Accident Investigation and Hazard Analysis June 18, 2015 Objectives: Accident Investigation Define accidents Review why accident investigations are important Review the purpose of accident investigations Review accident causes Discuss laying the foundation: Management s job Define components of an accident investigation 1
Definition of an Accident An undesired, unplanned event or sequence of events causing injury, ill health, or property damage They are caused by defects in your system Why accident investigations are important Moral responsibility for employee safety Direct and indirect costs The iceberg effect Discover and correct unsafe behaviors and conditions Visible show of concern for employee safety 2
Purpose of Accident Investigation Find the causes and correct them to prevent reoccurrence. Majority of accidents have more than one cause The critical questions Many accident investigations fail their primary purpose The critical questions to ask: Have we identified all the primary causes of this accident? What improvements in our system have we made to prevent a recurrence? How will we audit these improvements? 3
Some reasons why accident investigations fail Rush to find a cause then quit Insufficient information: Hurt back lifting box Use terms such as careless or freak accident No follow up on corrective actions recommended Jump to conclusions without full investigation Lack of management oversight: Lowering the bar Effective Accident Investigations Proactive elements necessary for success: Active management participation in safety program Effective and enforced safety policies and procedures Regular safety inspections Working safety committee Safety training programs 4
Laying the foundation: Management s job Develop the written policy and procedures Who s in charge: Company mission statement Who will investigate the accident? Develop and require qualitative and quantitative standards: Expectations of behavior Train the accident investigators and provide support Audit the program: Do the reports meet the standards (Do not lower the bar)! Laying the foundation: Management s job Educate all employees and management Develop uniform training program: Not a one shot deal Training program includes specifics on consequences Training should include workshops and focus on company loss sources 5
Accident Causes Unsafe acts versus unsafe conditions Approximately 95% of all illnesses and injuries are caused at least in part by unsafe behaviors Accident Causes Common unsafe acts Failure to follow proper procedure Failure to wear personal protective equipment Failure to use proper machine guarding Inadequate housekeeping in work area Horseplay Bypassing or disabling safety devices 6
Components of an Accident Investigation What to look for: Personnel involved Task (Method) Agency or equipment Environment Components of an Accident Investigation Personnel involved Training (general and task specific) Work History (include previous accidents) Medical Issues (include physical and cognitive limitations) Fatigue (hours worked) Experience (on Specific Task) 7
Components of an Accident Investigation Task/Method Were up to date proper work procedures developed and documented (JSA)? Were they followed? If not, why not? Were correct tools and equipment used? Was this a common task or an infrequent task? When was last training done? Was the appropriate safety equipment available and used? Components of an Accident Investigation Agency or equipment involved Was it the correct equipment for the job? If not, why not? Was it maintained and used properly? Were proper safeguards in place? 8
Components of an Accident Investigation Environment Were there weather conditions involved? Was lighting adequate? Was there smoke, noise, or other factors involved? Was housekeeping adequate? Were there any toxic materials involved? What if Employee s Violation of Safety Rule / Procedure Caused the Accident? Disciplinary Policies Purpose Obtain compliance with the following: Established rules of conduct (expectations of behavior) Safe working practices Standard operating procedures Progressive Discipline should be specific and spelled out in training (no double secret probation ) 9
