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Title: ACCIDENT PREVENTION


1
Photo Tulalip Bay by Diane L. Wilson-Simon
2
ACCIDENT INJURY PREVENTION
  • Instructor Kerrie Murphy
  • Edmonds Community College
  • This course is being supported under grant
    number SH16637SH7 from the Occupational Safety
    and Health Administration, U.S. Department of
    Labor. It does not necessarily reflect the views
    or policies of the U.S. Department of Labor, nor
    does mention of trade names, commercial products,
    or organizations imply endorsement by the U.S.
    Government.
  • With Thanks to Cooperation of the Tulalip
    Occupational Safety Health Administration
    (TOSHA)

3
Introduction Course Overview
4
PROaction versus REaction
  • Well thats an accident waiting to happen
  • Someone ought to do something
  • That someone is YOU!

5
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6
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7
What Is An Accident?
"9 1 1"
"EVACUATE"
CRASH
F I R E
! _at_ !
Call an Ambulance
8
What Is An Accident?
"That Was Close"
"Just Missed !"
"Whhoooaaa!"
! _at_ !
Near Miss
"Watch Out"
Almost Hit
L U C K Y
9
An Accident is
  • 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

10
Hazard
  • Existing or Potential Condition That Alone or
    Interacting With Other Factors Can Cause Harm
  • A Spill on the Floor
  • Broken Equipment

11
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
12
Safety
  • FREEDOM FROM DANGER OR HARM

Nothing is Free of
  • BUT - We can almost always make something SAFER

13
Safety Is Better Defined As.
  • A Judgement of the
  • Acceptability of Risk

14
RATIOS
15
OSHA METHOD330 Incidents29 Minor Injuries1
Major or Loss-Time Accident
16
Candy Jar Example
17
Types of Accidents
  • FALL TO
  • same level
  • lower level
  • CAUGHT
  • in
  • on
  • between
  • CONTACT WITH
  • chemicals
  • electricity
  • heat/cold
  • radiation
  • BODILY REACTION FROM
  • voluntary motion
  • involuntary motion

18
Types of Accidents (continued)
  • STRUCK
  • Against
  • stationary or moving object
  • protruding object
  • sharp or jagged edge
  • By
  • moving or flying object
  • falling object
  • RUBBED OR ABRADED BY
  • friction
  • pressure
  • vibration

19
Fatal Accidents - Workplace
  • U.S. WORKPLACE FATALITIES - 2006
  • 1. Vehicle Accidents 2413
  • 2. Contact With Objects and Equipment 983
  • 3. Falls 809
  • 4. Assaults Violent Acts 754

20
Fatal Accidents - Workplace
  • Washington State FATALITIES - 2006
  • 1. Vehicle Accidents 40
  • 2. Contact With Objects and Equipment 13
  • 3. Falls 19
  • 4. Assaults Violent Acts 4
  • NO NOTE If you wish to normalize or compare the
    Washington data with the Federal data, just
    multiply the Washington numbers by 47 (based on
    population)

21
Accident Causing Factors
  • Basic Causes
  • Management
  • Environmental
  • Equipment
  • Human Behavior
  • Indirect Causes
  • Unsafe Acts
  • Unsafe Conditions
  • Direct Causes
  • Slips, Trips, Falls
  • Caught In
  • Run Over
  • Chemical Exposure

22
Policy Procedures Environmental Conditions
Equipment/Plant Design Human Behavior
Basic Causes
Unsafe Conditions
Indirect Causes
Unsafe Acts
Slip/Trip Fall Energy Release Pinched Between
Direct Causes
ACCIDENT Personal Injury Property
Damage Potential/Actual
23
Basic Causes
  • Management
  • Environment
  • Equipment
  • Human Behavior
  • Systems Procedures
  • Natural Man-made
  • Design Equipment

24
Management
  • Systems Procedures
  • Lack of systems procedures
  • Availability
  • Lack of Supervision

25
Environment
  • Physical
  • Lighting
  • Temperature
  • Chemical
  • vapors
  • smoke
  • Biological
  • Bacteria
  • Reptiles

