Hazards and accident investigation
rude-1
project.zipProject/Preliminary Incident Investigation Form.docx
Preliminary Incident Investigation Form
Workplace Safety and Health Program
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A. Injured Employee Data |
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Employee Name |
Employee Age |
Years of Service |
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Work Organization/Location |
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Date of accident |
Time of Accident |
Regular Shift, day? night? other? |
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Primary Language Spoken |
Work Telephone |
Other/Cell Number |
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Supervisor |
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B. Incident Description – Proximate Causes Instructions: What happened? What caused the accident? What were the contributing factors? Reconstruct the sequence of events that led to the injury. Attach additional sheets if necessary. This document becomes an official accounting of the facts surrounding the accident. When documenting the facts, include answers to the following questions: |
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1. Where did the accident happen and who was involved? Provide a full description of the surroundings of the location and the individuals involved. |
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2. What was happening at the time of the accident and why was it taking place? |
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3. What were the events leading up to the accident? Describe the sequence in order and when they took place. |
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4. What exactly caused the injury and how did it happen? What were the mechanics, equipment, or tools involved? |
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5. Describe the injury or injuries that incurred. What body part and what kind of injury? (Indicate if no injury occurred.) |
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6. After review of all facts, what was the hazardous condition, unsafe work practice, or other causal factors (procedure, equipment, people, and environment) that contributed to the accident / injury? |
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C. Root Causes - Speculate about what factors in the Management System might have contributed to the accident. You do not have all the facts, but you can begin asking questions. What “why” questions might you ask? (Remember, you have lots of materials to give you hints about what part of the management system might have contributed to the accident.) Refer to your attachment “Root Cause Analysis.” I need to see at least 10 why questions. |
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D. Areas of Investigation – Describe where you will begin your investigation based on the “why” questions above. I need to see at least one area of investigation for each “why” question. (Use next page, too)
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Preliminary
Incident
Investigation Form
Workplace Safety and Health Program
A. Injured Employee Data
Employee Name
Employee Age
Years of Service
Work Organization/Location
Date of accident
Time of Accident
Regular Shift, day? night?
other?
a.m.
p.m.
Primary Language Spoken
Work Telephone
Other
/Cell Number
Supervisor
B.
Incident
Description
–
Proximate Causes
Instructions:
What happened? What caused the accident? What
were the contributing factors? Reconstruct the
sequence of events that led to the injury. Attach additional sheets if necessary. This document becomes an official
accounting of the facts surrounding the accident. When documenting the facts, include answers
to the following
questions:
1.
Where
did the accident happen and who was involved? Provide a full description of the surroundings of the location
and the individuals involved.
2.
What was happening at the time of the accident and why was it taking
place?
3.
What were the events leading up to the accident? Describe the sequence in order and when they took place.
4.
What exactly caused the injury and how did it happen? What were the mechanics, equipment, or tools involved?
Preliminary Incident Investigation Form
Workplace Safety and Health Program
A. Injured Employee Data
Employee Name Employee Age Years of Service
Work Organization/Location
Date of accident Time of Accident Regular Shift, day? night? other?
a.m.
p.m.
Primary Language Spoken Work Telephone Other/Cell Number
Supervisor
B. Incident Description – Proximate Causes
Instructions: What happened? What caused the accident? What were the contributing factors? Reconstruct the
sequence of events that led to the injury. Attach additional sheets if necessary. This document becomes an official
accounting of the facts surrounding the accident. When documenting the facts, include answers to the following
questions:
1. Where did the accident happen and who was involved? Provide a full description of the surroundings of the location
and the individuals involved.
2. What was happening at the time of the accident and why was it taking place?
3. What were the events leading up to the accident? Describe the sequence in order and when they took place.
4. What exactly caused the injury and how did it happen? What were the mechanics, equipment, or tools involved?
Project/ROOT CAUSE ANALYSIS.docx
ROOT CAUSE ANALYSIS
Root cause analysis is a process by which we uncover the causes which contributed to an incident in the workplace. There are 2 kinds of causes: proximate causes and root causes. Proximate causes are those immediate factors of the incident which lead to an unacceptable result. Root causes are those organizational factors that are ultimately responsible for the incident. ROOT CAUSES ARE ALWAYS A RESULT OF DEFECTS OR OMISSIONS IN THE MANAGEMENT SYSTEM.
