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INTRODUCTION & COURSE

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

A Spill on the Floor


Broken Equipment
RISK

A measure of the probability and severity of a


hazard to harm human health, property, or the
environment
A measure of how likely harm is to occur and an
indication of how serious the harm might be

Risk 0
SAFETY
FREEDOM FROM DANGER OR
HARM

Nothing is Free of

BUT - We can almost always make


something SAFER
SAFETY IS BETTER DEFINED AS.

A Judgement of
the
Acceptability of
Risk
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

1. Vehicle Accidents 2413


2. Contact With Objects and Equipment
983
3. Falls 809
FATAL ACCIDENTS -
4. Assaults & Violent Acts
WORKPLACE 754
Washington State FATALITIES - 2006
1. Vehicle Accidents 40
2. Contact With Objects and Equipment 13
3. Falls 19
4. Assaults & Violent Acts 4

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

Unsafe Indirect Causes Unsafe


Conditions
Acts
Slip/Trip Fall
Direct Causes Energy Release
Pinched Between

ACCIDENT
Personal Injury
Property Damage
Potential/Actual
Management
Systems & Procedures

Environment

Natural & Man-made


Equipment
Design & Equipment
Human Behavior
BASIC CAUSES

MANAGEMENT

Systems & Procedures


Lack of systems &
procedures
Availability
Lack of Supervision
ENVIRONMENT

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

Not limited to person


involved in accident
HUMAN FACTORS

Omissions &
Commissions

Deviations from SOP


Lacking Authority
Short Cuts
Remove guards
Human Behavior is a function of :

Activators (what needs to be done)

Competencies (how it needs to be done)

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")

Negative Reinforcement (R-)


("Do this or else you'll be penalized")
Behavior
Punishment (P)
("If you do this, you'll be penalized")

Extinction (E)
("Ignore it and it'll go away")
CONSEQUENCES
INFLUENCE BEHAVIORS
BASED UPON INDIVIDUAL
PERCEPTIONS OF:

Magnitude
{ positive
Significance or
Impact negative

Timing - immediate or future

Consistency - certain or uncertain


Behaviors that have consequences
that are:

Soon
Certain
Positive

Have a stronger effect on peoples


behavior

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:

What would you do as a worker if you had


to take 10-15 minutes to don the correct
P.P.E. to enter an area to turn off a control
valve which took 10 seconds?
HUMAN BEHAVIOR

Punishment or threatening workers is a behavioral


method used by some Safety Management programs
Punishment only works if:
It is immediate
Occurs every time there is an unsafe behavior
This is very hard to do
HUMAN BEHAVIOR
The soon, certain, positive reinforcement
from unsafe behavior outweighs the
uncertain, late, negative reinforcement
from inconsistent punishment

People tend to respond more positively to


praise and social approval than any other
factors
Some experts believe you can
HUMAN BEHAVIOR
change workers safety behavior by
changing their Attitude
Accident Report Safety Attitude
A persons Attitude toward any
subject is linked with a set of other
attitudes - Trying to change them
all would be nearly impossible
A Behavior change leads to a new
Attitude because people reduce
tension between Behavior and their
Attitude
Attitudes
however

ARE INSIDE A PERSONS HEAD


-THEREFORE THEY ARE NOT
OBSERVABLE NOR MEASURABLE

ATTITUDES CAN BE CHANGED


BY CHANGING BEHAVIORS

HUMAN BEHAVIOR
Attention Behavioral Safety approach
Focuses on getting workers to pay
Attention
Inability to control Attention is a
contributing factor in many injuries

You cant scare workers into a safety


focus with Pay Attention campaigns
1. Technology encourages short attention spans (TV
remote, Computer Mouse)
2. Increased Job Stress caused by uncertainty
(mergers & downsizing)
3. Lean staffing and increased workloads require
quick attention shifts between tasks
REASONS
4. Fast pace of FOR LACK
work little timeOF
to learn new tasks
and do familiar ones safely
ATTENTION
5. Work repetition can lull workers
into a loss of attention
6. Low level of loyalty shown to
employees by an ever reorganizing
employer may lead to:
a) Disinterested workers
b) Detached workers (no connection to
employer)
c) Inattentive workers