Audit and Follow up Basic question again: What have we done to change the operation to prevent a recurrence? It is important to audit completed investigations: Did the investigator determine real causes for the accident or nearmiss? Did the investigator develop corrective actions? Did the organization implement them? Summary Accident and near-miss investigations are a crucial element in a safety program Top management needs to support the program A written policy is the basis of the accident investigation and near-miss program Audit, audit, audit! 10
Let s shift gears from investigating an accident to a hazard analysis process Job Safety Analysis (JSA) is a hazard analysis process that is used to assist in identifying and controlling hazards in your workplace It is also known as job hazard analysis (JHA) The difference: The biggest difference between the two: Accident investigation is reactive; JSA and other hazard analyses are proactive The better you utilize tools such as JSA, the fewer accident investigations you may have to do 11
Why is Job Safety Analysis an important tool? Eliminates hazards in the workplace Protects workers from injury, illness or death Reduces workers compensation costs Establishes proper job procedures Recognizes that employees must be trained properly Objectives: Hazard Analysis Define a hazard and review the different types of hazards Review the three steps of a Job Safety Analysis Learn the hierarchy of hazard control measures Review completing a Job Safety Analysis Putting the JSA to use 12
What is a Hazard? A hazard is the potential for harm. In practical terms, a hazard often is associated with a condition or activity that, if left uncontrolled, can result in an injury or illness. Listing of Common Hazards Chemical Explosion Electrical Ergonomics Excavation Fall (Slip, Trip) Fire/Heat Mechanical Noise Radiation Struck By Struck Against Temperature Extremes Visibility Weather Phenomena 13
Common Hazards and Descriptions Ergonomics (Strain) - Damage of tissue due to overexertion (strains and sprains) Lifting, lowering, pushing, pulling, twisting Common Hazards and Descriptions Ergonomics (Strain) - Damage of tissue due to repetitive motion Repetitive motion injuries due to frequency, force exertion, awkward postures 14
Common Hazards and Descriptions Fall (Slip, Trip) - Conditions that result in falls (impacts) from height or traditional walking surfaces (such as slippery floors, poor housekeeping, uneven walking surfaces, exposed ledges, etc.) A Reminder Involve Your Employees Employees perform the job(s) and are the experts Employees can help determining solutions to the identified hazards Assists in employee buy in to solutions 15
JSA Three Step Process Step one: Determine which jobs/tasks to review (Setting priorities) Step two: Complete the JSA at the job/task at the site Step three: Develop controls The hierarchy of controls Step one: Determine which jobs/task to review. Priority should be given to jobs/tasks: With the highest injury or illness rates With the potential to cause severe/disabling injuries or illness In which one simple human error could lead to a severe accident or injury That are new to your operation or have undergone changes in processes and procedures 16
Stanford University Hazard Evaluation Index Probability 5 4 3 2 1 5 10 15 20 25 4 3 8 6 12 9 16 12 20 15 2 4 6 8 10 1 2 3 4 5 1 2 3 4 5 Severity PROBABILITY (over life of condition) 1. Remote Extremely unlikely to occur 2. Low Possible but unlikely to occur 3. Moderate Moderate risk of occurrence 4. High Likely to occur 5. Probable Very likely to occur in immediate future Stanford University Hazard Evaluation Index Probability 5 5 10 15 20 25 4 4 8 12 16 20 3 3 6 9 12 15 2 2 4 6 8 10 1 1 2 3 4 5 1 2 3 4 5 Severity SEVERITY 1. Slight Minor first aid injuries Losses under $50 2. Appreciable Injuries requiring a Losses between $50 physician s attention and $1,000 3. Serious 1 or more serious Losses between $1,000 injuries or illness and $100,000 4. Severe A death or disabling Losses between $100,000 injury or illness and $1 million 5. Catastrophic Multiple deaths and/or Losses in excess of $1 million disabling injury 17
Stanford University Hazard Evaluation Index Probability 5 4 3 5 4 3 10 8 6 15 12 9 20 20 16 12 25 25 20 15 2 2 4 6 8 10 1 1 2 3 4 5 1 2 3 4 5 Severity ACTION GUIDE 1-4 Institute corrective action if and when appropriate 5-9 Initiate corrective actions when practical 10-15 Institute all reasonable corrective action ASAP 16-25 Immediate corrective action must be taken The Three Steps to JSA Complete the JSA 18
Job Title Job Location Analyst Date Task # Hazard Type Task Description: Hazard Description: OSHA s Job Safety Analysis Form-3071 Appendix 3 - pg. 46 Consequence: Hazard Control: Rationale or Comment: Job Safety Analysis Form Heading Task Procedures Steps Potential Hazards Abatement Actions Final Approval 19
