14 12 10 10 6 6 2 6 284 Chemical Industry Accidents (Japan) Inadequate Standard Operational Procedure Error in Recognition or Confirmation Error in Judgment Poor Inspection Inadequate Directives Inadequate Operational Information Operational Error Unskilled Operation Imperfect Maintenance Other [Source: Hayashi, 1985] Accident Factors 405 Gold Mining Accidents (South Africa) Failed to Perceive Hazard Underestimated Hazard Failed to Respond to a Recognized Hazard Responded to Hazard Ineffectively 36 % 25 17 14 [Source: Lawrence, 1974] Accident Factors "Perception" as Contributing Factor [Source: Irvine et al.] Accident Data Collection Data on accidents routinely taken by .... Insurance companies Police departments Trade Associations and Unions Industry: occupational health unit Researchers Accident Reports typically include ... Nature of injury (strain, impact, amputation) Area of Body (head, back, finger, etc.) Type of Accident ("struck by", "caught between", "fell") Source (equipment, hand tools, body movement, etc.) Accident Data Collection Critical Incident Technique Purpose: detailed documentation of unsafe activities or near-miss accidents to develop preventative measures Basis: many more "close calls" rather than actual accidents in workplace Pros: correlation between observed "unsafe" acts & actual accidents preventative approach Cons: selective worker recall on details of incidents over which they had no control vs. ones they were responsible for definition of "critical" or "near miss" is vague Accident Prevention Procedural Checklists Substitute for memory and task lag time e.g. aircraft operation, military operations "danger", "warning", "hazard", "caution" ensure safe and productive job behavior management to give workers encouragement re: preferred methods of executing tasks and jobs bonuses, promotions, privileges (e.g. time off, better parking space locations), group safety records, tokens redeemable for catalog products Warning Signs Training Feedback Incentive Programs ("The Carrot") Workers Safety (5) Management/Process Failure Visible active senior management support for safety Safety policies Enforcement of safety policies Adequate supervision Knowledge of hazards Hazard corrective action Preventive maintenance Regular audits SYSTEMS & PROCEDURES LACK OF SYSTEMS & PROCEDURES INAPPROPRIATE SYSTEMS & PROCEDURES CONTRIBUTING FACTORS SYSTEMS & PROCEDURES LACK OF SYSTEMS & PROCEDURES INAPPROPRIATE SYSTEMS & PROCEDURES CONTRIBUTING FACTORS HUMAN BEHAVIOUR COMMON TO ALL ACCIDENTS NOT LIMITED TO THE PERSON INVOLVED IN THE ACCIDENT It is Important to bear in Mind that Investigation is not intended to place blame. WHO SHOULD INVESTIGATE DEPENDENT ON SEVERITY OF THE ACCIDENT INVESTIGATION TEAM INDIVIDUALS INVOLVED SUPERVISOR SAFETY SUPERVISOR UPPER MANAGEMENT OUTSIDE CONSULTANTS INVESTIGATION STRATEGY GATHER INFORMATION & ESTABLISH FACTS ISOLATE ESSENTIAL CONTRIBUTORY FACTORS DETERMINE CORRECTIVE ACTIONS IMPLEMENT CORRECTIVE ACTIONS INVESTIGATION STRATEGY FACT GATHERING BE IMPARTIAL & OBJECTIVE DO NOT BE INFLUENCED BY EITHER SIDE COMPILE PROCEDURES & RULES FOR THE AREA Gather information not only from the management but very much from the labour force and the ones near the accident. GATHER MAINTENANCE RECORDS ON EQUIPMENT INVOLVED INVESTIGATION STRATEGY FACT GATHERING (CONTINUED) ISOLATE ACCIDENT SCENE PHOTOS & DIAGRAMS (even Video ) DO NOT DISCARD OR DESTROY ANYTHING INVESTIGATION STRATEGY FACT GATHERING (CONTINUED) TIME IS OF THE ESSENCE OBTAIN INFORMATION INJURED WITNESSES SUPERVISORS OTHER PERSONNEL INVESTIGATION STRATEGY FACT GATHERING (CONTINUED) INTERVIEWS (SEPARATELY) WHAT WERE YOU DOING? HOW DO YOU THINK THE ACCIDENT OCCURRED? HOW WERE YOU TRAINED FOR THE JOB? WHAT WAS THE ENGINEER INSTRUCTION? WHAT IS THE SAFETY PROCEDURE FOR THIS JOB? INVESTIGATION STRATEGY FACT GATHERING (CONTINUED) OBTAIN FACTS NOT OPINIONS MAKE IT CLEAR THE OBJECT OF THE INVESTIGATION IS TO AVOID RECURRENCE, NOT TO APPORTION BLAME Interview Do Not's Intimidate the witness Interrupt Prompt Ask leading questions Show your own emotions Make lengthy notes while the witness is talking Analysis and Conclusion Isolate contributory factors Would the accident have occurred if this particular factor was not present? Determine Why the accident occurred A likely sequence of events and probably causes Draw conclusions and make recommendations based on key contributing factors and causes. Implement corrective actions and set a time table to complete them. REPORT Statement of injured or ill employee concerning the incident and injured employee information Witness statements Equipment involved Other factors or contributing