After reviewing the Session material on the Accident Investigation process $($Session $9$ recordings & related slides$),$ answer the $5$ accident investigation questions in this Forum.

The plant is experiencing some difficulties with a clamping device on a holding fixture that keeps a metal part in position while it is fed into an automatic stamping machine. The clamp does not always allow the metal part to be fed into the machine properly aligned. The worker who was operating the machine had $32$ years experience with this type of equipment. While attempting to make the necessary adjustments for $$smooth$$ operation without shutting off the power, he had to reach into the machine. He placed his left hand between the feed$-$in mechanism levers while his right hand was positioning the misaligned part between the open clamps of the fixture.

Unfortunately, the one$-$button actuating control was located immediately to the left of the worker$$s body, about hip level. The worker inadvertently depressed the button with his leg while reaching into the machine. The machine cycled $$ the feed mechanism slid forward while the fixture clamps closed. The worker had the portion of his left middle finger amputated. $1)$In chronological order, list the events up to and including the accident is this case.

$2)$The Direct Cause is also known as the "immediate cause". This is the step where energy was transferred to the worker$$s body, that the body could not resist. What event happened to cause the injury? E$.$g$.$: $$His finger was amputated by the moving saw blade.$$

$($Notice how you can usually combine the injury and the D$.$C$.$ in one simple sentence$)$

$3)$Determine Surface Causes. These are the Unsafe Acts and Unsafe Conditions. Also known as Human Factors and Situational Factors. $$Hint: what actions by the worker, or conditions in the workplace contributed to causing the accident AND are listed in the events? $($Do not speculate about what is not written down$)$

$4)$To determine each Root Cause.... for each Surface Cause. Ask yourself what failure$($s$)$ in the management system caused each unsafe action or condition to happen? This will lead you to identifying the root causes.... weaknesses in the safety management system.$$ These are all things that management can control. An example would be $$lack of training$.$

$5)$What Remedial Actions $($Controls$)$ would you put in place to prevent this situation from happening again?

Look at your Root Causes. For each root cause, you should come up with corrective remedial actions.

E$.$g$.$:$$ Root Cause $=$ No training program on the standard operating procedures for the xxx machine;$$ Control $=$ Implement training program on operating the xxx machine

$($Note: don't need to repeat root cause in this answer $-$ just provide your Controls$)$