Unit IV Case Study Incident Investigation Read Case III located on pages 560-562 in your textbook. Once you have read all of the materials, write an incident report utilizing the Guide for Identifying Causal Factors & Corrective Actions located on pages 156-160 in the textbook. What are your findings? What is/are your recommended corrective action(s)? Who is at fault, if anyone? Could this have been averted? How, or why? The project is required to be a minimum of 500 words (or a minimum of two pages double-spaced). You should follow APA style and referencing guidelines and choose articles from journals available on the CSU Online Library database. You may also use any website as a resource. Information about accessing the Blackboard Grading Rubric for this assignment is provided below I 562 Supervisors' Safety Manual 2. When there are properly marked aisles , truck drivers should be in struct and trained in proper proc edures. 3. Better illumination might also have pr evented installation had been going on for some tim the incident. Because th e, the area should have be e properly illuminated. 4. The area could have been roped off or marked. 5. A rigidly enforced rule against "n o riders" should have been instituted. 6. Installation of seat belts in equi pment of this type is a po ssibility, but because of the nature of th e work, not generally done. Summary Stress to the group that th e incident was caused by a combination of factors: The unsafe conditions were po or lighting, unmarked ai sles, and lack of signs. The unsafe procedures were the driver's "shortcutting" and picking up a rider. The lack of a rule against riders did not exonerate th e driver because he had to make room for the rider an d had to be aware that he was not in the best position to control the truck. Th e rider also must have been aware of the situation when he moved into the se at. CASE IV A truck driver and a millwr ight were in the process of moving a pump, weighing approximately 2,000 lbs, that was mounted on a sk id. They were using a crane, and as the operator mobile was backing up with the cr ane boom elevated at abou a 30-degree angle, the rear t wheels of the crane rose of f the ground. To sate for this overbalanced compencondition, the operator, wh ile proceeding backwards, raised the crane boom to an approximate 60 degr time was observing the 440-volt line. - load on the crane boom ee angle. His co worker and did not notice an ov at the erhead - The crane boom became approximately 18 ft (5.4 m entangled in the overhead 440-volt wires, ) above ground. When the located jumped off the operating operator observed this, platform and was he 440-volt line not injured. Th was not cut, so the crane e insulation boom did What could have been t become energized. done to prevent this inno the fu ture? ciden on the t or similar incidents in Case Studies 561 . ause he e attendant d requested a ride to another part of the facility bec new the drive would be going in that direction. and angled through a cleared The truck ver deviated from his aisle route ed for new machinery installation but darkened a a. This area was being prepar . and at that ti of night was not fully lighted of the cab, suddenly noticed The atten nt, who was sitting on the right side column. Before he could warn the that the truck as headed for a steel building ck and glanced off the column. driver, the lef front corner of the truck stru about 15 ft (4.6 m) The imp t threw the driver against the column and roximately 50 ft (15.3 m) away from t e truck. The truck continued for app to apply the brakes and bring the before the er could get behind the wheel truck to a s p. sion, and severe injuries to the The dri er suffered a skull fracture, concus y to the local hospital, where he left arm a chest. He was taken immediatel r. died from blood clot about three weeks late dent or similar incidents in What I uld have been done to prevent this inci the future n for Case Guide a d Background Informatio III are not designed to carry pasExplain the group, if asked, that these trucks driver must move over, which sengers. n order for a rider to sit on the seat, the n. puts hi or her in an awkward positio Fo11 wing are other pertinent facts: particular area. The isles were not marked in this ipment off" and there were no signs to indicate equ The rea was not "roped wa eing installed. equipped with a seat belt. Th truck was not the second shift (about 10 p.m.). on ed pen hap t den inci ended period of installation had been going on for an ext machinery ti e. p concerning riders. ere were no rules e driver was experienced. ortant factor ssible Solutions for Case III hin the main aisle was an imp the driver wit to stay might have prevented 1. The driver's failure ked aisles mar t. Properly in the inciden from taking a shortcut. 560 Supervisors' Safety Manual The eye shield was evidently not in place. There was no regulation regarding unauthorized use of equipment. The freight handler was not from this foreman's department. A grinding wheel of this type is proper for sharpening bale hooks. Possible Solutions for Case II 1. It should be obvious to the group that the primary cause of this incident was one or more unsafe procedures. The foreman made a mistake by assuming the freight handler knew how to use a bench grinder. The freight handler committed several unsafe procedures. First, he did not use the eye protection that was available. Second, he must have put the hook in a position that let the point slip between the tool rest and the wheel. 2. While you may get such comments from the group as "fire the foreman," the solution should focus on a rigidly enforced rule, "no unauthorized use of equipment." 