Procedures In Accident Investigation And Reporting Practiced Construction Essay
Chapter 1 Introduction
Background of the Problem
Section 15 (1) of the Occupational Safety and Health Act 1994 (Act 514) says “It shall be the duty of every employer and every self-employed person to ensure, so far as is practicable, the safety, health and welfare at work of all his employees”. It is a well known fact that no matter how good and well established a site safety program is, accidents do happened from time to time. There are many factors that contribute to these accidents, not to mention the degree of severity and it is the job of the Safety and Health Officer to determine precisely what really happens when an accident occur.
It is important to conduct accident investigations with accident prevention in mind. Investigations are NOT to place blame. Too often investigations degenerate into fingerprinting, blame fixing and fault-finding exercises because the persons involved do not understand the reasons for or real value which can be gained from good accident investigations. 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 also important to have a standardized and proper structure of accident investigation and reporting in order to get an accurate picture of what really transpired in an accident. Inaccuracies will most likely point to the wrong cause of accidents and this will inadvertently cause errors in deduction and also the wrong recommendations being made for the mitigation steps. In order to get a true representation and a clear picture of what causes an accident, there must be a standard in carrying out investigation, standard perfoma to be used, a set of general questions to be asked and equipments to help a Safety and Health Officer in carrying out his duties.
By having a standard operating procedure for accident investigation and reporting, and with the help from the Department of Safety and Health (DOSH), statistics could be derived and major contributors to accidents could be identified and properly studied mitigation steps could be formulated. This will undoubtedly benefit the industry as a whole.
Problem Statement
What is an accident? Accident can be defined as an unplanned and uncontrolled event that led to, or could have led to injury to persons, damage to property/plant/equipment, and impairment to the environment or some other loss to the company.
Problem that was observed at the Senai – Pasir Gudang – Desaru Expressway with regards to accident reporting is the communication breakdown that occurs; where the personnel involved does not know whom to call in a case of an emergency or fatality. Could this be because of insufficient training? Neglected induction courses? Ineffective tool-box meeting? This paper will try to find the root cause of this communication breakdown and in doing so will hopefully improve on the accident reporting and investigation procedures.
The Research Framework
We need to have a good understanding of the existing research results, on which to build new and relevant research activities for Occupational Safety and Health approaches. We also need to understand the appropriate research approaches for producing new knowledge. To make these activities manageable, we use a research framework. A research framework defines the categories of outputs that research can produce. It also defines a set of different research activities. Moreover, it defines what kind of research activities can be used to produce specific outputs.
In tackling the questions brought herewith, a combination of primary data obtained from real research undertaken at site in the form of questionnaires and interviews involving personnel from specific department of a company and secondary data from materials taken from magazines, newspapers, internet etc will be used. Data derived from both of these data acquisition activities will hopefully answers some of the questions to the problems faced by the Safety Officers and Supervisors at site.
Objective of Study
The objectives of the study undertaken are to:
To standardized the accident or incident reporting and investigating procedures practiced at site
To address any shortcomings concluded from the study undertaken
To ascertain the accident report mechanism currently practiced at site
Research Questions
Special consideration has to be taken in asking questions about accidents reporting and investigation. In order to ascertain where the communication breakdown occurs in an event of an accident, the main question that needs to be asked is:
Do you know whom to call in case of an emergency?
Is the Emergency Contact List prominently displayed at the site office or the work place?
Have you been given proper induction training before starting work?
Have you been given talks on what to do in an accident at your workplace?
These questions have to be asked to workers of many ethnicity and considerations have to be given to the sensitivity of different cultures and religions.
Significance of Study
It is hoped that after conclusions have been made from the study undertaken, the accident reporting and investigation procedures could be further improve in line with the Occupational Safety and Health Management principles.
Scope of Study
This study encompasses the accident reporting and investigation procedures practiced at the Senai – Pasir Gudang – Desaru Expressway project. Two fatalities have been recorded at the worksite thus far and improvement to the overall work safety is of paramount importance to avoid any more fatalities.
Accidents can yield positive results if we learn from what went wrong and prevent a reoccurrence. To achieve this we need to investigate the circumstances that led to the accident and report, record, analyses and correct its effects.
Definition of Terms
Below are the definitions of terms used for the purpose of this study.
SAFETY AND HEALTH OFFICER – a person appointed by the contractor at site to be responsible for maintaining safety and protection against accidents. This person shall have the authority to issue instructions and take proactive measures to prevent accidents.
HOT WORK – use of open flames, other heat sources and/or spark-producing devices where there is a potential for explosion or fire.
INCIDENT – an undesirable event, which has the potential to cause a serious accident.
LOSS PREVENTION – a before-the-loss procedure designed to identify and correct potential causes of accidents before they result in actual injuries or financial loss.
MATERIAL SAFETY DATA SHEET – a summary sheet supplied by the chemical manufacturers that identifies the hazards, proper handling procedures and emergency treatment for a particular chemical.
REGULATION – a rule, ordinance, law, legal regulation or device by which conduct or performances is controlled.
SAFE WORK PERMIT – a permit issued as a written record by which the employer or employee in charge of a unit, equipment, building or area authorizes a worker and/or crew to do a specific job at the worksite. It identifies the safe work practices required for the type of work to be performed in the specified job location.
SERIOUS INCIDENT – a life endangering event to people, property and environment, such as major collapse of structure or plant or any incident causing multiple injuries to workers.