26
Environment
27
Design and Equipment
  • Design
  • Workplace layout
  • Design of tools
  • equipment
  • Maintenance

28
Design and Equipment
  • Equipment
  • Suitability
  • Stability
  • Guarding
  • Ergonomic
  • Accessibility

29
Human Behavior
  • Common to
  • all accidents

Not limited to person involved in accident
30
Human Factors
  • Omissions Commissions
  • Deviations from SOP
  • Lacking Authority
  • Short Cuts
  • Remove guards

31
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)
32
ABC Model
  • Antecedents
  • (trigger behavior)
  • Behavior
  • (human performance)
  • Consequences
  • (either reinforce or punish behavior)

33
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")

34
Consequences Influence Behaviors Based Upon
Individual Perceptions of

positive or negative
Magnitude
  • Significance

Impact
  • Timing - immediate or future
  • Consistency - certain or uncertain

35
Human Behavior
  • Behaviors that have consequences that are
  • Soon
  • Certain
  • Positive
  • Have a stronger effect on peoples behavior

36
Some examples of Consequences
37
Why is one sign often ignored, the other one
often followed?
38
Human Behavior
  • Soon
  • 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

39
Human Behavior
  • Certain
  • 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

40
Human Behavior
  • Positive
  • A positive consequence influences behavior more
    powerfully than a negative consequence
  • Penalties and Punishment dont work
  • Speeding Ticket Analogy

41
Human Behavior
  • Example Smokers find it hard to stop smoking
    because the consequences are
  • 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)

42
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

43
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?

44
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

45
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

46
Human Behavior
  • Some experts believe you can 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

47
Are inside a persons head -therefore they are
not observable nor measurableAttitudes can be
changed by changing behaviors
Attitudes
however
48
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

49
Reasons for Lack of Attention
  • 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
  • 4. Fast pace of work little time to learn new
    tasks and do familiar ones safely

50
Reasons for Lack of 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

51
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

52
Human Behavior
  • Developing Personal Safety Awareness
  • Before starting, consider how to do job safely
  • Understand required P.P.E. and how to use it
  • Determine correct tools and ensure they are in
    good condition
  • Scan work area know what is going on
  • As you work, check work position reduce any
    strain
  • Any unsafe act or condition should be corrected
  • Remain aware of any changes in your workplace
    people coming, going, etc.
  • Talk to other workers about safety
  • Take safety home with you

53
Human Behavior
  • Some Thought Questions
  • Do you want to work safely?
  • Do you want others to work safely?
  • Do you want to learn how to prevent
    accidents/injuries?
  • How often do you think about safety as you work?
  • How often do you look for actions that could
    cause or prevent injuries?

54
Human Behavior
  • More Thought Questions
  • Have you ever carried wood without wearing
    gloves?
  • Have you ever left something in a walkway that
    was a tripping hazard?
  • Have you ever carried a stack of boxes that
    blocked your view?
  • Have you ever used a tool /equipment you didnt
    know how to operate?
  • Have you ever left a desk or file drawer open
    while you worked in an area?
  • Have you ever placed something on a stair Just
    for a minute?
  • Have you ever done anything unsafe because Ive
    always done it this way?

55
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!

56
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!!

57
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

58
OUTCOMES OF ACCIDENTS
  • NEGATIVE OUTCOMES
  • POSITIVE OUTCOMES

59
Direct Costs
  • Medical
  • Insurance
  • Lost Time
  • Fines

60
Compliance
  • 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

61
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

62
Indirect Costs
  • Injured, Lost Time Wages
  • Non-Injured, Lost Time Wages
  • Overtime
  • Supervisor Wages
  • Lost Bonuses
  • Employee Morale
  • Need For Counseling
  • Turn-over

63
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

64
REAL Costs
65
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66
OUTCOMES OF ACCIDENTS
  • POSITIVE ASPECTS
  • Accident investigation
  • Prevent repeat of accident
  • Improved safety programs
  • Improved procedures
  • Improved equipment design

67
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

68
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

69
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

70
Accident Prevention Program
  • Safety Meeting instead of Safety Committee
  • If less than 11 employees
  • Total
  • Per shift
  • Per location
  • Meet at least once/month
  • 1 Management Representative

71
Safety Meeting
  • You Must
  • Review inspection reports
  • Evaluate accident investigations
  • Evaluate APP and discuss recommendations
  • Document attendance and topics

72
Safety Committees
73
Safety Committees
Proactive Safety
  • 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

74
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
75
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.