3. The following procedures can also be set up: a. a policy regarding the sharpening of tools, such as returning tools to the tool crib for sharpening or replacement b. a training program if the freight handlers are to do the sharpening c. a lockout device interlocked with the starting switch to prevent the wheel from operating when the eye shield is not in the proper position Summary Point out to the group that the two cases, Case I and Case II, bring out the importance of unsafe conditions and unsafe procedures as the causes of incidents. Stress the importance of searching for all possible causes. Point out that in Case II there were a number of places where the incident prevention program needed tightening in order to prevent similar incidents in the future. Emphasize the importance of checking procedures and conditions in advance to prevent incidents of this type. Mention the importance of a job safety analysis as a tool for preventing incidents. CASE III A tool truck driver, making his routine crib stops, picked up a crib attendant. Case Studies 559 rder. The equipment should also be marked to indicate to the user that it as been inspected. The date of inspection should be shown. 11 electric tools must be grounded regardless of use or location. ake certain all workers understand that they are not to make repairs to tools or equipment. If tool crib attendants are to maintain equipment, they should be properly trained. mary marize the discussion by pointing out that the unsafe condition must be matedin this case, the improperly wired extension cord. The only way this be done is to test all extensions and make certain there are no other defective s. Once all the electrical equipment has been checked out, some procedures t be set up to make certain the equipment is kept in good condition. Because there are also unsafe procedures involved, provisions must be made elp prevent a recurrence. In this case the tool crib attendant did not folsafe procedures and the maintenance man did not make certain that the ension was okay. Safe procedures should be enacted and enforced. Stress the portance of eliminating all possible causes. ASE freight handler attempted to sharpen the point of a bale hook on a grinding heel. The foreman of the depai tuient saw him, but assumed that "anybody n use a little bench grinder." The freight handler caught the point of his hook etween the tool rest and the wheel. The wheel broke and a large piece of it truck him in the face. He was permanently disabled by the injury. What could have been done to prevent this incident or similar future ncidents? uide and Background Information for Case II Explain to the group, if asked, that this bench grinder was properly guarded and mounted. Also, the wheel was properly tested before mounting. Following are other pertinent facts: The tool rest was properly set 1/4-in from the wheel. Eye protection (goggles) was available, but obviously not used. 110 Supervisors.' SateDi Manual Causal Factors 0 Y N Comment Possible Corrective Actions Recommended Corrective Actions Provide emergency equipment as required. 3.10 Was emergency equipment specified for this job for example. emergency showers. eyewash fountains)? If yes. answer the following. If no, proceed to Part 4. 0 Y N Y 0 N Y 0 N 0 A. Was emergency equipment readily available? Install emergency equipment at appropriate locations. B. Was emergency equipment properly used? Incorporate use of emergency equipment in job procedures. Establish inspection/monitoring system for emergency equipment. Provide for immediate repair of defects. C. Did emergency equipment function properly? 3.11 List other causal factors in 'Comment' column. PART 4 MANAGEMENT 0 Y N 4.0 WAS A MANAGEMENT SYSTEM DEFECT A CONTRIBUTING FACTOR? If yes, answer the following. If no. STOP. Your causal factor identification exercise is complete. Causal Factors 0 Y Y N Improve supervisor capability in hazard recognition and reporting procedures. N 4.2 Was there a failure by supervision to detect or correct deviations from job procedure? Review job safety analysis and job procedures. Increase supervisor monitoring. Correct deviations. 4.3 Was there a supervisor/ employee review of hazards and job procedures for tasks performed infrequently? (Not applicable to all incidents.) Establish a procedure that requires a review of hazards and job procedures (preventive actions) for tasks performed infrequently. 4.4 Was supervisor responsibility and accountability adequately defined and understood? Define and communicate supervisor responsibility and accountability. Test for understandability and acceptance. N 4.5 Was supervisor adequately trained to fulfill assigned responsibility in accident prevention? Train supervisors in accident prevention fundamentals. N 4.6 Was there a failure to initiate corrective action for a known hazardous condition that contributed to this incident? Review management safety policy and level of risk acceptance. Establish priorities based on potential severity and probability of recurrence. Review procedure and responsibility to initiate and carry out corrective actions. Monitor progress. 0 Y N 0 Y N 0 Y 0 Y Possible Corrective Actions Was there a failure by supervision to detect, anticipate, or report a hazardous condition? 0 0 Figure 7-3. 4.1 Comment 4.7 List other causal factors in 'Comment' column. Concluded. Recommended Corrective Actions Chapter 7 Incident Investigation I Causal Factors Comment Possible Corrective Actions 3.2 Was employee(s) mentally and physically capable of performing the job? Review employee requirements for the job. Improve employee selection. Remove or transfer employees who are temporarily, either mentally or physically, incapable of performing the job. 3.3 Were any tasks in the job procedure too difficult to perform (for example, excessive concentration or physical demands)? Change job design and procedures. aE 3.4 Change job design and procedures. 