Southern Luzon State University

College of Engineering
Mechanical Engineering Department

ASSIGNMENT NUMBER 8

IBRE,RISSEL P.
BSME V- GN

SUBMITTED TO:
ENGR. EFREN DAYA

OCTOBER 10, 2018

 INTRODUCTION

A major concern of safety at work is preventing accidents at work. An accident at work

can be defined in different ways depending of the context in which it is used. Often also the

word incident is used, sometimes as a broader term encompassing ‘an accident' as a specific

type of incident, but sometimes the words accidents and incidents refer to two different

types of events. Prevention of accidents at work focuses on the causes of accidents. Accident

causation models provide a theoretical basis for explaining how accidents at work occur.

Statistical data give some details about the accidents that occur in the workplace: the

occurrence, the victims and the causes.

All accidents are incidents, but not all incidents are accidents. That's a very brief

answer to the common query about the difference between the two terms. The word

accident has a negative implication and could result in loss of life, or damage to goods. An

incident on the other hand can refer to any even that happens; it could be positive or

negative. Applying this definition makes it obvious the category "incidents" is larger than

the category "accidents". If all accidents are unplanned, unexpected events, some incidents

that result in damage or injury are highly planned events, such as terrorist attacks or bank

robberies.

PART 1

ACCIDENT - The National Safety Council defines an accident as an undesired event that

results in personal injury or property damage. Also, it is a situation that results in medical

attention (treatment beyond first aid) and/or lost time (missed work). For example, collision

between two cars.

WHAT IS AN ACCIDENT INVESTIGATION?

Accident investigation is the process of determining the root causes of accidents, on-

the-job injuries, property damage, and close calls in order to prevent them from occurring

again. As only 2% of all workplace incidents are thought to be unpreventable*, the primary

purpose of an investigation is to prevent future occurrences, not to place blame. Beyond

the primary purpose, the information obtained through the investigation should be used to

update and revise the investigator’s inventory of hazards, and/or the relevant safety

program(s) for hazard prevention and control.

For example, a Job Hazard Analysis may be generated or revised and employees

(re)trained to the extent that it fully reflects the recommendations made in the investigation

report. Further, implications from the root cause(s) of the accident should be analyzed for

their potential impact on other operations and procedures.

WHY IS ACCIDENT INVESTIGATION IMPORTANT?

Accidents are investigated to identify the causes of their occurrence and to determine

the actions that must be taken to prevent recurrence. It is essential that the accident

investigators probe deeply into both the events and the conditions that create accident

situations, and also the managerial control systems that let them develop so that the root

accident causes can be identified. Identification of these root causes necessitates

understanding the interaction of events and causal factors through a chronological chain of

activity starting with an initiating event through to the final loss producing occurrence. Vital

factors in accident causation emerge as sequentially or simultaneously occurring events that

interact with existing conditions. A meticulous trace of unwanted energy transfers and their

relationships to each other and to the people, plant, procedures, and controls implicated in

accident occurrence, further defines the sequence of accident development.

WHAT IS REQUIRED IN AN ACCIDENT INVESTIGATION?

 Develop an accident investigation process that focuses on: o fact finding, not fault

finding by determining the root causes of why the event occurred and making

changes so the event does not happen again.

 Set a policy that accidents and close calls (large and small) will be investigated with

equal vigor.

 Provide training and tools to staff conducting accident investigations.

 Audit completed investigations to ensure they are being completed on a timely

basis with an adequate level of detail.

THE GOALS OF A TIMELY AND THOROUGH ACCIDENT INVESTIGATION

• To determine the cause of the accident

• To prevent the accident from happening again

• To improve health and safety conditions in the workplace

• To determine whether a violation of federal or state safety and health standards

contributed to the accident

• To determine company or individual liability in case of future legal action

• To determine the need for repairs or replacement of damaged items

• To determine the need for additional education and training for employees. A thorough

and complete accident investigation involves several steps, specifically, background,

investigation, site investigation, interviews, analysis and reporting.

PART 2

INCIDENT - An incident is an unplanned, undesired event that adversely affects completion

of a task. It is also a situation with the potential to cause serious harm to a person. Generally,

the outcome results in first aid treatment. It may have either positive implications or

negative. For example, your phone is stolen, this is an incident.

 Near miss - describe incidents where no property was damaged and no personal

injury sustained, but where, given a slight shift in time or position, damage and/or

injury easily could have occurred. (In this guidance, the term near miss will be

taken to include dangerous occurrences);

 Undesired circumstance - a set of conditions or circumstances that have the

potential to cause injury or ill health, For example, untrained nurses handling

heavy patients.

