Transcript Accident_Cases_2.ppt

ACCIDENT CASE STUDY
WORKER NEARLY
KILLED IN WELDING
ACCIDENT
REPORT - SLIDE 1 OF 22
COPYRIGHT 1995©, SAFETY SERVICES®
ACCIDENT CASE STUDY
1 WORK SEVERELY INJURED IN WELDING ACCIDENT
OVERVIEW OF THE INCIDENT
You are a member of the safety committee and have been notified
to report to the maintenance department to conduct an
investigation of an accident. 1 worker has been taken to the
hospital with severe burns and heart arythmia from contact with an
electrical source. You and your group must conduct an accident
investigation and write a report to determine the root cause and
recommend corrective actions.
REPORT - SLIDE 2 OF 22
COPYRIGHT 1995©, SAFETY SERVICES®
ACCIDENT CASE CHRONOLOGY
7:00am:
7:02am:
7:02am:
7:05am:
7:05am:
7:09am:
7:09am:
7:10am:
7:10am:
7:11am:
7:15am:
7:21am:
8:03am:
8:10am:
Maintenance technician Madeline Hurt arrives to work
Hurt unlocks tool chest
Hurt turns on arc welder without area safety check
Hurt notices and ignores water on floor in department
Hurt searches for welding gloves, can’t find them
Hurt resumes work on a welding job from previous day
Table is not adjustable, part cannot be reoriented
Hurt stoops over and attempts to weld at odd angle
Hurt cannot properly weld hard-to-get-at section
Hurt lowers to left knee and contacts water on floor
Hurt resumes welding and is knocked unconscious
Bill Smith (co-worker) finds her unconscious, calls 911
Ambulance arrives, cares for, and transports victim
Bill Smith notifies you
REPORT - SLIDE 3 OF 22
COPYRIGHT 1995©, SAFETY SERVICES®
ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
Date/Time of Incident: 1996 Novem, 30, about 715
ACCEPTABLE
Date/Time of Incident: 11/30/96 (Month/Day/Year), 7:15 a.m.
COMMENTS:
Be consistent and accurate with Dates and Times. Accurately
reconstructing the accident may depend on accurate
timeframes.
REPORT - SLIDE 4 OF 22
COPYRIGHT 1995©, SAFETY SERVICES®
ACCIDENT INVESTIGATION
REPORT
DEFINITIONS
 Accident With Injury - Severity is not a factor
 Accident Without Injury - Vehicle or Property
Damages Result
 Near Miss - Had timing been different Injury or
property damage would have resulted
 Resulted in Death - Self Explanatory
REPORT - SLIDE 5 OF 22
COPYRIGHT 1995©, SAFETY SERVICES®
ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
Name: Maddy Hurt
ACCEPTABLE
Name: Madeline B. Hurt
COMMENTS:
Use full legal names only, the use of nick names can
sometimes cause confusion. If legal concerns arise, correct
names will become important. Review personnel records as
needed.
REPORT - SLIDE 6 OF 22
COPYRIGHT 1995©, SAFETY SERVICES®
ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
Assigned Job: Maintenance Man
ACCEPTABLE
Assigned Job: Maintenance Technician
COMMENTS:
Use the full duty title as it appears in their job description.
Review personnel records as needed.
REPORT - SLIDE 7 OF 22
COPYRIGHT 1995©, SAFETY SERVICES®
ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
Length of Service: Almost 15 Years
About 12 Years on this job
ACCEPTABLE
Length of Service: 14 years 11 Months
11 Years 10 Months on this job
COMMENTS:
Be consistent and accurate with timeframes. Review personnel
records as needed.
REPORT - SLIDE 8 OF 22
COPYRIGHT 1995©, SAFETY SERVICES®
ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
Location of Accident: Maintenance department.
ACCEPTABLE
Location of Accident: Maintenance department, Adjacent
to Arc Welding Machine (Serial - 011212) SW corner of
room.