In the old style of safety, our accident investigations focused on blaming the worker. Even though that seems like a good idea (it’s easy and we don’t have to think about it much), it doesn’t help us prevent accidents or save workers’ comp costs.
The only way we can prevent similar incidents in the future is to understand the underlying causes of accidents so that we can design the workplace to be Bubba-proof. You know Bubba. If there is any way to mess up, Bubba will find it. Our job is to make sure the easiest choice is the SAFEST ONE.
-------------------------------------------------------------------------------------------------------------------------
Here is an example:
An incident happens: A man on the night shift uses a screw driver to pry brads out of a piece of wood. One of the brads comes off and hits him in the eye. Let us investigate the same accident in 2 different ways.
I. Old style incident investigation:
Cause of accident:
1. Worker used the wrong tool to do the job.
2. Worker should have been wearing PPE.
Corrective actions:
1. Told worker to use the correct tool to do the job
2. Told worker to wear PPE
II. Modern safety practice:
Proximate cause of incident:
1. Screw driver was used instead of brad puller
2. No PPE was worn
Root causes:
1. The correct tool (brad puller) was not available to worker at the time his Supervisor said to do the job. Upon investigation, it was learned that people in the area routinely used unapproved tools to do jobs because the tool crib was not open all night.
2. Safety glasses were available to worker, but they were not used. At interview, worker stated that people in the area often did not wear safety glasses because the brand available wasn’t comfortable and that they fogged up.
Corrective actions:
1. After an extensive investigation interviewing Supervisors, Managers, looking at old records of incidents, and examining the tool crib area, it was determined that it was cost effective to keep one person manning the tool crib at night (there had been similar incidents because of using the wrong tools)
2. The worker involved in the incident and other workers and representatives of management got together to review all PPE for adequacy and ease of use. Several changes were made.
3. All Supervisors were made aware of the changes and were counseled to support workers taking the time to get correct tools and were tasked to monitor the use of new safety glasses carefully.
Let’s compare the two approaches:
In the old style of incident investigation, we blame the worker and put the burden of any changes upon him. Is this going to work for us? If the correct tools are not available for him, how is he going to choose the correct tool? If safety glasses are uncomfortable he probably should wear them anyway, but he probably won’t. Why not make it easier for him to comply? Remember, the object of the investigation is not to find someone to blame. It is to prevent future incidents from happening.
In the old style of incident investigation, have we prevented more similar incidents from happening to anyone else? Have we even prevented the incident from happening to the same guy? The answer is NO!
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In finding root causes we ask the question, WHY?
Why didn’t the worker use the correct tool?
Answer: It wasn’t available.
Why wasn’t it available?
Answer: The tool crib was closed at night.
Why was the tool crib closed at night?
Answer: To save money.
Is it worth the money saved to have the correct tools available? Let’s find out! (Here’s something I can do to go about fixing the problem!!!!) I’ll do a cost/benefit analysis to see if similar incidents would be worth the salary for someone to man the tool crib at night. I found that the workers’ comp costs for similar incidents was about $150,000 last year! Eight extra hours salary/week to man the tool crib would certainly be less then that………….
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Factors in the management system that you might think about changing include poor or inadequate supervision, emphasis on production instead of safety, inadequate training, poor job assignment, failure to maintain equipment, poor employee screening, not being responsive to employee feedback. There are a million other factors of management! Let’s see what you can think of………
ROOT CAUSE ANALYSIS
Root cause analysis is a process by which we uncover the causes which contributed to an incident in the
workplace. There are 2 kinds of causes: proximate causes and root causes. Proximate causes are those
immediate factors of the
incident which lead to an unacceptable result. Root causes are those organizational
factors that are ultimately responsible for the incident. ROOT CAUSES ARE ALWAYS A RESULT OF
DEFECTS OR OMISSIONS IN THE MANAGEMENT SYSTEM.
In the old style of safety, o
ur accident investigations focused on blaming the worker. Even though
that seems like a good idea (it’s easy and we don’t have to think about it much), it
doesn’t help us
prevent accidents or save workers’ comp costs.
The only way we can prevent simila
r incidents in the future is to understand the
underlying causes
of
accidents so that we can design the workplace to be Bubba
-
proof. You know Bubba. If there is any
way to mess up, Bubba will find it. Our job is to make sure the easiest choice is the SAF
EST ONE.