NOTE: The term incident is used in some situations and jurisdictions to cover both an

"accident" and "incident". It is argued that the word "accident" implies that the event was
related to fate or chance. When the root cause is determined, it is usually found that many

events were predictable and could have been prevented if the right actions were taken -

making the event not one of fate or chance (thus, the word incident is used). When incidents

are investigated, the emphasis should be concentrated on finding the root cause of the

incident so you can prevent the event from happening again. The purpose is to find facts

that can lead to corrective actions, not to find fault. Always look for deeper causes. Do not

simply record the steps of the event.

WHAT IS AN INCIDENT INVESTIGATION?

An incident investigation is an investigation into an unplanned, undesired event that

may not cause injury or damage, but hinders the completion of a task. Incident investigations

that focus on identifying and correcting root causes, not on finding fault or blame, also

improve workplace morale and increase productivity, by demonstrating an employer’s

commitment to a safe and healthful workplace. It is often conducted by a supervisor, but to

be most effective, these investigations should include managers and employees working

together, since each bring different knowledge, understanding and perspectives to the

investigation.

WHAT ARE THE STEPS INVOLVED IN INVESTIGATING AN INCIDENT?

First: Report the incident occurrence to a designated person within the organization.

Second: Provide first aid and medical care to injured person(s) and prevent further injuries

or damage.

Third : The incident investigation team would perform the following general steps:

 Scene management and scene assessment (secure the scene, make sure it is safe for

investigators to do their job).

 Witness management (provide support, limit interaction with other witnesses,

interview).

 Investigate the incident, collect data.

 Analyze the data, identify the root causes.

 Report the findings and recommendations.

 The organization would then:

 Develop a plan for corrective action.

 Implement the plan.

 Evaluate the effectiveness of the corrective action.

 Make changes for continual improvement.

REASONS TO INVESTIGATE A WORKPLACE INCIDENT

 To find out the cause of incidents and to prevent similar incidents in the future

 To fulfill any legal requirements

 To determine the cost of an incident

 To determine compliance with applicable regulations (e.g., occupational health and

safety, criminal, etc.)

 To process workers' compensation claims

TOP ENGINEERING AND CONSTRUCTION SAFETY INCIDENTS

1. FALLS
Today reports that falls had the highest fatality rate in the construction

industry, accounting for over a third of the 57.7% of deaths caused by the fatal four.

The report also indicates that the highest number of construction fatalities—48% of

total fatalities— were to specialty trade constructors, those who work in foundations,

structures and concrete. Heavy and civil engineering (utilities, sewer, oil, roads and

bridges) accounted for 17% of worker deaths.

2. STRUCK BY OBJECTS
OSHA shares this example: An employee was struck by a nail from a nail gun

fired by another employee through a wall made of wallboard. These types of

preventable fatalities are increasing and in 2010, 402 occupational fatalities were

caused by struck-by hazards in the United States.

3. ELECTROCUTION
For electrocution and lockout/tag out policies, OSHA advises that a

lockout/tag out standard gives each employer the flexibility to develop an energy
 control program suited to the needs of the particular workplace and the types of

machines and equipment being maintained or serviced.

4. CAUGHT IN/BETWEEN
Trenching and excavation are two crucial parts of the construction process,

with very hazardous work environments, especially for lone workers. The Centers for

Disease Control and Prevention (CDC) reports that cave-ins can occur while trenching

where workers can easily become caught in, or stuck in between materials.

“Preventing Worker Death from Trench Cave-ins” reminds construction workers that

there is no reliable warning when a cave-in may occur. This story of a construction

laborer who died when trench walls collapsed is a sobering example of the risks your

employees face every day.

5. WORKING ALONE
More people work alone than you think. Berg Insight reports there are a

whopping 53 million lone workers in Canada, the United States and Europe combined.

That’s about 15 percent of the overall workforce. The International Data Corporation

(IDC) estimates that approximately 1.3 billion people worldwide are mobile workers,

many of whom work alone continuously or at various times during their workday.

These working scenarios can be dangerous, and without the proper safety measures

in place, can be fatal to your employees.

6. CUTTING CORNERS

Working in a high-risk environment with many moving parts and volatile

materials calls for motivated personnel. Mistakes and carelessness can lead to injuries

and even fatalities. Clear safety measures, processes, communication and equipment

can help alleviate this risk.

7. TRAINING
Many organizations believe they have the appropriate training in place for

their employees. Ask yourself: Is our training following best practices? Does it truly

cover the ins and outs of engineering and construction work, including scaffolding,

machinery, handling materials, electrical, cranes and even trenching? What about the
 potential for health incidents? Working with dangerous equipment and moving

objects can be challenging.