causes Corrective action plan INVESTIGATION STRATEGY ISOLATE ESSENTIAL CONTRIBUTORY FACTORS INVESTIGATION TEAM EVALUATES ALL FACTORS CONCERNED INVESTIGATION STRATEGY ISOLATE ESSENTIAL CONTRIBUTORY FACTORS INVESTIGATION TEAM ISOLATES THE KEY FACTOR(S) BY ASKING THE FOLLOWING QUESTION.... INVESTIGATION STRATEGY WOULD THE ACCIDENT HAVE HAPPENED IF THIS PARTICULAR FACTOR WAS NOT PRESENT? INVESTIGATION STRATEGY DETERMINE CORRECTIVE ACTIONS INVESTIGATION TEAM INTERPRETS & DRAWS CONCLUSION DISTINCTION BETWEEN INTERMEDIATE & UNDERLYING CAUSES INVESTIGATION STRATEGY DETERMINE CORRECTIVE ACTIONS INVESTIGATION TEAM RECOMMENDATIONS BASED ON KEY CONTRIBUTORY FACTORS AND UNDERLYING CAUSES INVESTIGATION STRATEGY IMPLEMENT CORRECTIVE ACTIONS INVESTIGATION TEAM RECOMMENDATION(S) MUST BE COMMUNICATED CLEARLY STRICT TIME TABLE ESTABLISHED FOLLOW UP CONDUCTED BENEFITS OF ACCIDENT INVESTIGATION PREVENTING RECURRENCE IDENTIFYING OUT-MODED PROCEDURES IMPROVEMENTS TO WORK ENVIRONMENT BENEFITS OF ACCIDENT INVESTIGATION INCREASED PRODUCTIVITY IMPROVEMENT OF OPERATIONAL & SAFETY PROCEDURES RAISES SAFETY AWARENESS LEVEL BENEFITS OF ACCIDENT INVESTIGATION WHEN AN ORGANIZATION REACTS SWIFTLY AND POSTIVELY TO ACCIDENTS AND INJURIES, ITS ACTIONS REAFFIRM ITS COMMITMENT TO THE SAFETY AND WELLBEING OF ITS EMPLOYEES Are we to leave our children a country ridden with accidents and their corresponding burden of human and economic loss? Raymond J. Colvin, Sr. NYU.......1959 Summery What are the different types of accidents? What causes or contributes to accidents? How do you perform an accident investigation? What documentation should be completed? Food Service Accident Analysis Retail Grocery Store Accident Accident Information Pre-event 15-year old Part Time Worker in retail grocery store Hired to clean meat department and wash down tables Instructed not to touch any of the equipment except meat grinder Training offered by employer Written Policy Did not address age specific info regarding control of hazardous energy Management On-The-Job Department-Specific Training Company's First Serious Injury Accident Information Electric cord for meat grinder was still attached to energized receptacle Receptacle was located behind a desk and not accessible for routine disconnect Therefore, was connected at all times On/Off switch, located on left side of grinder Was unprotected from inadvertent operation Magnetic Safety Switch, located under plastic tub used for feeding meat into machine Not functional since store was purchased 16 years prior Store employees were not aware of its presence Accident Information During Accident Employee arrived and began to perform regular duties Grinder had already been disassembled and shut down Cord was not disconnected from receptacle Employee cleaned parts and began reassembly Accident Information Attached barrel shape housing to transmission case Inserted to the grinder's auger through the front of the housing Then, he reached through the feed hopper (throat) with his right hand to guide the auger into engagement During this process he accidentally leaned against the on/off switch activating it The grinder started and the auger began to feed his hand and arm through the grinder housing Accident Information Post-Accident Employee Shut Down Machine and withdrew his arm He left the meat department room and made his way to the front of the store Store manager assisted employee by applying pressure to the injured right arm while another employee dialed 911 EMS arrived within 10 minutes and employee was transported to local hospital Employee suffered amputation of lower right arm Accident Investigation Safety Equipment and measures Power cord not located in easily accessible location On/Off switch not protected from inadvertent operation Magnetic Safety switch not functional Switch mounted on top of motor started designed to be pulled closed when contact made with magnet on underneath side of plastic meat feeding tub. Magnet mounted underneath plastic tub had fallen off Switch was then bypassed by previous store owner Employer and staff were unaware of this safety device Would have prevented this accident Accident Investigation Regulation Violations Child-Labor Laws 14 & 15 year olds prohibited from occupations: Requiring the performance of duties in work rooms or work places where goods are manufactured, mined, or processed Involving the tending, including the cleaning and assembling of power-driven machinery Involving operating, setting-up, cleaning, oiling, or repairing power-driven food grinders . A minimum age of 18 has been established for operating powered meat grinders Accident Investigation Human Error