-------------------------------------------------------------------------------------------------------------------------
Here is an example:
An
incident
happens
:
A m
an
on the night shift
uses
a
screw driver to pry brads out of a piece of wood.
One of the brads comes off and hits him in the eye.
Let us investigate the same accident in 2 different
ways.
I.
Old style incident investigation:
Cause of accident:
1.
Worker used the wrong tool
to do the job
.
2.
Worker should have been wearing PPE.
Corrective action
s
:
1.
Told worker to use the correct tool to do the job
2.
Told worker to wear PPE
II.
Modern safety practice:
Proximate cause of incident:
1.
Screw driver was used instead of brad puller
2.
No PPE was worn
Root causes:
1.
The correct tool (brad puller) was not available to worker at the time his Supervisor said
to do the job. Upon investigation,
it was learned that
people in the area routinely used
unapproved tools
to do jobs because
the tool crib was not open all night.
2.
S
afety glasses were available to worker, but they were not used. At interview, worker
stated that
people in the area often did not wear safety glasses
because the brand available
wasn’t comfortable
and that
they fogged up
.
Corrective actions:
1.
After an ext
ensive investigation interviewing Supervisors, Managers, looking at old
records of incidents, and examining the tool crib area, it was determined that it was cost
effective to keep one person manning the tool crib at night (there had been similar
incidents
because of using the wrong tools)
2.
The worker involved in the incident and other workers and representatives of
management
got together to review all PPE for adequacy and ease of use. Several
changes were made.
3.
A
ll Supervisors
were made
aware of the chang
es and w
ere counseled to
support workers
taking the time to get correct tools and w
ere tasked to
monitor the use of new safety
glasses carefully.
ROOT CAUSE ANALYSIS
Root cause analysis is a process by which we uncover the causes which contributed to an incident in the
workplace. There are 2 kinds of causes: proximate causes and root causes. Proximate causes are those
immediate factors of the incident which lead to an unacceptable result. Root causes are those organizational
factors that are ultimately responsible for the incident. ROOT CAUSES ARE ALWAYS A RESULT OF
DEFECTS OR OMISSIONS IN THE MANAGEMENT SYSTEM.
In the old style of safety, our accident investigations focused on blaming the worker. Even though
that seems like a good idea (it’s easy and we don’t have to think about it much), it doesn’t help us
prevent accidents or save workers’ comp costs.
The only way we can prevent similar incidents in the future is to understand the underlying causes of
accidents so that we can design the workplace to be Bubba-proof. You know Bubba. If there is any
way to mess up, Bubba will find it. Our job is to make sure the easiest choice is the SAFEST ONE.
-------------------------------------------------------------------------------------------------------------------------
Here is an example:
An incident happens: A man on the night shift uses a screw driver to pry brads out of a piece of wood.
One of the brads comes off and hits him in the eye. Let us investigate the same accident in 2 different
ways.
I. Old style incident investigation:
Cause of accident:
1. Worker used the wrong tool to do the job.
2. Worker should have been wearing PPE.
Corrective actions:
1. Told worker to use the correct tool to do the job
2. Told worker to wear PPE
II. Modern safety practice:
Proximate cause of incident:
1. Screw driver was used instead of brad puller
2. No PPE was worn
Root causes:
1. The correct tool (brad puller) was not available to worker at the time his Supervisor said
to do the job. Upon investigation, it was learned that people in the area routinely used
unapproved tools to do jobs because the tool crib was not open all night.
2. Safety glasses were available to worker, but they were not used. At interview, worker
stated that people in the area often did not wear safety glasses because the brand available
wasn’t comfortable and that they fogged up.
Corrective actions:
1. After an extensive investigation interviewing Supervisors, Managers, looking at old
records of incidents, and examining the tool crib area, it was determined that it was cost
effective to keep one person manning the tool crib at night (there had been similar
incidents because of using the wrong tools)
2. The worker involved in the incident and other workers and representatives of
management got together to review all PPE for adequacy and ease of use. Several
changes were made.
3. All Supervisors were made aware of the changes and were counseled to support workers
taking the time to get correct tools and were tasked to monitor the use of new safety
glasses carefully.
Project/SPECIAL PROJECT.docx
SPECIAL PROJECT
Your special project involves making decisions about hazards; it involves ranking hazards by risk and doing an accident investigation.