76
How effective can a Committee be?
77
Safety CommitteePolicy Statement
A written and publicized statement is an
effective means of providing guidance and
demonstrating commitment
78
Safety Committee Focus
  • Long Term Goals
  • Objectives to Achieve
  • Time Frame
  • Short Term Goals
  • Assignments between Meetings
  • Work toward achieving Long-Term Plan

79
Planning the Safety Meeting
  • Select topics
  • Set post the agenda
  • Schedule safety meeting
  • Prepare meeting site
  • Encourage participation

80
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
81
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
82
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

83
Emergency Plan
  • Anticipate What Could Go Wrong and Plan for those
    Situations
  • Drill for Emergency Situations

84
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

85
Record Keeping Updating
  • 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
    work or motion
  • This information in posted every year from
    February 1 to April 30 in the OSHA 300A Summary

86
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
  • NOTE The new OSHA Recordkeeping Rule lists the
    specific First Aid Treatments

87
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

88
HAZARD ANALYSIS
89
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

90
Step 1 Identify Hazards
  • HAZARD condition with the potential to
    cause personal injury, death and property damage

91
Hazard Identification
  • Review Records
  • Talk to Personnel
  • Accident Investigations
  • Follow Process Flow
  • Write a Job Safety Analysis
  • Use Inspection Checklists

92
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

93
Levels of Risk Awareness
  • Unaware Doesnt 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

94
Who is at Risk?
  • Contractors
  • Janitorial
  • Maintenance
  • Others
  • Members of Public
  • Passers-by
  • Neighbors
  • Workers
  • Visitors
  • Invited
  • Customers
  • Emergency services
  • Delivery drivers
  • Uninvited
  • Trespassers
  • Burglars

95
STEP 3 Make Risk Decisions
What can we do to reduce the risk? Does the
benefit outweigh the risk?
96
STEP 4 Implement Controls
  • Substitution
  • Engineering controls
  • Administrative Controls
  • Personal Protective Equipment

97
Hazard Controls
  • Source
  • Path
  • Receiver

98
Hazard Control
  • Administrative Engineering
  • Protective Equipment/Clothing

99
Engineering
  • Hazard Elimination
  • Add-On Safety Design
  • Active vs. Passive
  • User Instructions (Manual)

Ventilation Design/Layout Safety Devices
100
Administrative
  • Safety Rules
  • Disciplinary Policy - Accountability
  • Preventative Maintenance
  • Training
  • Proficiency/Knowledge Demonstrations

101
Step 5 Supervise
  • Ensure risk control measures are implemented
  • Track progress
  • Feedback

102
JOB SAFETY ANALYSIS
103
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

104
Job Safety Analysis
105
Job Safety Analysis Priorities
  • New Jobs
  • Potential of Severe Injuries
  • History of Disabling Injuries
  • Frequency of Accidents

106
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!)

107
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

108
Key Steps TOO MUCHChanging 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

109
Key Steps NOT ENOUGHChanging a Flat Tire
  • Park car
  • Take off flat tire
  • Put on spare tire
  • Drive away

110
Key Job Steps JUST RIGHTChanging 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

111
Job Safety Analysis
  • Steps
  • Park set brake
  • Remove Spare Jack
  • Loosen lugs

112
Job Safety Analysis
  • Steps
  • Park set brake
  • Remove Spare Jack
  • Loosen lugs
  • Hazards
  • Hit by traffic
  • Back Strain
  • Foot/Toe impact
  • Shoulder strain

113
Job Safety Analysis
  • Steps
  • Park set brake
  • Remove Spare Jack
  • Loosen lugs
  • Hazards
  • Hit by traffic
  • Back Strain
  • Foot/Toe impact
  • Shoulder strain
  • 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