Changing a Light Bulb Task/Procedures Potential Hazards Abatement Actions 1. Pick up ladder and bulbs from maintenance closet 2. Carry ladder and bulbs to light fixture 3. Extend out ladder braces and climb ladder 4. Take off light cover, remove bulb & descend ladder 5. Climb ladder, install bulb & re-secure light cover Job Hazard Analysis Possible trip hazards in closet Strain from carrying ladder & possible breakage of bulbs Possible pinch point from braces & possibility of fall Dust falling from fixture into eye, possibility of bulbs breaking or losing balance and falling Dust falling from fixture into eye, possibility of bulbs breaking or losing balance and falling Maintain a clean closet. Have a ladder & bulbs on each floor. Only transport bulbs in boxes designed to carry bulbs. Train employees on proper ladder setup and 3 point contact. Mandate the use of safety glasses and utilize the right height ladders (3pt contact hard to maintain) Mandate the use of safety glasses and utilize the right height ladders. Place old light bulbs back in the case to minimize breaking exposure. 6. Descend ladder Possibility of falling Maintain three point contact Complete the JSA Examine the environment of a job with your employee Are there materials on the floor that could trip a worker? Is lighting adequate? Is there excessive noise in the work area, hindering communication or causing a hearing loss? 20
Complete the JSA Examine the environment of a job with your employee Are trucks or motorized vehicles properly equipped with brakes, overhead guards, backup signals, and horns? Are employees wearing the applicable personal protective equipment (PPE) for the jobs they are performing? Complete the JSA Examine the environment of a job with your employee Are work stations designed to prevent back and wrist injuries? Are employees trained in the event of a fire, explosion, or toxic gas release? 21
Complete the JSA Identify Hazards: What can go wrong? What are the consequences? How could it arise? What are other contributing factors? How likely is it that the hazard will occur? Probability 5 4 3 2 1 5 4 3 10 8 6 15 12 9 20 16 12 25 20 15 2 4 6 8 10 1 2 3 4 5 1 2 3 4 5 Severity The Three Steps to JSA Develop controls 22
Most Effective ENG Least Effective Hazard Control Measures: The hierarchy of controls Engineering Controls Elimination / minimization of hazard Removal Substitution of process, equipment, or materials Enclosure Isolation: Interlocks or machine guards Local or exhaust ventilation Hazard Control Measures: The hierarchy of controls Most Effective ENG ADM Administrative Controls: Written operating procedures and work permits Exposure time limitations Monitoring the use of highly hazardous materials Alarms, signs, and warnings Training Least Effective 23
Safety Training and Education Instruct each employee in the expectations of behavior for that job The more specific the better A JSA is an excellent method to develop expected behaviors and avoid freestyling Note: Workers in their first year of employment with a new employer account for more than 50% of disabling claims Hazard Control Measures: The hierarchy of controls Most Effective ENG Personal Protective Equipment examples: Hearing protection Hard hats Safety glasses ADM PPE To be used when: Engineering controls are not feasible When safe work practices do not provide enough protection During emergencies when engineering controls may not be feasible Least Effective 24
Put the JSA to use Post JSA s at the workstation (Not in a three ring binder in the office!) Use as the primary training tool Refer to and reinforce often in safety meetings Use as your expectation of behaviors: The only way! Use pictures and graphics to illustrate the correct way When to Review your JSA s? If an injury or illness occurs on a specific job If a near miss occurs on a specific job If the essential functions of a job have changed Periodically reviewing your job safety analysis (JSA) ensures that the JSA remains current and continues to help reduce workplace accidents. 25
Summary Loss Summary The 3 Steps to JSA Most Effective ENG ADM PPE Least Effective www.newmexicomutual.com Patrice Antonio Risk and Safety Management Assistant New Mexico Mutual Phone: 505-343-2860 patrices@newmexicomutual.com 26
Thank You for Joining Us Have a Safe Day! 27