Safety Management Part 2

Safety Management

Accident Investigation and reporting

An Accident: An unwanted, unforeseen, unplanned event which results in an injury or loss of some kind

Near Miss (Incident): An unwanted/unplanned event that has the potential to result in a loss

Immediate/Direct Cause: The unsafe act or condition that results in an accident or incident

Root/Underlying Cause: The failure of procedures, management systems that have resulted in the unsafe act or condition

 

Occupational Accident: An occurrence arising out of or in the course of work that results in a fatal or non-fatal occupational injury

Occupational injury: Death, any personal injury or disease resulting from an occupational accident

Commuting (travel) Accident: An accident resulting in occupational injury involving loss of working time occurring on the direct way between the place of work

Recent definitions for accident and near miss

Accident: An incident with a loss of some kind is called accident.

Near miss: An incident without loss of any kind is called incident.

Accidents causes

            

Causes of Accidents

    Individual and job factors

a)     Unclear lines of responsibility

b)    Poor supervision

c)     Lack of information, instruction and training

d)    Ineffective communication

    Unsafe Acts

a)     Misuse of equipment

b)    Not following safe procedures

c)     Showing off

d)    Many others

    Unsafe Conditions

a)     Poor Housekeeping

b)    Poor design and construction

c)     Poor illumination

d)    Hot weather

e)     Many others

Accident Prevention

Accident Prevention is the technique of anticipating and controlling events so that accidents are eliminated and the subsequent costs in time and money are avoided

The key to a successful prevention programme is management committed to health and safety

                  

Frank Birds pyramid is similar to that of Heinrich triangle but states that for every 341 cases 300 cases will be near misses and dangerous occurrences, 30 will be property damages and 10 minor and 1 major accident.

Principles of Prevention

•      Avoid Risks

•      Evaluate risks

•      Combat risks at source

•      Adapt to Individual

•      Adapt to technical progress

•      Coherent Policy

•      Priority  to collective measures

•      Instruction to employees

Preventative Strategy

Safe Place

Equipment/Access/Egress

Materials (Articles/Substances)/Environment:

Safe Person

Information, Instruction and Training

Safe Behaviour

Awareness, Knowledge, Competence

Supervision

Health Surveillance

Personal Protective Equipment

Safe Systems

Policies and Standards

Rules

Procedures

Safe systems of work

Permits to work

Clear lines of responsibility

Accident Investigation and analysis

Emergency preparedness

Purchasing controls

Aims of Accident Investigation

•      Determine cause to prevent recurrence

•      Identify weaknesses in management systems

•      Identify weaknesses in risk assessment

•      Demonstrate management commitment

•      Comply with country’s legal requirements

•      Collect data to establish losses

•      Provide information for Civil/Criminal actions

•      Provide information to insurance company

Immediate &

Longer Term Actions

•      First aid for injured party

•      Calling medical assistance if necessary

•      Make area safe

•      Isolation of the accident scene

•      Implement emergency plan

•      Report to enforcing authority if necessary

•      Identification of witnesses

•      Full investigation to determine root cause

•      Making recommendations

•      Implementing corrective action

Overall Investigation process

Preparation Before Investigation

•      Who should be involved and depth of investigation

•      Accident scene untouched

•      Collate relevant existing documents

•      Identifying who are witnesses

•      Have legal requirements been met?

•      Any equipment needed?

•      Method to be adopted

•      Style of report and who should receive it

Investigation Team

Line Manager: Knowledge of the processes

Supervisor: Also has knowledge of the process

Safety Representative: Has legal right

Safety Practitioner: To advise on health & safety

Engineer: Advise on technical matters

Senior Manager from different department: Unbiased

Equipment required for investigation (Investigation Kit):

a) Camera

b) Writing materials

c) Investigation forms

d) Measuring tape

e) Area plans

f) Protective equipment

g) A checklist

Four Steps to Investigation

1)    Gather the information (the where, when and who of the adverse event)

2)    Analyse the information (the ‘what happened and why’ stage)

3)    Identify the risk control measures (possible solutions to be identified)

4)    The action plan and its implementation (which should have SMART objectives)

1) Gather the Information

What activities were being carried out?

Was there anything unusual?

Were there adequate safe working procedures?

Were they being followed?

Was the risk known? If so why not controlled?

Did the organisation and arrangement of the work influence the accident?

Was maintenance and cleaning sufficient?

Was the safety equipment sufficient?

Materials

-- Materials or substance

Equipment

--Tools, vehicles, machinery etc.

Environment

--Lighting, temperature etc

People

--Human error, inexperience, training

Other Factors

Nature of the work e.g. routine

Specialist examinations

Medical reports

Interviews/witness statements

Do not dismiss contradictory evidence

Documents

•      Risk assessments

•      Safe systems of work

•      Incident/accident history

•      Training records

•      Maintenance records

•      Equipment instructions

•      Monitoring, e.g. dust, noise

•      Supervision rotas

•      Inspection reports

•      Pre–start equipment checks

2) Analyse the information

Analysis should determine:

Cause of the injury

Immediate/direct causes

•      Unsafe acts e.g. not wearing correct PPE

•      Unsafe condition e.g. a cable trailing across a busy walkway

Root/underlying causes

“Root Cause Analysis”

Entire chain of events is evaluated to find "Root Causes" as well as the immediate cause

"Root causes” are safety system inadequacies

Personal factors

Physical or mental condition, skills, knowledge, etc.