You must follow these instructions exactly for full credit.
The project is worth 50 points. You are to type up all results and fill out your Incident Investigation form and submit it on your Final Project Dropbox. The title page should include SPECIAL PROJECT, the name of the course, your name and date. Each section should be typed separately with a title page, for example, “PART I RANKING HAZARDS BY RISK.” Use 12 point font.
Grading: your Special Project will be graded by
1. Conformance with assignment instructions 35%
2. Neatness and spelling and grammar 15%
3. Thoroughness of conclusions and recommendations 50%
PART I - RANKING HAZARDS BY RISK
Rank these hazards below by risk according to Chapter 6 Dropbox, Part 2 and your Chapter 6. (Please read it carefully, especially if you didn’t do well in your Dropbox assignment.) Type another page as a letter to your boss explaining which hazard you should tackle in order and why. Remember, safety is an art as well as a science. You should have at least ¾ page of narrative. At this stage, do not use cost as a consideration.
You are the safety manager at a facility in Borger, Texas. You manufacture pipeline for the oil field. Your first task is to identify hazards in the facility. The facility has approximately 400 workers.
After you have identified hazards you come up with the following list:
1. Exposed electrical wires on the conveyor belt. Approximately 20 workers work around the conveyor belt every day. The exposed wires are not really near to their work area, but if they dropped something, they might brush against them.
2. One of the stamping machines leaks oil. Approximately 30 workers have direct contact with the floor every day. They do wear non-slip boots, but the boots don’t always work to prevent slipping.
3. Some of the lights are burned out in one section of the plant where 200 workers work all the time. The tasks they perform are not detailed, but sometimes they have trouble seeing potential hazards on the floor.
4. In the basement there are pipes overhead about 5 feet from the ground. About 25 workers have to pass under the pipes every week or so because the aisle runs directly under the pipes.
5. Two workers work with corrosive chemicals that can burn skin badly. The containers in which the corrosive containers are stored are not labeled properly. They work every day.
PART II - INCIDENT INVESTIGATION AND ANALYSIS
When an accident occurs, the Supervisor usually completes the initial investigation; however, as Safety Officer, the final investigation and the recommended countermeasures are your responsibility.
Based on a thorough reading of your Chapter 10, complete the following case study. You should use the incident investigation form attached. If you do not know the information in the blanks, type “N/A”. You may need additional sheets to write your causal factors and corrective actions. Use the information in Chapter 10 to suggest some avenues for further investigation since you do not have all the facts yet. (Often you will be asked to submit a preliminary report before you have done a thorough analysis. In the Causal Factors and Corrective Actions section, you are to have two separate sections: “Proximate Factor” and “Root Cause Factors.” Think about factors of the person, environment, management, and equipment for Proximate Factors and management system flaws for your Root Cause Factors.
________________________________________________
You are the Safety Manager for a small manufacturing company. You make cardboard containers. You have approximately 250 employees. Your plant is about 30 years old. The average age of your workforce is 40. Some of your employees have been there for 25 years or more. You have 25 % female employees and 15 % non-English speaking. You are a Union shop. Your plant is divided into 4 work areas and 2 shifts with different supervision in each area and shift. The shifts are from 7:00 – 7:00.
Accident Investigation
You receive a call at your home at 3:00 a.m. explaining that Alejandro Garcia, full-time employee on the night shift has been seriously hurt. He was cleaning out the cardboard feeder in the packaging area when the feeder started up again severing two of his fingers on his right hand. In addition, he sprained his neck trying to free his hand. Alejandro has been on the job for 6 months. He is 20 years old. His Supervisor Steve Anderson has had more accidents in his department than any other Supervisor. You have smelled alcohol on Alejandro’s breath on one occasion, but you have no other evidence that Alejandro is a drinker.
You rush to the plant. You cannot interview the employee since he was sent to St. Anthony’s hospital, but your boss insists that you provide him with a preliminary report by the morning.
You survey the scene. Here is what you learn:
1. The safety on the cardboard feeder than Alejandro was working on had been tampered with by the insertion of a penny in the automatic stop, which prevented the automatic stop from working.