0 3.5 List other causal factors in 'Comment" column. Y 0E Y Y 0 N N Is the job structured to encourage or require devialion from job procedures (for example, incentive, piecework, work pace)? Recommended Corrective Actions 3.6 WAS LACK OF PERSONAL PROTECTIVE EQUIPMENT OR EMERGENCY EQUIPMENT A CONTRIBUTING FACTOR IN THE INJURY? I Y II If yes, answer the following. If no, proceed to Part 4. Note: The following causal factors relate to the injury. Causal Factors 3.7 Was appropriate personal protective equipment (PPE) specified for the task or job? Comment Possible Corrective Actions Review methods to specify PPE requirements. If yes, answer A, B, and C. If no, proceed to 3.8. Y 1 59 A. Was appropriate PPE available? Provide appropriate PPE. Review purchasing and distribution procedures. B. Did employee(s) know that wearing specified PPE was required? Review job procedures. Improve job instruction. C. Did employee(s) know how to use and maintain the PPE? Improve job instruction. 3.8 Was the PPE used properly when the injury occurred? Determine why and take appropriate action. Implement procedures to monitor and enforce use of PPE. 3.9 Was the PPE adequate? Review PPE requirements. Check standards, specifications, and certification of the PPE. N ur 7 3. Continued. - Recommended Corrective Actions 1 58 Supervisors' Safety Manual Causal Factors B. Was employee(s) informed of the job procedures for dealing with the hazardous condition as an interim action? Y Y Y Possible Corrective Actions Review job procedures and instruction. Provide guardrails, barricades, barriers, warning lights, signs, or signals. 0 2.4 Was the hazardous condition created by the location/ position of equipment/ material visible to employee(s)? Change lighting or layout to increase visibility of equipment. Provide guardrails, barricades, barriers, warning lights, signs or signals, floor stripes, etc. 0 2.5 Was there sufficient workspace? Review workspace requirements and modify as required. 2.6 Were environmental conditions a contributing factor (for example, illumination, noise levels, air contaminant, temperature extremes, ventilation, vibration, radiation)? Monitor, or periodically check, environmental conditions as milked. Check results against acceptable levels. Initiate action for those found unacceptable. N N N 0LI N Y 0 Recommended Corrective Actions Review job procedures for hazand avoidance. Review supervisory responsibility. Improve employee/supervisor communications. Take action to remove or minimize hazard. 2.3 Was employee(s) supposed to be in the vicinity of the equipment/material? 0 Y Comment 2.7 List other causal factors in "Comment" column. PART 3 PEOPLE 0LI Y N 3.0 WAS THE JOB PROCEDURE(S) USED A CONTRIBUTING FACTOR? If yes, answer the following. If no, proceed to Part 3.6. Causal Factors 0 Y N 3.1 Was there a written or known procedure (rules) for this job? Comment Possible Corrective Actions Perform job safety analysis and develop sate job procedures. If yes, answer A, B, and C. If no, proceed to 3.2. A. Did job procedures anticipate the factors that contributed to the accident? Perform job safety analysis and change job procedures. 0 B. Did employee(s) know the job procedure? Improve job instruction. Train employees in correct job procedures. N C. Did employee(s) deviate from the known job procedure? Determine why. Encourage all employees to report problems with an established procedure to supervisor. Review job procedure and modify if necessary. Counsel or discipline employee. Provide closer supervision. 0 Y Y N N 0 Y Figure 7-3. Continued. Recommended Corrective Actions Chapter 7 Incident Investigation 1 57 Causal Factors O Y O 1.7 N N Y N Y N O Comment lid employee(s) know here to obtain equipment/ ool(s)/material required for he job? Possible Corrective Actions Recommended Corrective Actions Review procedures for storage, access, delivery, or distribution. Review job procedures for obtaining equipment/tool(s)/ material. 1.8 Was substitute equipment/ tool(s)/material used in place of correct one? Provide correct equipment /tool(s)/material. Warn against use of substitutes in job procedures and in job instruction. Did the design of the create operator stress or encourage operator error? Review human factors engineering principles. Alter equipment/ tool(s) to make it more compatible with human capability and limitations. Review purchasing procedures and specifications. Check out new equipment and job procedures involving new equipment before putting into service. Encourage employees to report potential hazardous conditions created by equipment design. 10 Did the general design or quality of the equipment/ tool(s) contribute to a hazardous condition? Review criteria in codes, standards, specifications, and regulations. Establish new criteria as required. 11 List other causal factors in "Comment' column. 'ART 2 ENVIRONMENT e .0 WAS THE LOCATION OF EQUIPMENT/MATERIALS/EMPLOYEE(S) A CONTRIBUTING FACTOR? If yes, answer the following.lf no, proceed to Part 3. Causal Factors Comment Possible Corrective Actions O Y Y 2.1 N O N Did the location/position of equipment/material/ employee(s) contribute to a hazardous condition? 2.2 Was the hazardous condition recognized? If yes, answer A and B. If no, proceed to 2.3. Y N A. Was the hazardous condition reported? gure 7' 3. Continued. Perform job safety analysis. Review job procedures. Change the location, position, or layout of the equipment. Change position of employee(s). Provide guardrails, barricades, barriers, warning lights, signs, or signals. Perform Oti safety analysis. Improve employee ability to recognize existing or potential hazardous conditions. Provide test equipment, as required, to detect hazard. Review any change or modification of equipment/tools/materials. Train employees in reporting procedures. Stress individual acceptance of responsibility. Recommended Corrective Actions 1 56 Supervisors' Safety Manual GUIDE FOR IDENTIFYING CAUSAL FACTORS & CORRECTIVE ACTIONS Case Number Answer questions by placing an X in the "V" circle or box for yes or in the "N" or box for no. PART 1 EQUIPMENT 0 El 1.0 WAS A HAZARDOUS CONDITION[S] A CONTRIBUTING FACTOR? If yes, answer the following. If no, proceed to Part 2. N Y Causal Factors 1.1 N Y 0 N Y 0 Did any defect(s) in equipment/tool(s)/material contribute to hazardous condition(s)? 