Miscommunication between management and employee Management Instructed employee to clean disassembled parts and assemble partially (unclear) Management reports that he had instructed employee to only attach auger-housing and to tighten the bolts and nuts finger-tight Did not inform employee of what hazards the restrictions are designed to guard against Activating the On/Off switch while assembling the parts Employee Believed the assembly process was more extensive Only 4 parts to reassemble and could easily be deduced without instruction Accident Investigation Primary Cause of Accident Haddon's 10 Countermeasures Energy Transfer Model Pre-accident countermeasures most applicable to this accident Prevent Energy Release Move cord to easily accessible location Protect on/off switch from unintended operation Repair Magnetic Safety Switch Training of Employees should be corrected to include hazard recognition dangers working with energized equipment Child-Labor Laws need to be followed Recommendations Employer should develop and implement appropriate procedures to control the release of hazardous energy, including lockout/ tag out procedures After Accident, cord was relocated to easily accessible receptacle Established procedures to lockout/tagout equipment at end of day and while servicing or repairing Recommendations Employer should ensure that all equipment, including manufacture-provided safety devices, is maintained in safe operating conditions Have manufacturer of distributor inspect equipment at time of purchase or especially if previously owned Should be regularly examined by employees who have been trained to recognize the hazards Defects should be corrected before returning equipment to service After accident, owner contacted technician to repair Magnetic Safety Switch Recommendations Employer should ensure that all equipment is survey regularly to identify appropriate safety control improvements After the accident, employer added guard to on/off switch to prevent accidental activation Made from electrical junction box Similar to recessed switch design Manufacturer provides similar protection for currently produced equipment U-shaped guard over on/off switch Recommendations Employers should know and comply with child labor laws and establish the type of work that minors can perform Be very clear about job function and hazards if these functions are violated Continually check to make sure rules are being adhered to Recommendations Employer should ensure that workers are trained to recognize hazards and avoid the hazards of equipment operation and maintenance Include in-depth description of potential hazards if restrictions and procedures are not followed Dangers of working with energized equipment Why Safety standards? SAFETY Absolute safety ,in the sense of a degree of safety which satisfies all individuals or groups under all condition, is neither attainable nor affordable. SPACE ACCIDENTS Video clip 55 min Reference Mr.Ken Roberts, MS, CIH, CSP, Environmental Services Officer Professor Feyen Other references to be given on the general reference section. END References This presentation is put together from, course books , other presentations as well as various websites in the forms of text, photos, audio and video clips. All the references will be given in the general reference section on the web Ct Reference Anderson and Chaffin, "A biomechanical evaluation of five lifting techniques", Applied Ergonomics, 17(1):2-8, 1986. Bush-Joseph, et al., "Influence of dynamic factors on the lumbar spine moment in lifting", Ergonomics, 31(2):211-216, 1988. Callaghan, Occupational Biomechanics and Ergonomics, University of Guelph, course notes, 2002. Chaffin et al., Occupational Biomechanics, 1999. Fisher, Analysis of Spinal Stresses During Lifting, 1967. Hayashi, "Hazard analysis in chemical complexes in Japan--Especially those caused by human error", Ergonomics, 28(6):835-841, 1985. Institute for Work and Health, www.iwh.on.ca Modified from the Presentation of Ken Roberts, MS, CIH, CSPEnvironmental Services Officer And the Presentation of Professor Feyen Irvine et al., "Stairway risers and treads: acceptable and preferred dimensions", Applied Ergonomics, 21(3): 215-225, 1990. Lawrence, "Human error as a cause of accidents in gold mining", Journal of Safety Research, 6:78-88, 1974. NIOSH (National Institute for Occupational Safety and Health), Work Practices Guide to Manual Lifting, 1981. Sanders & McCormick, Human Factors in Engineering Design, 1993. Workplace Issues II:Worker Selection,Training, and Safety, Rad Zdero, Ph.D. University of Guelph ...
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