2. The automatic stop was supposed to have received periodic maintenance but the records were not found.
3. The Supervisor did not find Alejandro for 20 minutes even though Alejandro had been yelling
4. There is only one Supervisor in the area due to budget cutbacks
5. Alejandro’s training records are incomplete, and you can’t tell when he was trained the last time to do his job.
6. The employee has had numerous accidents since he has been here.
7. Lockout/tagout procedures had been written, but lockout/tagout was not used.
8. Alejandro was supposed to have a helper, but the helper called in sick, and no one else was there to replace him.
SPECIAL PROJECT
Your special project involves making decisions about hazards;
it involves ranking hazards by risk
and
doing an accident
investigation.
You must follow these instructions exactly for full
credit.
The project is worth
50
points. You are to type up all results
and fill out your Incident Investigation form and submit it on your Final
Project Dropbox.
The title page should include SPECIAL PROJECT,
the name of the course,
your name
and date. Each section should be
typed se
parately with a title page, for example, “PART I
RANKING
HAZARDS BY RISK.” Use
12 point font.
Grading: your Special Project will be graded by
1.
Conformance
with assignment instructions
3
5%
2.
Neatness and spelling and grammar
15%
3.
Thoroughness of
conclusions and recommendations
50
%
SPECIAL PROJECT
Your special project involves making decisions about hazards;
it involves ranking hazards by risk and doing an accident
investigation. You must follow these instructions exactly for full
credit.
The project is worth 50 points. You are to type up all results
and fill out your Incident Investigation form and submit it on your Final
Project Dropbox. The title page should include SPECIAL PROJECT,
the name of the course, your name and date. Each section should be
typed separately with a title page, for example, “PART I RANKING
HAZARDS BY RISK.” Use 12 point font.
Grading: your Special Project will be graded by
1. Conformance with assignment instructions 35%
2. Neatness and spelling and grammar 15%
3. Thoroughness of conclusions and recommendations 50%
ROOT CAUSE ANALYSIS
Root cause analysis is a process by which we uncover the causes which contributed to an incident in the
workplace. There are 2 kinds of causes: proximate causes and root causes. Proximate causes are those
immediate factors of the
incident which lead to an unacceptable result. Root causes are those organizational
factors that are ultimately responsible for the incident. ROOT CAUSES ARE ALWAYS A RESULT OF
DEFECTS OR OMISSIONS IN THE MANAGEMENT SYSTEM.
In the old style of safety, o
ur accident investigations focused on blaming the worker. Even though
that seems like a good idea (it’s easy and we don’t have to think about it much), it
doesn’t help us
prevent accidents or save workers’ comp costs.
The only way we can prevent simila
r incidents in the future is to understand the
underlying causes
of
accidents so that we can design the workplace to be Bubba
-
proof. You know Bubba. If there is any
way to mess up, Bubba will find it. Our job is to make sure the easiest choice is the SAF
EST ONE.
-------------------------------------------------------------------------------------------------------------------------
Here is an example:
An
incident
happens
:
A m
an
on the night shift
uses
a
screw driver to pry brads out of a piece of wood.
One of the brads comes off and hits him in the eye.
Let us investigate the same accident in 2 different
ways.
I.
Old style incident investigation:
Cause of accident:
1.
Worker used the wrong tool
to do the job
.
2.
Worker should have been wearing PPE.
Corrective action
s
:
1.
Told worker to use the correct tool to do the job
2.
Told worker to wear PPE
II.
Modern safety practice:
Proximate cause of incident:
1.
Screw driver was used instead of brad puller
2.
No PPE was worn
Root causes:
1.
The correct tool (brad puller) was not available to worker at the time his Supervisor said
to do the job. Upon investigation,
it was learned that
people in the area routinely used
unapproved tools
to do jobs because
the tool crib was not open all night.
2.
S
afety glasses were available to worker, but they were not used. At interview, worker
stated that
people in the area often did not wear safety glasses
because the brand available
wasn’t comfortable
and that
they fogged up
.
Corrective actions:
1.
After an ext
ensive investigation interviewing Supervisors, Managers, looking at old
records of incidents, and examining the tool crib area, it was determined that it was cost
effective to keep one person manning the tool crib at night (there had been similar
incidents
because of using the wrong tools)
2.
The worker involved in the incident and other workers and representatives of
management
got together to review all PPE for adequacy and ease of use. Several
changes were made.
3.
A
ll Supervisors
were made
aware of the chang
es and w
ere counseled to
support workers
taking the time to get correct tools and w
ere tasked to
monitor the use of new safety
glasses carefully.