0 Y N 0 Y N 0 Y N 0 Y N 0 Y N Possible Corrective Actions Recommended Corrective Actions Review procedure for inspecting, reporting, maintaining, repairing, replacing, or recalling defective equipment/tool(s)/ material used. If yes, answer A and B. If no, proceed to 1.3. Perform job safety analysis. Improve employee ability to recognize existing or potential hazardous conditions. Provide test equipment, as required, to detect hazard. Review any change or modification of equipmentitool(s)/material. A. Was the hazardous conditions(s) reported? Train employees in reporting procedures. Stress individual acceptance of responsibility. B. Was employee(s) informed of the hazardous condition(s) and the job procedures for dealing with it as an interim measure? Review job procedures for hazard avoidance. Review supervisory responsibility. Improve supervisor/employee communications. Take action to remove or minimize hazard. 1.2 Was the hazardous condition(s) recognized? N Y Comment 1.3 Was there an equipment inspection procedure(s) to detect the hazardous condition(s)? Develop and adopt procedures (for example, an inspection system) to detect hazardous conditions. Conduct test. 1.4 Did the existing equipment inspection procedure(s) detect the hazardous condition(s)? Review procedures. Change f requency or comprehensiveness. Provide test equipment as required. Improve employee ability to detect defects and hazardous conditions. Change job procedures as required. 1.5 Was the correct equipment/ tool(s)/material used? Specify correct equipment/ tool(s)/material in job procedures. 1.6 Was the correct equipment/tool(s)/material readily available? Provide correct equipment/tool(s)/material. Review purchasing specifications and procedures. Anticipate future requirements. Figure 7-3. A causal factors analysis breaks down each incident into areas that contribute to an injury: equipment, environment, personnel, and management. By answering each question and placing an X in either a circle or a box will determine that item's relationship to the injury as a causal factor. Chapter 7 Incident Investigation 155 Ind ent Investigation 22. Task and activity at time of incident. First, record the general type of task the employee was performing when the incident occurred (for example, ipe fitting, lathe maintenance, or operating a punch press). Then record e specific activity in which the employee was engaged when the incident ccurred (for example, oiling shaft, bolting pipe flanges, or removing mate'al from the press). Check the appropriate box to indicate whether the jured employee was working alone, with a co-worker, or with a crew. 23. sture of employee. Record the injured worker's posture in relation to the rroundings at the time of the incident (for example, standing on a ladd r, squatting under a conveyor, or standing at a machine). 24. S ervision at time of accident. Indicate whether, at the time of incident, t injured employee was directly supervised, indirectly supervised, or not ervised. If appropriate, indicate whether supervision was not feasible e time. Deter ning Causal Factors (Root Causes) An imp tant part of any incident investigation is the causal factors analysis (root ca es), or determining those causes that directly contributed to the incident. Id tifying all factors that came into play to cause an injury or near miss and con ting those items is the only way to ensure proper steps have been taken to event a recurrence. In using a causal factors analysis, the opportunity to identi all of the facts, and not focus on blame is established. Causal factors to any inc ent are grouped into four main areas: equipment, environment, personnel, an management. The ca sal factors analysis approach to identifying those areas that have a causative r ationship to the incident greatly improves the organization's chances of preventi future similar incidents. In addition, this approach to incident invesligation allo s for more employee involvement as well as objectivity in determining the root ause of the incident (Figure 7-3). 25. Causal actors. Record causal factors (events and conditions that contributed to e incident) that were identified by use of the causal factors analysis the list. 26. Correc e actions. Describe recommended corrective actions to be taken after th incident to prevent recurrence. These include immediate, temporary, or nterim actions (for example, removed oil from floor) and permanent ac ns (for example, repaired leaking oil line). Unit IV Case Study Incident Investigation Read Case III located on pages 560-562 in your textbook. Once you have read all of the materials, write an incident report utilizing the Guide for Identifying Causal Factors & Corrective Actions located on pages 156-160 in the textbook. What are your findings? What is/are your recommended corrective action(s)? Who is at fault, if anyone? Could this have been averted? How, or why? The project is required to be a minimum of 500 words (or a minimum of two pages double-spaced). You should follow APA style and referencing guidelines and choose articles from journals available on the CSU Online Library database. You may also use any website as a resource. Information about accessing the Blackboard Grading Rubric for this assignment is provided below