114
Develop Solutions
  • Fix-A-Flat
  • No off-road driving
  • Buy self-sealing tires
  • Maintenance / Change-out program
  • Find a new way to do job
  • Change physical conditions that create hazards
  • Change the work procedure
  • Reduce frequency

115
JSA EXERCISE
116
INSPECTIONS
117
Inspections
  • Fact-Finding vs. Fault Finding
  • Sound knowledge of the plant
  • Knowledge of relevant standards codes
  • Systematic inspection steps
  • Method of evaluating data

118
Inspection Limitations
  • Blinder affect
  • Rote inspections
  • All Check - No action
  • Who is inspecting?

119
Outcomes
  • Improve Safety
  • New Way to Do Job
  • Change Physical Conditions
  • Change Work Procedures
  • Reduce Frequency of Dangerous Job

120
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

121
Change in Physical Conditions
  • Tools, materials, equipment layout or location
  • Study change carefully for other benefits (costs,
    time savings)

122
Change in Work Procedures
  • What should the worker do to eliminate the
    hazard?
  • How should it be done?
  • Document changes in detail

123
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

124
Performing Safety Audits
125
Guide for Personal Audits
  • The guide has five steps
  • Audit
  • React
  • Communicate
  • Follow up
  • Raise standards

126
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

127
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
  • Acceptable because...
  • Not acceptable because...
  • Deteriorated because...
  • Improved because

128
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

129
Follow Up
  • Critical for success of the safety program
  • Allows you to demonstrate that it is important
  • Must communicate your assessment to the employees

130
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

131
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

132
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

133
Observation Techniques
  • Remember ABBI -- look Above, Below, Behind,
    Inside
  • Develop a questioning attitude
  • Use all senses
  • sight
  • hearing
  • smell
  • touch

134
Inspections and Field Observations
  • Use a checklist
  • Ask questions
  • Take notes
  • Respect lines of communication
  • Draw conclusions

135
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

136
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

137
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

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139
Management Commitment
  • Should Management Consider Safety as a Priority
    in Conducting Business

??
140
Management Commitment
  • NO !

141
PRIORITIES CHANGE
  • SAFETY MUST BE A VALUE!!

142
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.

143
SHARED VISION EXERCISE
144
AVAILABLE RESOURCES
  • OSHA Website www.osha.gov
  • Washington State Labor Industries Website
    www.lni.wa.gov

145
ACCIDENT INVESTIGATION
146
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

147
THE ACCIDENT
  • WHAT IS AN ACCIDENT?

148
THE ACCIDENT
  • An
  • unplanned and unwelcome event
  • that interrupts normal activity

149
Accidents are What Happens to Somebody Else
  • BUT REMEMBER
  • YOU
  • are somebody else
  • to somebody else

150
THE ACCIDENT
  • MINOR ACCIDENTS
  • Such as paper cuts to fingers or dropping a box
    of materials

151
THE ACCIDENT
  • MORE SERIOUS ACCIDENTS
  • Such as a forklift dropping a load or someone
    falling off a ladder

152
THE ACCIDENT
  • Accidents that occur over an extended time frame
  • Such as hearing loss or an illness resulting from
    exposure to chemicals

153
THE ACCIDENTNEAR-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!

154
THE ACCIDENT
  • ACCIDENTS HAVE TWO THINGS IN COMMON

155
THE ACCIDENT
  • They all have outcomes from the accident

156
THE ACCIDENT
  • They all have contributory factors that cause
    the accident

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OUTCOMES OF ACCIDENTS
  • NEGATIVE Results
  • Injury possible death
  • Disease
  • Damage to equipment property
  • Litigation costs, possible citations
  • Lost productivity
  • Morale

159
OUTCOMES OF ACCIDENTS
  • POSITIVE Results
  • Accident investigation
  • Prevent repeat of accident
  • Change to safety programs
  • Change to procedures
  • Change to equipment design

160
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

161
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
162
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

163
ACCIDENT INVESTIGATION
You Must
  • Conduct a preliminary investigation for
  • serious injuries with immediate symptoms
  • Document the investigation findings

164
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

165
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)

166
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

167
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

168
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?