ROOT CAUSE ANALYSIS
Root cause analysis is a process by which we uncover the causes which contributed to an incident in the
workplace. There are 2 kinds of causes: proximate causes and root causes. Proximate causes are those
immediate factors of the incident which lead to an unacceptable result. Root causes are those organizational
factors that are ultimately responsible for the incident. ROOT CAUSES ARE ALWAYS A RESULT OF
DEFECTS OR OMISSIONS IN THE MANAGEMENT SYSTEM.
In the old style of safety, our accident investigations focused on blaming the worker. Even though
that seems like a good idea (it’s easy and we don’t have to think about it much), it doesn’t help us
prevent accidents or save workers’ comp costs.
The only way we can prevent similar incidents in the future is to understand the underlying causes of
accidents so that we can design the workplace to be Bubba-proof. You know Bubba. If there is any
way to mess up, Bubba will find it. Our job is to make sure the easiest choice is the SAFEST ONE.
-------------------------------------------------------------------------------------------------------------------------
Here is an example:
An incident happens: A man on the night shift uses a screw driver to pry brads out of a piece of wood.
One of the brads comes off and hits him in the eye. Let us investigate the same accident in 2 different
ways.
I. Old style incident investigation:
Cause of accident:
1. Worker used the wrong tool to do the job.
2. Worker should have been wearing PPE.
Corrective actions:
1. Told worker to use the correct tool to do the job
2. Told worker to wear PPE
II. Modern safety practice:
Proximate cause of incident:
1. Screw driver was used instead of brad puller
2. No PPE was worn
Root causes:
1. The correct tool (brad puller) was not available to worker at the time his Supervisor said
to do the job. Upon investigation, it was learned that people in the area routinely used
unapproved tools to do jobs because the tool crib was not open all night.
2. Safety glasses were available to worker, but they were not used. At interview, worker
stated that people in the area often did not wear safety glasses because the brand available
wasn’t comfortable and that they fogged up.
Corrective actions:
1. After an extensive investigation interviewing Supervisors, Managers, looking at old
records of incidents, and examining the tool crib area, it was determined that it was cost
effective to keep one person manning the tool crib at night (there had been similar
incidents because of using the wrong tools)
2. The worker involved in the incident and other workers and representatives of
management got together to review all PPE for adequacy and ease of use. Several
changes were made.
3. All Supervisors were made aware of the changes and were counseled to support workers
taking the time to get correct tools and were tasked to monitor the use of new safety
glasses carefully.
Project/SPECIAL PROJECT.docx
SPECIAL PROJECT
Your special project involves making decisions about hazards; it involves ranking hazards by risk and doing an accident investigation. You must follow these instructions exactly for full credit.
The project is worth 50 points. You are to type up all results and fill out your Incident Investigation form and submit it on your Final Project Dropbox. The title page should include SPECIAL PROJECT, the name of the course, your name and date. Each section should be typed separately with a title page, for example, “PART I RANKING HAZARDS BY RISK.” Use 12 point font.
Grading: your Special Project will be graded by
1. Conformance with assignment instructions 35%
2. Neatness and spelling and grammar 15%
3. Thoroughness of conclusions and recommendations 50%
PART I - RANKING HAZARDS BY RISK
Rank these hazards below by risk according to Chapter 6 Dropbox, Part 2 and your Chapter 6. (Please read it carefully, especially if you didn’t do well in your Dropbox assignment.) Type another page as a letter to your boss explaining which hazard you should tackle in order and why. Remember, safety is an art as well as a science. You should have at least ¾ page of narrative. At this stage, do not use cost as a consideration.
You are the safety manager at a facility in Borger, Texas. You manufacture pipeline for the oil field. Your first task is to identify hazards in the facility. The facility has approximately 400 workers.
After you have identified hazards you come up with the following list:
1. Exposed electrical wires on the conveyor belt. Approximately 20 workers work around the conveyor belt every day. The exposed wires are not really near to their work area, but if they dropped something, they might brush against them.
2. One of the stamping machines leaks oil. Approximately 30 workers have direct contact with the floor every day. They do wear non-slip boots, but the boots don’t always work to prevent slipping.
3. Some of the lights are burned out in one section of the plant where 200 workers work all the time. The tasks they perform are not detailed, but sometimes they have trouble seeing potential hazards on the floor.