Unit IV Case Study Incident Investigation Read Case III located on pages 560-562 in your textbook. Once you have read all of the materials, write an incident report utilizing the Guide for Identifying Causal Factors & Corrective Actions located on pages 156-160 in the textbook. What are your findings? What is/are your recommended corrective action(s)? Who is at fault, if anyone? Could this have been averted? How, or why? The project is required to be a minimum of 500 words (or a minimum of two pages double-spaced). You should follow APA style and referencing guidelines and choose articles from journals available on the CSU Online Library database. You may also use any website as a resource. Information about accessing the Blackboard Grading Rubric for this assignment is provided below I 562 Supervisors' Safety Manual 2. When there are properly marked aisles , truck drivers should be in struct and trained in proper proc edures. 3. Better illumination might also have pr evented installation had been going on for some tim the incident. Because th e, the area should have be e properly illuminated. 4. The area could have been roped off or marked. 5. A rigidly enforced rule against "n o riders" should have been instituted. 6. Installation of seat belts in equi pment of this type is a po ssibility, but because of the nature of th e work, not generally done. Summary Stress to the group that th e incident was caused by a combination of factors: The unsafe conditions were po or lighting, unmarked ai sles, and lack of signs. The unsafe procedures were the driver's "shortcutting" and picking up a rider. The lack of a rule against riders did not exonerate th e driver because he had to make room for the rider an d had to be aware that he was not in the best position to control the truck. Th e rider also must have been aware of the situation when he moved into the se at. CASE IV A truck driver and a millwr ight were in the process of moving a pump, weighing approximately 2,000 lbs, that was mounted on a sk id. They were using a crane, and as the operator mobile was backing up with the cr ane boom elevated at abou a 30-degree angle, the rear t wheels of the crane rose of f the ground. To sate for this overbalanced compencondition, the operator, wh ile proceeding backwards, raised the crane boom to an approximate 60 degr time was observing the 440-volt line. - load on the crane boom ee angle. His co worker and did not notice an ov at the erhead - The crane boom became approximately 18 ft (5.4 m entangled in the overhead 440-volt wires, ) above ground. When the located jumped off the operating operator observed this, platform and was he 440-volt line not injured. Th was not cut, so the crane e insulation boom did What could have been t become energized. done to prevent this inno the fu ture? ciden on the t or similar incidents in Case Studies 561 . ause he e attendant d requested a ride to another part of the facility bec new the drive would be going in that direction. and angled through a cleared The truck ver deviated from his aisle route ed for new machinery installation but darkened a a. This area was being prepar . and at that ti of night was not fully lighted of the cab, suddenly noticed The atten nt, who was sitting on the right side column. Before he could warn the that the truck as headed for a steel building ck and glanced off the column. driver, the lef front corner of the truck stru about 15 ft (4.6 m) The imp t threw the driver against the column and roximately 50 ft (15.3 m) away from t e truck. The truck continued for app to apply the brakes and bring the before the er could get behind the wheel truck to a s p. sion, and severe injuries to the The dri er suffered a skull fracture, concus y to the local hospital, where he left arm a chest. He was taken immediatel r. died from blood clot about three weeks late dent or similar incidents in What I uld have been done to prevent this inci the future n for Case Guide a d Background Informatio III are not designed to carry pasExplain the group, if asked, that these trucks driver must move over, which sengers. n order for a rider to sit on the seat, the n. puts hi or her in an awkward positio Fo11 wing are other pertinent facts: particular area. The isles were not marked in this ipment off" and there were no signs to indicate equ The rea was not "roped wa eing installed. equipped with a seat belt. Th truck was not the second shift (about 10 p.m.). on ed pen hap t den inci ended period of installation had been going on for an ext machinery ti e. p concerning riders. ere were no rules e driver was experienced. ortant factor ssible Solutions for Case III hin the main aisle was an imp the driver wit to stay might have prevented 1. The driver's failure ked aisles mar t. Properly in the inciden from taking a shortcut. 560 Supervisors' Safety Manual The eye shield was evidently not in place. There was no regulation regarding unauthorized use of equipment. The freight handler was not from this foreman's department. A grinding wheel of this type is proper for sharpening bale hooks. Possible Solutions for Case II 1. It should be obvious to the group that the primary cause of this incident was one or more unsafe procedures. The foreman made a mistake by assuming the freight handler knew how to use a bench grinder. The freight handler committed several unsafe procedures. First, he did not use the eye protection that was available. Second, he must have put the hook in a position that let the point slip between the tool rest and the wheel. 2. While you may get such comments from the group as "fire the foreman," the solution should focus on a rigidly enforced rule, "no unauthorized use of equipment." 