REASONS FOR LACK OF


ATTENTION
HUMAN BEHAVIOR

Focusing on Awareness is a typical educational


approach to change safety behavior

Example: You provide employees with a


persuasive rationale for wearing safety glasses
and hearing protection in certain work areas
HUMAN BEHAVIOR

Developing Personal Safety Awareness


A) Before starting, consider how to do job safely
B) Understand required P.P.E. and how to use it
C) Determine correct tools and ensure they are in
good condition
D) Scan work area know what is going on
E) As you work, check work position reduce any
strain
F) Any unsafe act or condition should be corrected
G) Remain aware of any changes in your workplace
people coming, going, etc.
H) Talk to other workers about safety
I) Take safety home with you
HUMAN BEHAVIOR
Some Thought Questions:
1. Do you want to work safely?
2. Do you want others to work safely?
3. Do you want to learn how to prevent
accidents/injuries?
4. How often do you think about safety as
you work?
5. How often do you look for actions that
could cause or prevent injuries?
HUMAN BEHAVIOR
More Thought Questions:
a) Have you ever carried wood without wearing
gloves?
b) Have you ever left something in a walkway that
was a tripping hazard?
c) Have you ever carried a stack of boxes that
blocked your view?
d) Have you ever used a tool /equipment you didnt
know how to operate?
e) Have you ever left a desk or file drawer open
while you worked in an area?
f) Have you ever placed something on a stair Just
for a minute?
g) Have you ever done anything unsafe because
Ive always done it this way?
HUMAN BEHAVIOR
TIME!

All this safety stuff takes time


doesnt it?

Im too busy!

I cant possibly do all this!

The boss wants the job done now!


HUMAN BEHAVIOR
Does rushing through the job,
working quickly without considering
safety, really save time?

Remember if an incident occurs,


the job may not get done on time
and someone could be injured and
that someone could be YOU!!
SAFETY INTERVENTION STRATEGIES

Approach # of Studies # of Subjects Reduction %


Behavior Based 7 2,444 59.6%
Ergonomics 3 n/a 51.6%
Engineering Change 4 n/a 29.0%
Problem Solving 1 76 20.0%
Govt. Action 2 2 18.3%
Mgt. Audits 4 n/a 17.0%
Stress Management 2 1,300 15.0%
Poster Campaign 26 100 14.0%
Personnel Selection 26 19,177 3.7%
Near-miss Reports 2 n/a 0%
OUTCOMES OF ACCIDENTS

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)

Penalties (as high as $ 2,000) may be assessed

COMPLIANCE
COMPLIANCE

Up to 35% of the penalty can be deducted based upon an


employer's "good faith - Good faith is based upon:
Awareness of the Law
Efforts to comply with the Law before the
inspection
Correction of hazards during the inspection
Cooperation & Attitude during the inspection
Overall safety and health efforts including the
Accident Prevention Program
INDIRECT COSTS
Injured, Lost
Time Wages
Non-Injured, Lost
Time Wages
Overtime
Supervisor
Wages
Lost Bonuses
Employee Morale
Need For
Counseling
Turn-over
INDIRECT COSTS
Equipment Rental
Cancelled Contracts
Lost Orders
Equipment/Material
Damage
Investigation Team
Time
Decreased Production
Light Duty
New Hire Learning
Time
Administrative Time
Community Goodwill
Public/Customer
Perception
3rd Party Lawsuits
REAL COSTS
OUTCOMES

OF ACCIDENTS
POSITIVE ASPECTS
Accident investigation
Prevent repeat of accident
Improved safety programs
Improved procedures
Improved equipment design
ACCIDENT PREVENTION PROGRAM

Must Be
Written
Tailored to particular hazards for a particular plant or
operation
Minimum Elements
Safety Orientation Program
Safety and Health Committee
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

Designated Safety and Health Committee


Management Representatives
Employee Elected Representatives
Max. 1 year
Must be equal # or more employee
representatives than employer representatives
Elected Chairperson
Self-determine frequency of meetings
1 hour or less unless majority votes
Minutes
Keep for 1 Year
Available for review by OSHA Personnel
ACCIDENT PREVENTION
Safety Meeting instead of Safety
PROGRAM
Committee
If less than 11 employees
Total
Per shift
Per location
Meet at least once/month
1 Management Representative
You Must
Review inspection reports
Evaluate accident investigations
Evaluate APP and discuss
recommendations
Document attendance and topics