4. In the basement there are pipes overhead about 5 feet from the ground. About 25 workers have to pass under the pipes every week or so because the aisle runs directly under the pipes.
5. Two workers work with corrosive chemicals that can burn skin badly. The containers in which the corrosive containers are stored are not labeled properly. They work every day.
PART II - INCIDENT INVESTIGATION AND ANALYSIS
When an accident occurs, the Supervisor usually completes the initial investigation; however, as Safety Officer, the final investigation and the recommended countermeasures are your responsibility.
Based on a thorough reading of your Chapter 10, complete the following case study. You should use the incident investigation form attached. If you do not know the information in the blanks, type “N/A”. You may need additional sheets to write your causal factors and corrective actions. Use the information in Chapter 10 to suggest some avenues for further investigation since you do not have all the facts yet. (Often you will be asked to submit a preliminary report before you have done a thorough analysis. In the Causal Factors and Corrective Actions section, you are to have two separate sections: “Proximate Factor” and “Root Cause Factors.” Think about factors of the person, environment, management, and equipment for Proximate Factors and management system flaws for your Root Cause Factors.
________________________________________________
You are the Safety Manager for a small manufacturing company. You make cardboard containers. You have approximately 250 employees. Your plant is about 30 years old. The average age of your workforce is 40. Some of your employees have been there for 25 years or more. You have 25 % female employees and 15 % non-English speaking. You are a Union shop. Your plant is divided into 4 work areas and 2 shifts with different supervision in each area and shift. The shifts are from 7:00 – 7:00.
Accident Investigation
You receive a call at your home at 3:00 a.m. explaining that Alejandro Garcia, full-time employee on the night shift has been seriously hurt. He was cleaning out the cardboard feeder in the packaging area when the feeder started up again severing two of his fingers on his right hand. In addition, he sprained his neck trying to free his hand. Alejandro has been on the job for 6 months. He is 20 years old. His Supervisor Steve Anderson has had more accidents in his department than any other Supervisor. You have smelled alcohol on Alejandro’s breath on one occasion, but you have no other evidence that Alejandro is a drinker.
You rush to the plant. You cannot interview the employee since he was sent to St. Anthony’s hospital, but your boss insists that you provide him with a preliminary report by the morning.
You survey the scene. Here is what you learn:
1. The safety on the cardboard feeder than Alejandro was working on had been tampered with by the insertion of a penny in the automatic stop, which prevented the automatic stop from working.
2. The automatic stop was supposed to have received periodic maintenance but the records were not found.
3. The Supervisor did not find Alejandro for 20 minutes even though Alejandro had been yelling
4. There is only one Supervisor in the area due to budget cutbacks
5. Alejandro’s training records are incomplete, and you can’t tell when he was trained the last time to do his job.
6. The employee has had numerous accidents since he has been here.
7. Lockout/tagout procedures had been written, but lockout/tagout was not used.
8. Alejandro was supposed to have a helper, but the helper called in sick, and no one else was there to replace him.
SPECIAL PROJECT
Your special project involves making decisions about hazards;
it involves ranking hazards by risk
and
doing an accident
investigation.
You must follow these instructions exactly for full
credit.
The project is worth
50
points. You are to type up all results
and fill out your Incident Investigation form and submit it on your Final
Project Dropbox.
The title page should include SPECIAL PROJECT,
the name of the course,
your name
and date. Each section should be
typed se
parately with a title page, for example, “PART I
RANKING
HAZARDS BY RISK.” Use
12 point font.
Grading: your Special Project will be graded by
1.
Conformance
with assignment instructions
3
5%
2.
Neatness and spelling and grammar
15%
3.
Thoroughness of
conclusions and recommendations
50
%
SPECIAL PROJECT
Your special project involves making decisions about hazards;
it involves ranking hazards by risk and doing an accident
investigation. You must follow these instructions exactly for full
credit.
The project is worth 50 points. You are to type up all results
and fill out your Incident Investigation form and submit it on your Final
Project Dropbox. The title page should include SPECIAL PROJECT,
the name of the course, your name and date. Each section should be
typed separately with a title page, for example, “PART I RANKING
HAZARDS BY RISK.” Use 12 point font.
Grading: your Special Project will be graded by
1. Conformance with assignment instructions 35%
2. Neatness and spelling and grammar 15%
3. Thoroughness of conclusions and recommendations 50%