3. The following procedures can also be set up: a. a policy regarding the sharpening of tools, such as returning tools to the tool crib for sharpening or replacement b. a training program if the freight handlers are to do the sharpening c. a lockout device interlocked with the starting switch to prevent the wheel from operating when the eye shield is not in the proper position Summary Point out to the group that the two cases, Case I and Case II, bring out the importance of unsafe conditions and unsafe procedures as the causes of incidents. Stress the importance of searching for all possible causes. Point out that in Case II there were a number of places where the incident prevention program needed tightening in order to prevent similar incidents in the future. Emphasize the importance of checking procedures and conditions in advance to prevent incidents of this type. Mention the importance of a job safety analysis as a tool for preventing incidents. CASE III A tool truck driver, making his routine crib stops, picked up a crib attendant. Case Studies 559 rder. The equipment should also be marked to indicate to the user that it as been inspected. The date of inspection should be shown. 11 electric tools must be grounded regardless of use or location. ake certain all workers understand that they are not to make repairs to tools or equipment. If tool crib attendants are to maintain equipment, they should be properly trained. mary marize the discussion by pointing out that the unsafe condition must be matedin this case, the improperly wired extension cord. The only way this be done is to test all extensions and make certain there are no other defective s. Once all the electrical equipment has been checked out, some procedures t be set up to make certain the equipment is kept in good condition. Because there are also unsafe procedures involved, provisions must be made elp prevent a recurrence. In this case the tool crib attendant did not folsafe procedures and the maintenance man did not make certain that the ension was okay. Safe procedures should be enacted and enforced. Stress the portance of eliminating all possible causes. ASE freight handler attempted to sharpen the point of a bale hook on a grinding heel. The foreman of the depai tuient saw him, but assumed that "anybody n use a little bench grinder." The freight handler caught the point of his hook etween the tool rest and the wheel. The wheel broke and a large piece of it truck him in the face. He was permanently disabled by the injury. What could have been done to prevent this incident or similar future ncidents? uide and Background Information for Case II Explain to the group, if asked, that this bench grinder was properly guarded and mounted. Also, the wheel was properly tested before mounting. Following are other pertinent facts: The tool rest was properly set 1/4-in from the wheel. Eye protection (goggles) was available, but obviously not used. 110 Supervisors.' SateDi Manual Causal Factors 0 Y N Comment Possible Corrective Actions Recommended Corrective Actions Provide emergency equipment as required. 3.10 Was emergency equipment specified for this job for example. emergency showers. eyewash fountains)? If yes. answer the following. If no, proceed to Part 4. 0 Y N Y 0 N Y 0 N 0 A. Was emergency equipment readily available? Install emergency equipment at appropriate locations. B. Was emergency equipment properly used? Incorporate use of emergency equipment in job procedures. Establish inspection/monitoring system for emergency equipment. Provide for immediate repair of defects. C. Did emergency equipment function properly? 3.11 List other causal factors in 'Comment' column. PART 4 MANAGEMENT 0 Y N 4.0 WAS A MANAGEMENT SYSTEM DEFECT A CONTRIBUTING FACTOR? If yes, answer the following. If no. STOP. Your causal factor identification exercise is complete. Causal Factors 0 Y Y N Improve supervisor capability in hazard recognition and reporting procedures. N 4.2 Was there a failure by supervision to detect or correct deviations from job procedure? Review job safety analysis and job procedures. Increase supervisor monitoring. Correct deviations. 4.3 Was there a supervisor/ employee review of hazards and job procedures for tasks performed infrequently? (Not applicable to all incidents.) Establish a procedure that requires a review of hazards and job procedures (preventive actions) for tasks performed infrequently. 4.4 Was supervisor responsibility and accountability adequately defined and understood? Define and communicate supervisor responsibility and accountability. Test for understandability and acceptance. N 4.5 Was supervisor adequately trained to fulfill assigned responsibility in accident prevention? Train supervisors in accident prevention fundamentals. N 4.6 Was there a failure to initiate corrective action for a known hazardous condition that contributed to this incident? Review management safety policy and level of risk acceptance. Establish priorities based on potential severity and probability of recurrence. Review procedure and responsibility to initiate and carry out corrective actions. Monitor progress. 0 Y N 0 Y N 0 Y 0 Y Possible Corrective Actions Was there a failure by supervision to detect, anticipate, or report a hazardous condition? 0 0 Figure 7-3. 4.1 Comment 4.7 List other causal factors in 'Comment' column. Concluded. Recommended Corrective Actions Chapter 7 Incident Investigation I Causal Factors Comment Possible Corrective Actions 3.2 Was employee(s) mentally and physically capable of performing the job? Review employee requirements for the job. Improve employee selection. Remove or transfer employees who are temporarily, either mentally or physically, incapable of performing the job. 3.3 Were any tasks in the job procedure too difficult to perform (for example, excessive concentration or physical demands)? Change job design and procedures. aE 3.4 Change job design and procedures. 