SAFETY MEETING
SAFETY
COMMITTEES
Proactive
SAFETY 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

Meetings should not be cancelled


SAFETY COMMITTEES
The Goal of the committee is to facilitate a safe
workplace
Objectives that guide a committee towards the goal include:
Motivate, educate and train at all levels to ID, Reduce, &
Avoid Hazards
Incorporate safety into every aspect of the organization
Create a culture where each person is responsible for
safety of self and others
Encourage and utilize ideas from all sources
FOUR POINTS TO
REMEMBER:
Communication: Must be a loop system

Dedication: From everyone

Partnership: Between Management


and Employees
Participation: An important part of
team working.
HOW
EFFECTIVE
CAN A
COMMITTEE
BE?
SAFETY COMMITTEE
POLICY STATEMENT

A written and publicized statement is an


effective means of providing guidance and
demonstrating commitment
Long Term Goals
Objectives to Achieve
Time Frame
Short Term Goals
Assignments between Meetings
Work toward achieving Long-Term Plan

SAFETY COMMITTEE FOCUS


PLANNING THE SAFETY
MEETING

Select topics
Set & post the agenda
Schedule safety meeting
Prepare meeting site
Encourage participation
CONDUCTING A SAFETY MEETING

Provide an attendance list or sign in sheet


Provide a meeting agenda
Call meeting to order and review meeting topics
Cover any old business
Primary meeting topic
Future agendas
Close meeting and document
COMPONENTS OF AN
AGENDA
Opening statement including reason for
attendance, objective, and time
commitment
Items to be discussed
Generate alternative solutions
Decide among the alternatives
Develop a plan to solve the problem
Assign task to carry out plan
Establish follow-up procedures
Summarize and adjourn
REGULAR AGENDA ITEM

Review Policies & Plans such as:


Hazard Communication Program
Personal Protective Equipment
Respiratory Protection
Housekeeping
Machine Safeguarding
Safety Audits
Record Keeping
Emergency Response Plans
EMERGENCY PLAN

Anticipate
What Could
Go Wrong and
Plan for those
Situations

Drill for
Emergency
Situations
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

RECORD KEEPING AND


UPDATING
IMMEDIATELY REPORT:
Any accident that involves: 1. Injury
2. Illness 3. Equipment or property damage

Any near-misses. A near miss is an


event that, strictly by chance, does not result
in actual or observable injury, illness, death,
or property damage. Examples: slips, trips &
falls, compressed gas cylinder falling,
overexposures to a chemical

Any hazards such as: Exposed


electrical wires, Damaged PPE, Improper
material storage, Improper chemical use,
Horseplay, Damaged equipment, Missing or
loose machine guards
HAZARD
ANALYSIS
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

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

Probability - How likely is the hazard?


Likely
Not likely
Severity - What will happen if encountered?
Death
Serious Injury
Damage to property
Unaware: Doesnt realize at-risk

Post-Awareness: Realizes Risk After Task


Completion

Engaged-Awareness: Recognizes Risk While


Performing Task(s) and corrects the
situation
LEVELS OF RISK
AWARENESS
Proactive-Awareness: Foresee Hazards
and Begins Task Only When Safe to Proceed
Workers Contractors
Janitorial
Visitors
Maintenance
Invited
Customers
Emergency Others
services
Members of Public
Delivery drivers
Passers-by
Uninvited
WHO IS AT RISK?
Trespassers
Neighbors
Burglars
STEP 3: MAKE RISK DECISIONS

What can we do to reduce the risk?