Job factors

Equipment, workplace conditions

Recommendations may include:

Policies

Equipment

Training

3) Identify the risk control measures

There may be:

•      No control measures in place

•      Control measures in place that were not used

•      Control measures in place that failed

•      Combinations of the above 

Measures should be evaluated for:

•      Their ability to prevent recurrences

•      Whether they are practical

•      Whether they will be used

•      Whether they will remain effective 

4) Take Action

•      Involve Senior Management

•      Highest priority risks control measures  implemented first

•      Lower risks control measure in order of priority

•      Specific Senior Manager in charge of implementation

Report to Management

The investigation is not complete until a report is prepared and submitted

Recommended outline

Background Information

Where and when the accident occurred

Who and what were involved

Operating personnel and other witnesses

Account of the Accident (What happened?)

Sequence of events

Extent of damage

Accident type

Agency or source (of energy or hazardous material)

Report shall contain the following:

Who – The injured person

When – Date and time

Where – Location

What – Accident/injury

How – Detail of events

Why – Analysis of cause

Recommendations

Documentation

Possible breaches of law

Type of data collected

Incidents/Accidents

•      Incident /accident or near miss reports

•      Reports to enforcing authorities

•      Reports to insurers

Work related ill health

•      Sickness absence reports

•      Health surveillance

•      Medical diagnosis from outside organisation

Categorising Accident Data

•      Category of person affected

•      Injury type

•      Part of body injured

•      Severity of injury

•      Age/sex of person

•      Work activity

•      Shift/time of day

•      Location of accident

Accident Statistics

Accident Incident Rate:

Number of defined accidents / Average number employed x 1000

Fatal Accident Incidence Rate:

Number of fatalities / Average number employed x 1000                                                                               

Accident Frequency Rate

Number of defined accidents in period / Total person hours worked in period x 100,000

Accident Severity (or Gravity) Rate

Total number of days lost in a period / Total person hours worked in a period x 1000

Frequency & Incidence Rates

Communicating Data

Safety committees

Team briefings

Company magazines

Board meetings

Performance reviews for managers

Annual reports

Benefit of using accident data

a) Shows patterns and trends

     Pattern - Repeated events

     Trend -  A line of general direction

b) Identify weaknesses in procedures

c) Prioritise safety measures

d) Identify areas for improvement

e) Set targets for reduction

Reporting of Accidents

Competent authority who should implement a policy for:

•         The recording, notification and investigation of occupational accidents and diseases

•         The recording, notification and investigation of commuting accidents, dangerous occurrences and incidents

•         Compilation, analysis and publication of statistics on such accidents, diseases and dangerous occurrences

Establish procedures for employers to ensure information on accidents is maintained

Also many Countries require reporting of certain types of injury, diseases, dangerous occurrences and commuting accidents

Examples of Reportable Events

Injuries: Death, fracture, amputations etc.

Diseases: Dermatitis, Asthma, lung diseases

Dangerous occurrences: Collapse of cranes, contact with overhead power lines, etc

Commuting accidents

Examples of Non Reportable Events

Near Misses, First Aid cases.

Reasons for Failure to Report Accidents

•      Ignorance of procedures

•      Over complicated procedures

•      Peer pressure

•      Management retribution

•      Preserve accident record

•      Lack of management response

Benefits of Collecting Near Miss Data

1.     To identify underlying causes which may allow preventative action to be taken before something more serious occurs

2.     Gives message to workforce that all failures are taken seriously not just those leading to injury

3.     Generally accepted near misses greatly outnumber accidents and can therefore produce more data from which a greater understanding of the deficiencies in management systems can be identified and rectified

Accident Causation Models

Domino Sequence

1)    Lack of Management control

2)    Basic Causes – Personal/Job factors

3)    Immediate Causes ( Unsafe Acts/conditions)

4)     Accident/Incident

5)    Loss/Injury

Domino sequence states that the accident occurs only if there are series of failure.

Swiss Cheese model

1.     Fallible Decisions

2.     Latent Failures

3.     Preconditions

4.     Unsafe acts

5.     System Defenses

Failure of the above factors leads to accident.

Cost of an Accident:

There are two types of costs

1.     Direct Costs

2.     Indirect Costs

1.     Direct Costs (Insured)

Accidents are more expensive than most people realize because of the hidden costs. Some costs are obvious — for example, Workers' Compensation claims which cover medical costs and indemnity payments for an injured or ill worker. These are the direct costs of accidents.

2.     Indirect Costs

But what about the costs to train and compensate a replacement worker, repair damaged property, investigate the accident and implement corrective action, and to maintain insurance coverage? Even less apparent are the costs related to schedule delays, added administrative time, lower morale, increased absenteeism, and poorer customer relations. These are the indirect costs — costs that aren't so obvious until we take a closer look.

Direct vs. Indirect Costs

•         Indirect Costs are from 2 to 20 Times direct Costs