COMMENTS:
Fully describe the location and pertinent surroundings.
The location can sometimes contribute to the accident.
Accuracy is also needed for reconstruction.
REPORT - SLIDE 9 OF 22
COPYRIGHT 1995©, SAFETY SERVICES®
ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
How Accident Occurred: Maddy was zapped by the green
welder (real dirty one) when she put her knee in water
leaking from the drinking fountain which Ted was
supposed to fix Tuesday. I feel real bad about this.
COMMENTS:
1.
2.
3.
4.
Is this sufficient for you to understand what happened?
Can the root cause be determined?
Can you develop measures to prevent recurrence?
Specifically, what is wrong with this narrative?
REPORT - SLIDE 10 OF 22
COPYRIGHT 1995©, SAFETY SERVICES®
ACCIDENT INVESTIGATION
REPORT
ACCEPTABLE
How Accident Occurred: The employee received a high
voltage electric shock (220v) which incapacitated her. At
the time of the accident she was welding a T-Joint on mild
steel with the voltage regulator set at 110 amps. She knelt
on her left knee to obtain a better angle for the weld not
realizing that water was leaking from a drinking fountain
on the other side of the partition separating the
maintenance department from the general facility. The
working surface was poured cement.
Arc Welding
Machine (Serial - 011212) was being used at the time, the
nonconductive handle grip was cracked which caused an
electrical short causing the injury. The water leak was a
contributing factor.
REPORT - SLIDE 11 OF 22
COPYRIGHT 1995©, SAFETY SERVICES®
ACCIDENT INVESTIGATION
REPORT
How Accident Occurred:
COMMENTS:
1. Preventing recurrence by allowing reconstruction of
the accident should be the primary outcome.
2. The use of irrelevant information such as your feelings
may disguise the causes of the accident and hinder
the investigation.
3. Accuracy is critical for reconstruction.
4. At this point you should not affix blame. The object of
the investigation is to determine the root cause not
find the fall-guy (or gal).
REPORT - SLIDE 12 OF 22
COPYRIGHT 1995©, SAFETY SERVICES®
ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
What Factors Led To The Accident:
1.
2.
3.
4.
Ted ignored water fountain work order request.
Maddy never checks her equipment right.
Maddy has trouble following directions.
I’ll try and get my points across better in the future.
COMMENTS:
1. Is this sufficient for you to develop preventative measures?
2. Can the root cause be determined?
3. Specifically, what is wrong with these statements?
REPORT - SLIDE 13 OF 22
COPYRIGHT 1995©, SAFETY SERVICES®
ACCIDENT INVESTIGATION
REPORT
ACCEPTABLE
What Factors Led To The Accident:
1.
2.
3.
4.
5.
6.
Possible lack of timely repair of the leaking drinking fountain.
Possible lack of training in preoperational equipment checks.
Possible lack of policy for preoperational equipment checks.
Possible lack of an adjustable welding table/surface.
Possible lack of proper inspection of the welding area.
Possible lack of a hotwork permit.
REPORT - SLIDE 14 OF 22
COPYRIGHT 1995©, SAFETY SERVICES®
ACCIDENT INVESTIGATION
REPORT
What Factors Led To The Accident:
COMMENTS:
1.
2.
3.
4.
5.
6.
7.
8.
Stick to the facts!
If needed break the sequence of events down chronologically.
Avoid affixing blame.
Think logically and objectively.
Think about what was missing from the safety equation.
What engineering controls failed or were missing/unavailable?
What administrative controls were lacking or unavailable?
What PPE was lacking or unavailable?
REPORT - SLIDE 15 OF 22
COPYRIGHT 1995©, SAFETY SERVICES®
ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
Part of Body Injured: Was shocked real bad.
ACCEPTABLE
Part of Body Injured: Sustained severe electrical burns
(2nd degree) to the left knee and left hand (palm, thumb
and 1st digit).
Minor heart arythmia (confirmed by
emergency room) also sustained because of electrical
discharge.