Does the benefit outweigh the risk?
STEP 4: IMPLEMENT CONTROLS

Substitution
Engineering controls
Administrative Controls
Personal Protective
Equipment
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

Ensure risk control


measures are
implemented
Track progress
Feedback
JOB SAFETY
ANALYSIS
JOB SAFETY ANALYSIS

Break down a task into its component steps

Determine hazards connected with each key step

Identify methods to prevent or protect against the


hazard
JOB SAFETY ANALYSIS
JOB SAFETY ANALYSIS
PRIORITIES

New Jobs
Potential of Severe Injuries
History of Disabling Injuries
Frequency of Accidents
OBSERVATION OF THE
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

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
KEY STEPS NOT ENOUGH
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

Park & set brake


Remove jack & tire from
trunk
Loosen lug nuts
Jack up car
Remove tire
Set new tire
Jack down car
Tighten lug nuts
Store tire & jack
JOB SAFETY ANALYSIS
Steps
Park & set
brake
Remove
Spare &
Jack
Loosen lugs
JOB SAFETY ANALYSIS

Steps Hazards
Park & set Hit by
brake traffic

Remove Spare Back


& Jack Strain
Foot/Toe
impact

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

Find a new way Fix-A-Flat


to do job

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

Determine the work goal of the job, and then


analyze the various ways of reaching this goal to
see which way is safest
Consider work saving tools and equipment
CHANGE IN PHYSICAL
CONDITIONS

Tools, materials, equipment layout or location


Study change carefully for other benefits (costs,
time savings)
What should the worker do to eliminate the
hazard?
How should it be done?
Document changes in detail

CHANGE IN WORK
PROCEDURES
REDUCE FREQUENCY OF
DANGEROUS JOB

What can be done to reduce the frequency of the


job??
Identify parts that cause frequent repairs -
change
Reduce vibration save machine parts
PERFORMING SAFETY
AUDITS
The guide has five steps
Audit
React
Communicate
GUIDE FOR PERSONAL
Follow up
AUDITS Raise standards
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

AUDIT
Take notes
REACT

How you react is the strongest


element in improving the safety
culture
Your reaction tells what is acceptable
and not acceptable
You must come away from each
inspection with a reaction:
1. Acceptable because...
2. Not acceptable because...
3. Deteriorated because...
4. Improved because
COMMUNICATE

In order for the contact to be


productive, your subordinate/co-worker
must understand that:
You inspected his or her area
You are pleased (or displeased) with what
you saw because of
You expect him or her to react to your
comments and to improve
You will audit the area again in a specified
number of days
Critical for success of the safety program
Allows you to demonstrate that it is important
Must communicate your assessment to the
employees

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

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
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

OBSERVATION TECHNIQUES
Observe activity -- do not avoid the action
Remember ABBI -- look Above,
Below, Behind, Inside
Develop a questioning attitude

Use all senses


sight
hearing

OBSERVATION TECHNIQUES
smell
touch
INSPECTIONS AND FIELD
OBSERVATIONS

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

Day-to-Day Knowledge Accident Prevention


comes from where the Plan Development
work is actually done
and hazards actually Safety Committee
exist.
Safety Bulletin Board

Crew-Leader
Meetings
SHARED VISION
EXERCISE
OSHA Website: www.osha.gov

Washington State Labor & Industries


Website: www.lni.wa.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:

Such as paper cuts to fingers or dropping


a box of materials

THE ACCIDENT
MORE SERIOUS ACCIDENTS

Such as a forklift dropping a load or


someone falling off a ladder

THE ACCIDENT
Accidents that occur over an extended
time frame:
Such as hearing loss or an illness resulting
from exposure to chemicals

THE ACCIDENT
THE ACCIDENT
Also know as a Near Hit
NEAR-MISS
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!
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

THE ACCIDENT
OUTCOMES OF ACCIDENTS
NEGATIVE Results

Injury & possible death


Disease
Damage to equipment & property
Litigation costs, possible citations
Lost productivity
Morale
OUTCOMES OF ACCIDENTS
POSITIVE Results

Accident investigation
Prevent repeat of accident
Change to safety programs
Change to procedures
Change to equipment design
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
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

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

INDIRECT AND ROOT


CAUSES
ACCIDENT INVESTIGATION

You Must:

Conduct a preliminary investigation for:


serious injuries with immediate symptoms

Document the investigation findings


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
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)
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
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
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?
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
WHY NOT RELY ON OSHA &
POLICE TO INVESTIGATE?