0 3.5 List other causal factors in 'Comment" column. Y 0E Y Y 0 N N Is the job structured to encourage or require devialion from job procedures (for example, incentive, piecework, work pace)? Recommended Corrective Actions 3.6 WAS LACK OF PERSONAL PROTECTIVE EQUIPMENT OR EMERGENCY EQUIPMENT A CONTRIBUTING FACTOR IN THE INJURY? I Y II If yes, answer the following. If no, proceed to Part 4. Note: The following causal factors relate to the injury. Causal Factors 3.7 Was appropriate personal protective equipment (PPE) specified for the task or job? Comment Possible Corrective Actions Review methods to specify PPE requirements. If yes, answer A, B, and C. If no, proceed to 3.8. Y 1 59 A. Was appropriate PPE available? Provide appropriate PPE. Review purchasing and distribution procedures. B. Did employee(s) know that wearing specified PPE was required? Review job procedures. Improve job instruction. C. Did employee(s) know how to use and maintain the PPE? Improve job instruction. 3.8 Was the PPE used properly when the injury occurred? Determine why and take appropriate action. Implement procedures to monitor and enforce use of PPE. 3.9 Was the PPE adequate? Review PPE requirements. Check standards, specifications, and certification of the PPE. N ur 7 3. Continued. - Recommended Corrective Actions 1 58 Supervisors' Safety Manual Causal Factors B. Was employee(s) informed of the job procedures for dealing with the hazardous condition as an interim action? Y Y Y Possible Corrective Actions Review job procedures and instruction. Provide guardrails, barricades, barriers, warning lights, signs, or signals. 0 2.4 Was the hazardous condition created by the location/ position of equipment/ material visible to employee(s)? Change lighting or layout to increase visibility of equipment. Provide guardrails, barricades, barriers, warning lights, signs or signals, floor stripes, etc. 0 2.5 Was there sufficient workspace? Review workspace requirements and modify as required. 2.6 Were environmental conditions a contributing factor (for example, illumination, noise levels, air contaminant, temperature extremes, ventilation, vibration, radiation)? Monitor, or periodically check, environmental conditions as milked. Check results against acceptable levels. Initiate action for those found unacceptable. N N N 0LI N Y 0 Recommended Corrective Actions Review job procedures for hazand avoidance. Review supervisory responsibility. Improve employee/supervisor communications. Take action to remove or minimize hazard. 2.3 Was employee(s) supposed to be in the vicinity of the equipment/material? 0 Y Comment 2.7 List other causal factors in "Comment" column. PART 3 PEOPLE 0LI Y N 3.0 WAS THE JOB PROCEDURE(S) USED A CONTRIBUTING FACTOR? If yes, answer the following. If no, proceed to Part 3.6. Causal Factors 0 Y N 3.1 Was there a written or known procedure (rules) for this job? Comment Possible Corrective Actions Perform job safety analysis and develop sate job procedures. If yes, answer A, B, and C. If no, proceed to 3.2. A. Did job procedures anticipate the factors that contributed to the accident? Perform job safety analysis and change job procedures. 0 B. Did employee(s) know the job procedure? Improve job instruction. Train employees in correct job procedures. N C. Did employee(s) deviate from the known job procedure? Determine why. Encourage all employees to report problems with an established procedure to supervisor. Review job procedure and modify if necessary. Counsel or discipline employee. Provide closer supervision. 0 Y Y N N 0 Y Figure 7-3. Continued. Recommended Corrective Actions Chapter 7 Incident Investigation 1 57 Causal Factors O Y O 1.7 N N Y N Y N O Comment lid employee(s) know here to obtain equipment/ ool(s)/material required for he job? Possible Corrective Actions Recommended Corrective Actions Review procedures for storage, access, delivery, or distribution. Review job procedures for obtaining equipment/tool(s)/ material. 1.8 Was substitute equipment/ tool(s)/material used in place of correct one? Provide correct equipment /tool(s)/material. Warn against use of substitutes in job procedures and in job instruction. Did the design of the create operator stress or encourage operator error? Review human factors engineering principles. Alter equipment/ tool(s) to make it more compatible with human capability and limitations. Review purchasing procedures and specifications. Check out new equipment and job procedures involving new equipment before putting into service. Encourage employees to report potential hazardous conditions created by equipment design. 10 Did the general design or quality of the equipment/ tool(s) contribute to a hazardous condition? Review criteria in codes, standards, specifications, and regulations. Establish new criteria as required. 11 List other causal factors in "Comment' column. 'ART 2 ENVIRONMENT e .0 WAS THE LOCATION OF EQUIPMENT/MATERIALS/EMPLOYEE(S) A CONTRIBUTING FACTOR? If yes, answer the following.lf no, proceed to Part 3. Causal Factors Comment Possible Corrective Actions O Y Y 2.1 N O N Did the location/position of equipment/material/ employee(s) contribute to a hazardous condition? 2.2 Was the hazardous condition recognized? If yes, answer A and B. If no, proceed to 2.3. Y N A. Was the hazardous condition reported? gure 7' 3. Continued. Perform job safety analysis. Review job procedures. Change the location, position, or layout of the equipment. Change position of employee(s). Provide guardrails, barricades, barriers, warning lights, signs, or signals. Perform Oti safety analysis. Improve employee ability to recognize existing or potential hazardous conditions. Provide test equipment, as required, to detect hazard. Review any change or modification of equipment/tools/materials. Train employees in reporting procedures. Stress individual acceptance of responsibility. Recommended Corrective Actions 1 56 Supervisors' Safety Manual GUIDE FOR IDENTIFYING CAUSAL FACTORS & CORRECTIVE ACTIONS Case Number Answer questions by placing an X in the "V" circle or box for yes or in the "N" or box for no. PART 1 EQUIPMENT 0 El 1.0 WAS A HAZARDOUS CONDITION[S] A CONTRIBUTING FACTOR? If yes, answer the following. If no, proceed to Part 2. N Y Causal Factors 1.1 N Y 0 N Y 0 Did any defect(s) in equipment/tool(s)/material contribute to hazardous condition(s)? 