COMMENTS:
Fully describe the extent of injuries.
records if needed.
Review medical
REPORT - SLIDE 16 OF 22
COPYRIGHT 1995©, SAFETY SERVICES®
ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
Investigators Comments: Bill from maintenance asked
me to respond to the accident scene a couple of minutes
after it happened.
I arrived soon thereafter, and
completed this report.
ACCEPTABLE
Investigators Comments: Maintenance Technician (Bill
Smith) notified me (11/30/96 - 8:10 a.m.) that a severe
electrical injury had been sustained by Madeline B. Hurt. I
arrived at the accident scene at approximately 8:15 a.m.
The victim had already been transported by ambulance to
No Hope Hospital. This report is the result of my
investigation.
REPORT - SLIDE 17 OF 22
COPYRIGHT 1995©, SAFETY SERVICES®
ACCIDENT INVESTIGATION
REPORT
Investigators Comments:
COMMENTS:
1.
2.
3.
4.
5.
Describe the facts surrounding your involvement.
Identify key names, places, and timeframes.
Think logically and objectively.
Don’t be afraid to reword in the interest of clarity.
Don’t be redundant, save your comments for the proper place in
the report.
REPORT - SLIDE 18 OF 22
COPYRIGHT 1995©, SAFETY SERVICES®
ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
Specific Action(s) That Will Be Taken:
1.
2.
3.
4.
Get the water fountain fixed.
Have Maddy checks her equipment every time.
Discipline Maddy for not following directions.
Try and get my point across better in the future.
COMMENTS:
1.
2.
3.
4.
Is this sufficient to ensure completion of corrective actions?
Can estimated completion dates be identified?
Have action items be assigned to a specific person?
Is anyone held accountable to ensure completion?
REPORT - SLIDE 19 OF 22
COPYRIGHT 1995©, SAFETY SERVICES®
ACCIDENT INVESTIGATION
REPORT
ACCEPTABLE
Specific Action(s) That Will Be Taken:
1.
2.
3.
4.
5.
6.
7.
8.
Establish responsible parties for action items.
Ensure a priority system is in place for repair of equipment.
Ensure timely repair of facility equipment is accomplished.
Determine if training or retraining needs to be conducted.
Conduct training or retraining before similar work is performed.
Assess if an adjustable welding table/surface is needed.
Review & update related safety policies and procedures.
Review & update current preoperational welding requirements.
(i.e., hotwork permit, safety checklists etc.)
9. Ask co-workers for their input!
REPORT - SLIDE 20 OF 22
COPYRIGHT 1995©, SAFETY SERVICES®
QUESTIONS TO BE CONSIDERED
 What caused the injury to occur?
 Do you believe there is a single cause to this accident that, if
removed would have prevented it?
 Do you believe there are multiple causes?
 Are multiple OSHA Standard violations involved?
 What could upper management have done?
 What could the supervisor have done?
 What could the co-workers have done?
 To what extent is a lack of written policy responsible?
 What written policies need to be developed?
 To what extent is a lack of training responsible?
 Were the hazards associated with welding fully understood?
REPORT - SLIDE 21 OF 22
COPYRIGHT 1995©, SAFETY SERVICES®
ACCIDENT CASE FACTS
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


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Safety discipline weak
Training deficiencies probably exist
Welding Safety Program not used, non-existent or ineffective
Hotwork permit not used, non-existent or ineffective
Maintenance department allowed “lone-wolf” situation
Hazards associated with welding not fully understood
PPE (lack of welding gloves) may have prevented contact
Repair priority system not used, non-existent or ineffective
Supervisor did not have established “rounds” in department
Written safety procedures not used, non-existent or ineffective
Written safety procedures did not address “lone-wolf” situation
Engineering controls may be a factor (i.e. lack of adjustable
table)
REPORT - SLIDE 22 OF 22
COPYRIGHT 1995©, SAFETY SERVICES®