8. TIME

Does your business have an emergency response protocol? Has it been

updated lately and how is it triggered? Do you have a work-alone policy? It is crucial

to understand that the unexpected can occur, and should it become a reality that

your team faces, be assured that you’ve implemented the policies and processes

required to keep your team safe.

9. FAILURE TO PROVIDE SAFETY PROCEDURES

Does your business have an emergency response protocol You need to be

confident that you’ve implemented the policies and processes required to keep your

team safe. Updating your safety policies, procedures and addressing your work alone

safety monitoring program can mitigate the risks in engineering and construction. It

must ensure that if an injury, health incident or assault occurs, your monitoring

program efficiently pinpoints your crewmembers’ precise location—indoors and

outdoors— and directs a prompt emergency response.

10. NO SAFETY MONITORING TECHNOLOGY

You should consider the lone-worker safety monitoring options available.

Available options range from manual check-in processes and supervisory spot

checks to modern safety monitoring technology,

PART 3

WHAT IS AN INVESTIGATION?

Investigation refers to the process of collecting information in order to reach some

goal. The purpose of this is to explore in detail the allegations, to examine the evidence in

depth, and to determine specifically whether misconduct has been committed.

Every year people are killed or injured at work. Over 40 million working days are lost

annually through work-related accidents and illnesses. Investigating accidents and

incidents explains why you need to carry out investigations.

BASIC STEPS FOR CONDUCTING AN INVESTIGATION

1. Secure the scene.

This is the beginning of your analysis. Your primary goal is to secure the scene

as soon as possible in order to prevent further injuries, ensure the well-being of the

affected employee, and to protect any critical physical clues from being spoiled.

2. Collect the facts.

Focus on finding the facts about the event. Remember to gather valid

information without drawing conclusions or assigning blame. Document your

observations. Take photos and check video surveillance if available. Interview

employees and witnesses. Review relevant records, such as maintenance, training,

policies, procedures, etc.

3. Develop the sequence of events.

Review and accurately arrange the gathered information to determine the

order of events. Constructing an accurate timeline may be critical to an effective

analysis. Document what happened before, during and after the event. Arrange

this information to accurately determine the order of events.

4. Determine potential causal factors.

Every accident / incident is caused by a set of contributing factors. These

factors represent the surface or root causes that led to the event. The goal is to

identify these by analyzing how or why each consecutive event happened. Use the

following diagram as an example.

5. Recommend or implement corrective measures.

Your recommendations should be relevant and concise. Identify, either

independently or as part of a collaborative effort, and describe the recommended

corrective measure(s), who will be responsible for implementation, and the

 anticipated completion date. Follow up to ensure that the corrective measures are

implemented within the appropriate time frame, and incorporated into the

appropriate policy, procedure, or safety program in order to prevent future

occurrences

6. Communicate the outcomes of the investigation.

Train your employees on what changes will be / have been implemented. Share

your experience with peers so they, too, may enjoy a safer and more productive work

environment.

INVESTIGATION TEAM SHOULD BE AWARE OF THE FOLLOWING:

1. Act as soon as possible after the incident

2. Visit the scene before physical evidence is disturbed

3. Not prejudge the situation

4. Not remove anything from the scene

5. Enquire if anyone else has moved anything

6. Take photographs and/or sketches to assist in reconstructing the incident.

After the initial investigation is complete the team should also know the following:

1. Identify, label and keep all evidence. For example, tools, defective equipment,

fragments and chemical samples

2. Interview witnesses separately

3. Check to see if there have been any “near misses” in similar circumstances

4. Note down all sources of information

5. Keep records to show that the investigation was conducted in a fair and impartial

manner

WHEN DO YOU CONDUCT AN ACCIDENT/INCIDENT INVESTIGATION?

• All incidents, whether a near miss or an actual injury-related event, should be

investigated.
• Near miss reporting and investigation allow you to identify and control hazards before

they cause a more serious incident.

• Accident/incident investigations are a tool for uncovering hazards that either were

missed earlier or have managed to slip out of the controls planned for them.

• It is useful only when done with the aim of discovering every contributing factor to the

accident/incident to "foolproof" the condition and/or activity and prevent future

occurrences.

• In other words, your objective is to identify root causes, not to primarily set blame.

PART 4

WHAT IS A CAUSAL FACTOR ANALYSIS?

It is a number of factors that contribute to an incident. Events and Causal Factors

Analysis (ECFA) is an important component in the accident investigation repertoire of

methods. It is designed as a stand alone technique but is most powerful when applied with

other techniques found in the Management Oversight and Risk Tree (MORT) program. ECFA

serves three main purposes in investigations:

(1) assists the verification of causal chains and event sequences;

(2) provides a structure for integrating investigation findings;

(3) assists communication both during and on completion of the investigation.