Focus On
Culpability
Minor Accidents
Not Investigated
PREVENTION
Protect Company
Interests
OSHA
Requirements
INVESTIGATING
ACCIDENTS

How to find out what really happened



Find the cause
Prevent similar
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

Control the Scene

Gather Facts

Analyze Data

Establish Causes

Write Report

Take Corrective Action


The actual procedures used in a
INVESTIGATIVE PROCEDURES
particular investigation depend on
the nature and results of the
accident
All investigations start with a
collection of data and are followed
by analysis of that data
An investigation is not complete
until all data is analyzed and a
final report is completed
The key result should be to prevent a
repeat of the same accident
Fact finding:
What happened?
What was the root cause?
THE AIM
What OFbeTHE
should done to prevent repeat of
INVESTIGATION
the accident?
Exonerate individuals or management

Satisfy insurance requirements

THE AIM
Defend OF THE
a position for legal argument

INVESTIGATION
Or, to assign blame
IS NOT TO:
12
11 1
10 2
9 3

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

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

8 4
7 5
6
COMPANY ACCIDENT FORMS

Must be filled out completely by the


employee and employees immediate
supervisor (this includes foremen)
Must be turned in to Safety within 24 hours
of incident
Prevent repeat of the accident
Identifying outmoded procedures
Improvements to the work environment
Increased productivity
Improvement of operational & safety
procedures
Raise safety awareness level

BENEFITS OF ACCIDENT
INVESTIGATION
WHEN AN ORGANIZATION REACTS
SWIFTLY AND POSITIVELY TO ACCIDENTS
AND INJURIES, ITS ACTIONS REAFFIRM ITS
COMMITMENT TO THE SAFETY AND WELL-
BEING OF ITS EMPLOYEES!

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

ISOLATE THE SCENE


Ensure that medical care is provided to
the injured people before proceeding with
the investigation

PROVIDE CARE TO THE


INJURED
Eliminate the hazards:
Control chemicals
De-energize
De-pressurize
Light it up
Shore it up
Ventilate

SECURE THE SCENE FOR


SAFETY
FACT FINDING

Gather evidence from many


sources during an investigation
Get information from witnesses
and reports as well as by
observation
Dont try to analyze data as
evidence is gathered
Examine the
GATHER accident scene -
EVIDENCE
Look for things that will help
you understand what happened:
Dents, cracks, scrapes, splits, etc.
in equipment
Tire tracks, footprints, etc.
Spills or leaks
Scattered or broken parts
Any other possible evidence
GATHER EVIDENCE

Diagram the scene:


Use blank paper or graph paper.
Mark the location of all
pertinent items; equipment,
parts, spills, persons, etc.
Note distances and sizes,
pressures and temperatures
Note direction (mark north on
the map)
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
GATHERcameras
Digital EVIDENCE
are not
recommended - digital images
can be easily altered
PHOTOGRAPHS

Unbiased Recording
Keep Log of Photos
Overall to Close-up
Color if possible
Supplement with Video
Data includes:
Persons involved
Date, time, location
Activities at time of accident
Equipment involved
List of witnesses

GATHER DATA
REVIEW RECORDS

Check training records


Was appropriate training provided?
When was training provided?
Check equipment maintenance records
Is regular PM or service provided?
Is there a recurring type of failure?
Check accident records
Have there been similar incidents or
injuries involving other employees?
DOCUMENTS

Collect All Related


Documents
Inspection Logs
Policy & Procedures Manual
JSA (Job Safety Analysis)
Equipment Operations
Manuals
Insurance Records
Employee Records
Police Reports
THOSE WHO DO NOT KNOW THE
Repeat
PAST ARE DESTINED TO:
Repeat
Repeat

Repeat
Repeat
Repeat

It.
ISOLATE FACT FROM FICTION

Use NORMS-based analysis of information


Not an interpretation
Observable
Reliable
Measurable
Specific
If an item meets all five of above, it is a fact
NORMS OF OBJECTIVITY

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

Put your emotions aside!