0 Y N 0 Y N 0 Y N 0 Y N 0 Y N Possible Corrective Actions Recommended Corrective Actions Review procedure for inspecting, reporting, maintaining, repairing, replacing, or recalling defective equipment/tool(s)/ material used. If yes, answer A and B. If no, proceed to 1.3. Perform job safety analysis. Improve employee ability to recognize existing or potential hazardous conditions. Provide test equipment, as required, to detect hazard. Review any change or modification of equipmentitool(s)/material. A. Was the hazardous conditions(s) reported? Train employees in reporting procedures. Stress individual acceptance of responsibility. B. Was employee(s) informed of the hazardous condition(s) and the job procedures for dealing with it as an interim measure? Review job procedures for hazard avoidance. Review supervisory responsibility. Improve supervisor/employee communications. Take action to remove or minimize hazard. 1.2 Was the hazardous condition(s) recognized? N Y Comment 1.3 Was there an equipment inspection procedure(s) to detect the hazardous condition(s)? Develop and adopt procedures (for example, an inspection system) to detect hazardous conditions. Conduct test. 1.4 Did the existing equipment inspection procedure(s) detect the hazardous condition(s)? Review procedures. Change f requency or comprehensiveness. Provide test equipment as required. Improve employee ability to detect defects and hazardous conditions. Change job procedures as required. 1.5 Was the correct equipment/ tool(s)/material used? Specify correct equipment/ tool(s)/material in job procedures. 1.6 Was the correct equipment/tool(s)/material readily available? Provide correct equipment/tool(s)/material. Review purchasing specifications and procedures. Anticipate future requirements. Figure 7-3. A causal factors analysis breaks down each incident into areas that contribute to an injury: equipment, environment, personnel, and management. By answering each question and placing an X in either a circle or a box will determine that item's relationship to the injury as a causal factor. Chapter 7 Incident Investigation 155 Ind ent Investigation 22. Task and activity at time of incident. First, record the general type of task the employee was performing when the incident occurred (for example, ipe fitting, lathe maintenance, or operating a punch press). Then record e specific activity in which the employee was engaged when the incident ccurred (for example, oiling shaft, bolting pipe flanges, or removing mate'al from the press). Check the appropriate box to indicate whether the jured employee was working alone, with a co-worker, or with a crew. 23. sture of employee. Record the injured worker's posture in relation to the rroundings at the time of the incident (for example, standing on a ladd r, squatting under a conveyor, or standing at a machine). 24. S ervision at time of accident. Indicate whether, at the time of incident, t injured employee was directly supervised, indirectly supervised, or not ervised. If appropriate, indicate whether supervision was not feasible e time. Deter ning Causal Factors (Root Causes) An imp tant part of any incident investigation is the causal factors analysis (root ca es), or determining those causes that directly contributed to the incident. Id tifying all factors that came into play to cause an injury or near miss and con ting those items is the only way to ensure proper steps have been taken to event a recurrence. In using a causal factors analysis, the opportunity to identi all of the facts, and not focus on blame is established. Causal factors to any inc ent are grouped into four main areas: equipment, environment, personnel, an management. The ca sal factors analysis approach to identifying those areas that have a causative r ationship to the incident greatly improves the organization's chances of preventi future similar incidents. In addition, this approach to incident invesligation allo s for more employee involvement as well as objectivity in determining the root ause of the incident (Figure 7-3). 25. Causal actors. Record causal factors (events and conditions that contributed to e incident) that were identified by use of the causal factors analysis the list. 26. Correc e actions. Describe recommended corrective actions to be taken after th incident to prevent recurrence. These include immediate, temporary, or nterim actions (for example, removed oil from floor) and permanent ac ns (for example, repaired leaking oil line). Unit IV Case Study Incident Investigation Read Case III located on pages 560-562 in your textbook. Once you have read all of the materials, write an incident report utilizing the Guide for Identifying Causal Factors & Corrective Actions located on pages 156-160 in the textbook. What are your findings? What is/are your recommended corrective action(s)? Who is at fault, if anyone? Could this have been averted? How, or why? The project is required to be a minimum of 500 words (or a minimum of two pages double-spaced). You should follow APA style and referencing guidelines and choose articles from journals available on the CSU Online Library database. You may also use any website as a resource. Information about accessing the Blackboard Grading Rubric for this assignment is provided below