169
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

170
Why Not Rely On OSHA Police To Investigate?
  • Focus On Culpability
  • Minor Accidents Not Investigated
  • PREVENTION
  • Protect Company Interests
  • OSHA Requirements

171
Investigating Accidents
  • How to find out what really happened

172
Why Investigate Accidents?
  • Find the cause
  • Prevent similar accidents
  • Protect company interests

173
At which level do we investigate?
174
Investigation Strategy
  • Need For Investigation
  • Control the Scene
  • Gather Facts
  • Analyze Data
  • Establish Causes
  • Write Report
  • Take Corrective Action

175
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

176
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?

177
The Aim of the InvestigationIS NOT TO
  • Exonerate individuals or management
  • Satisfy insurance requirements
  • Defend a position for legal argument
  • Or, to assign blame

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181
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

182
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

183
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!

184
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

185
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

186
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

187
Provide Care to the Injured
  • Ensure that medical care is provided to the
    injured people before proceeding with the
    investigation

188
Secure the Scene for Safety
  • Eliminate the hazards
  • Control chemicals
  • De-energize
  • De-pressurize
  • Light it up
  • Shore it up
  • Ventilate

189
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

190
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

191
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)

192
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

193
Photographs
  • Unbiased Recording
  • Keep Log of Photos
  • Overall to Close-up
  • Color if possible
  • Supplement with Video

194
Gather Data
  • Data includes
  • Persons involved
  • Date, time, location
  • Activities at time of accident
  • Equipment involved
  • List of witnesses

195
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?

196
Documents
  • Collect All Related Documents
  • Inspection Logs
  • Policy Procedures Manual
  • JSA (Job Safety Analysis)
  • Equipment Operations Manuals
  • Insurance Records
  • Employee Records
  • Police Reports

197
Those who do not know the past are destined to
  • Repeat
  • Repeat
  • Repeat
  • Repeat
  • Repeat
  • Repeat
  • It.

198
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

199
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 dont agree on
    what they observed.
  • Non-Measurable - A number isnt used.
  • General - Based on non-detailed descriptions.

200
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

201
Record Evidence
  • Keep All Notes in Bound Notebook
  • Include Date - Time - Place Vantage Point
  • Keep Originals
  • Rewrite in Report Form

202
Samples
  • Collect Perishables First
  • Fluids
  • Open Containers
  • Filings
  • Chemicals
  • Air

203
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

204
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

205
Interviews
  • Excellent Source of first hand knowledge
  • May Present Pitfalls in form of
  • Bias
  • Perspective
  • Embellishment
  • Omissions

206
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

207
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

208
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

209
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

210
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?

211
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, excuses,
    or explanations, politely decline that knowledge
    and remind them to stick with the facts

212
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

213
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

214
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?

215
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?

216
Witness Interviews
  • DO
  • Separate Witnesses
  • Written Statements
  • Open ended questions
  • Provide Diagrams
  • Encourage Details
  • Show Concern
  • Record w/permission
  • DONT
  • Suggest Answers
  • Interrogate
  • Focus on Blame
  • Dismiss Details
  • Bar Emotions
  • Make Judgments

217
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?

218
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

219
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?

220
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

221
Indirect Causes
  • Unsafe conditions what material conditions,
    environmental conditions and equipment conditions
    contributed to the accident
  • Unsafe Acts what activities contributed to the
    accident

222
Breakdown of Unsafe Conditions
  • Inadequately guarded or unguarded equipment
  • Defective tools, equipment or materials
  • Fire and explosion hazard
  • Unexpected movement hazard
  • Projection hazards

223
Breakdown of Unsafe Conditions
  • Housekeeping
  • Hazardous environmental conditions
  • Improper ventilation
  • Improper illumination
  • Unsafe dress or apparel

224
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

225
Basic Causes
  • Management
  • Environment
  • Equipment
  • Human Behavior
  • Systems Procedures
  • Design Equipment

226
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?

227
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?

228
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.

229
What controls failed?
  • List the specific engineering, administrative
    and training controls that failed and how these
    failures contributed to the accident

230
What controls worked?
  • List any controls that prevented a more serious
    accident or minimized collateral damage or
    injuries
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