Dont 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
Keep All Notes in Bound Notebook

Include Date - Time - Place


Vantage Point

Keep Originals

Rewrite in Report Form

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

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
Excellent Source of first hand knowledge

May Present Pitfalls in form of:


Bias
Perspective
Embellishment
INTERVIEWS
Omissions
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
ASK WHAT HAPPENED
Interview as soon as
possible after the
incident
Do not interrupt medical
care to interview
Interview each person
separately
INTERVIEW
Do not allowVICTIMS
witnesses&
WITNESSES
to confer prior to
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
THE INTERVIEW
Remind them that these
facts will be used to
prevent a recurrence of the
incident
Take Notes!
Ask open-ended questions
What did you see?
What happened?
Do not make suggestions
If the person is stumbling over a word or
concept, do not help them out

THE INTERVIEW
Use closed-ended questions later to gain
more detail
After the person has provided their
explanation, these type of questions can
be used to clarify
Where were you standing?
What time did it happen?

THE INTERVIEW
Dont 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,


THE INTERVIEW
excuses, or explanations, politely
decline that knowledge and remind
them to stick with the facts
Summarize what you have been told
Correct misunderstandings of the events
between you and the witness

Ask the witness/victim for


recommendations to prevent recurrence
These people will often have the best
solutions to the problem

THE INTERVIEW
Get a written, signed statement from the witness
It is best if the witness writes their own statement;
interview notes signed by the witness may be used
if the witness refuses to write a statement

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?

ASK ALL WITNESSES


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?
ASK SUPERVISORS
What could have prevented the
accident?
WITNESS INTERVIEWS

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

EVALUATES ALL FACTORS CONCERNED

ISOLATES THE KEY FACTOR(S) BY ASKING THE


FOLLOWING QUESTION....

WOULD THE ACCIDENT HAVE HAPPENED IF THIS


PARTICULAR FACTOR WAS NOT PRESENT?
DETERMINE CAUSES

Employee actions
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

Unsafe Acts what activities 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

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
Management
Systems & Procedures

Environment

Equipment
Design & Equipment
Human Behavior
BASIC CAUSES

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?

MANAGEMENT
FIND ROOT CAUSES

When you have determined the


contributing factors, dig deeper!
If employee error, what caused that
behavior?
If defective machine, why wasnt it
fixed?
If poor lighting, why not corrected?
If no training, why not?
CONTRIBUTION
Engineering ControlsOF SAFETY
- machine
guards, safety controls, isolation of
CONTROLS SUCH
hazardous areas, AS:
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.
List the specific engineering,
administrative and training controls that
failed and how these failures contributed
to the accident

WHAT CONTROLS FAILED?


List any controls that prevented a more
serious accident or minimized collateral
damage or injuries

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

Accident Reports should contain the


following:
Description of incident and injuries
Sequence of events
Pertinent facts discovered during
investigation
Conclusions of the investigator(s)
Recommendations for correcting
problems
PREPARE A REPORT, (CONT.)
Be objective!

State facts
Assign cause(s), not blame
If referring to an 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 - as a result of the


finding is there a need to make changes
to:
RECOMMENDATIONS
Employee training?
Work Stations Design?
Policies or procedures?
Consider
-Effectiveness -Cost
-Feasibility -Effect on Productivity
-Time to Implement -Employee Acceptance
-Management Acceptance

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

ACCIDENTS NOT REPORTED


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
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

Review and comment


Refuse to accept inadequate reports
Establish controls to follow up on
corrective actions
Be responsive to recommendations
Hold responsible persons accountable
Emphasize that accident investigations
are FACT-finding, not FAULT-finding
Encourage investigators to challenge
the system
SUMMARY

Most accident investigations follow formal


procedures
An investigation is not concluded until completion
of a final report
A successful accident investigation determines
what happened and how and why the accident
occurred
Investigations are an effort to prevent a similar or
perhaps more disastrous sequence of events
OTHER ACCIDENT INVESTIGATION
TOOLS
PROBLEM SOLVING
FAULT TREE

Deductive, top-down method of analyzing


Identify all elements that could cause Accident
Performed graphically using AND and OR gates
Create symbolic representation of events
resulting in the Accident
Entire system and human interactions are analyzed
PROBLEM SOLVING
FAULT TREE

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

Materials People Environment


FIVE WHYS DIAGRAM

Undesired Event
Why?
Direct Cause
Why?
Contributing Cause
Why?
Contributing Cause
Why?
Contributing Cause
Why?
Root Cause
ACCIDENT
ANALYSIS AND
REPORT
(HANDOUT)
TEST

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