ACCIDENT / INCIDENT CAUSAL FACTORS

There are two major components that contribute to the cause of an accident / incident;

surface cause and the root cause.

1. The surface cause is the condition or act that directly caused the incident. An

example of a surface cause is a small spill of oil on the floor that someone slipped

on.
 2. The root cause is the system failure that allowed the surface cause to occur. For

example, a root cause may be a lack of preventive maintenance that resulted in the

fork truck leaking oil on the floor. A thorough investigation will reveal the root

cause of the incident. Corrective measures that address the root cause have the

greatest potential to prevent accident / incident recurrence.

Accurate ECF analysis can help satisfy these general purposes in the following ways:

1. Provides a cause-oriented explanation of the accident;

2. Provides a basis for beneficial changes to prevent future accidents and operational

errors;

3. helps delineate areas of responsibility;

4. helps assure objectivity in the conduct of the investigation;

5. organizes quantitative data (time, velocity, temperature, etc.) Related to loss

producing events and conditions;

6. Acts as an operational training tool;

7. Provides an effective aid to future systems design.

More specifically, ECFA:

1. Aids in developing evidence, in detecting all causal factors through sequence

development, and in determining the need for in-depth analysis;

2. Clarifies reasoning;

3. Illustrates multiple causes. As previously stated, accidents rarely have a single

“cause”. Charting helps illustrate the multiple causal factors involved in the accident

sequence, as well as the relationship of proximate, remote, direct, and contributory

causes;

4. Visually portrays the interactions and relationships of all involved organizations and

individuals;

5. Illustrates the chronology of events showing relative sequence in time;

6. Provides flexibility in interpretation and summarization of collected data;

 7. Conveniently communicates empirical and derived facts in a logical and orderly

manner;

8. Links specific accident factors to organizational and management control factors.

SEVEN KEY ELEMENTS IN THE PRACTICAL APPLICATION OF ECFA TO ACHIEVE HIGH

QUALITY ACCIDENT INVESTIGATIONS.

1. Begin early. As soon as you start to accumulate factual information on events and

conditions related to the accident, begin construction of a “working chart” of events

and causal factors. It is often helpful also to rough out a fault tree of the occurrence

to establish how the accident could have happened. This can prevent false starts

and ‘wild goose chases” but must be done with caution so that you don’t lock

yourself into a preconceived model of the accident occurrence.

2. Use proper guidelines. These will assist you in getting started and staying on track as

you reconstruct the sequences of events and conditions that influenced accident

causation and amelioration. Remember to keep the proper perspective in applying

these guidelines; they are intended to guide you in simple application of a valuable

investigative tool. They are not hard and fast rules that must be applied without

question or reason. Analytical techniques should be servants not masters.

3. Proceed logically with available data. Events and causal factors usually do not

emerge during the investigation in the sequential order in which they occurred.

Initially, there will be many holes and deficiencies in the chart. Efforts to fill these

holes and get accurate tracking of the event sequences and their derivation from

contributing conditions will lead to deeper probing by investigators that will uncover

the true facts involved. In proceeding logically, using available information to direct

the search for more, it is usually easiest to use the accident or loss event as the starting

point and reconstruct the pre-accident and post-accident sequences from that

vantage point.
4. Use an easily updated format. As additional facts are discovered and analysis of

those facts further identify causal factors, the working chart will need to be updated.

Unless a format is selected which displays the emerging information in an easily

modified form, construction of the chart can be very repetitious and time-consuming.

5. Correlate use of ECFA with that of other MORT investigative tools. The optimum

benefit from MORT-based investigations can be derived when such powerful tools as

ECFA, MORT chart based analysis, change analysis, and energy trace and barrier

analysis are used to provide supportive correlation.

6. Select the appropriate level of detail and sequence length for the ECF chart. The

accident, itself, and the depth of investigation specified by the investigation

commissioning authority will often suggest the amount of detail desired. These, too,

may dictate whether ending the ECF chart at the accident or loss-producing event is

adequate, or whether the amelioration phase should be included. The way the

amelioration was conducted will also influence whether this should be included and

in how much depth it should be discussed.

7. Make a short executive summary chart when necessary. The ECF working chart will

contain much detail so it can be of greatest value in shaping and directing the

investigation. In general, significantly less detail is required in the ECF chart presented

in the investigation report, because the primary purpose is to provide a concise and

easy-to-follow orientation to the accident sequence for the report reader. When a

detailed ECF chart is felt to be necessary to show appropriate relationships in the

analysis section of an appendix of the report, an executive summary chart of only one

or two pages should be prepared and included in the report to meet the above stated

purpose.

IBRE, RISSEL P.
BSME V- GN