SUB-CONTRACTOR – a business, firm, partnership, consultant or individual hired by the Contractor to perform a specific task or job; or any business, firm, partnership, consultant or individual, other than employees of the Contractor, working on or around Contractor’s property.
VISITOR – any person temporarily on the worksite who is not regularly involved in the daily worksite activities. This includes, but is not limited to, delivery personnel, invited guest, the general public, etc.
WILL, SHALL OR MUST – to be understood as a mandatory condition.
Chapter 2 Accident Investigation and Reporting
Introduction
The failure of people, equipment, supplies, or surroundings to behave or react as expected causes most of them. Accident investigations determine how and why these failures occur. By using the information gained through an investigation, a similar, or perhaps more disastrous, accident may be prevented. It is important to conduct accident investigations with prevention in mind.
Definition of Accident Investigation and Reporting
The term “accident” can be defined as an unplanned event that interrupts the completion of an activity, and that may (or may not) include injury or property damage.
An incident usually refers to an unexpected event that did not cause injury or damage this time but had the potential. “Near miss” or “dangerous occurrence” is also terms for an event that could have caused harm but did not.
Accidents occur when hazards escape detection during preventive measures, such as a job or process safety analysis, when hazards are not obvious, or as the result of combinations of circumstances that were difficult to foresee. A thorough accident investigation may identify previously overlooked physical, environmental, administrative, or process hazards, the need for new or more extensive safety training, or unsafe work practices. The primary focus of any accident investigation should be the determination of the facts surrounding the incident and the lessons that can be learned to prevent future similar occurrences.
Importance of Accident Investigation and Reporting
The first priority whenever an accident occurs is to deal with the emergency and ensure that any injuries or illnesses receive prompt medical attention. The accident investigation should begin immediately thereafter. This ensures that details of what occurred will be fresh in people’s minds and that witnesses don’t influence one another by talking about the accident. It also minimizes the likelihood that important evidence is not moved, lost, taken, destroyed, or thrown away before the scene has been thoroughly inspected. There are indeed significant gains from good quality accident investigations. Most importantly, accident investigation are carried out to find out the cause of accidents and to prevent similar accidents in the future. Apart from this, accident investigation is also carried out to learn from what went wrong. Determination of the cause of the accident is also an important factor. Preventing recurrence of the accident, improving the work environment, compliance of regulatory requirements, finding out the cost of the accident, to fulfil moral obligation, defining trends, provision of information in case of litigation, reduction of operating costs by control of accidental losses and to express concern by the management are some of the importance of carrying out an effective accident investigation and reporting.
Conclusion
All accidents should be investigated. The depth and complexity of the investigation will vary with the circumstances and seriousness of the accident. The Safety Officer or other individual responsible for operations involved in an accident should ensure that an investigation is conducted and that when appropriate, corrective actions are taken. Incidents that involve no injury or property damage should still be investigated to determine the hazards that should be corrected. The same principles apply to a quick inquiry of a minor incident and to the more formal investigation of a serious event.
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). For simplicity, we will use the term accident to mean all of the above events.
When accidents are investigated, the emphasis should be concentrated on finding the root cause of the accident rather than the investigation procedure itself so we can prevent it from happening again. The purpose is to find facts that can lead to actions, not to find fault. Always look for deeper causes. Do not simply record the steps of the event.
Chapter 3 Methodology
Introduction
The important criteria in adopting a research methodology should depend on what information we need to collect in order to make an informed conclusion to questions that arises from problems that needs to be addressed. The more focused we are about what we want to gain by our research, the more effective and efficient we can be in our research, the shorter the time it will take us and ultimately the less it will cost us (whether in your own time, the time of your employees and/or the time of a consultant).
There are trade offs, too, in the breadth and depth of information we get. The more breadth we want, usually the less depth we’ll get (unless we have a great deal of resources to carry out the research).
Study Location
The study location would be the project site of the Senai-Pasir Gudang-Desaru Expressway with emphasis on the personnel involved at the work site. These personnel would be the Safety and Health Officer and Supervisor, the work supervisors and foremen whom are responsible over several workers.
Questionnaire
Questionnaires are an inexpensive way to gather data from a potentially large number of respondents. Often they are the only feasible way to reach a number of reviewers large enough to allow statistically analysis of the results. A well-designed questionnaire that is used effectively can gather information on both the overall performance of the test system as well as information on specific components of the system. If the questionnaire includes demographic questions on the participants, they can be used to correlate performance and satisfaction with the test system among different groups of users.
For the purpose of this study, I have prepared a simple questionnaire directed at key personnel at the work site with questions encompassing various aspects of occupational safety and health such as written safety and health program, manager’s responsibility, supervisor’s responsibility, safety manager’s role, employees, safety committees, safety and health inspection, regulatory compliance, safety and health training, injury and illness prevention activities, accident investigation and reporting and lastly on emergency preparedness. A sample of this questionnaire is attached together with this project paper in appendix 1.
Analysis of Data
When analyzing data from questionnaires, always start from review of the research goals, i.e., the reason we undertook the research in the first place. This will help us organize our data and focus our analysis. For example, if we want to improve a program by identifying its strengths and weaknesses, we can organize data into program strengths, weaknesses and suggestions to improve the program. If we want to fully understand how our program works, we could organize data in the chronological order in which customers or clients go through our program. If we are conducting a performance improvement study, we can categorize data according to each measure associated with each overall performance result, e.g., employee learning, productivity and results.
Chapter 4 Research Results
Introduction
A total of 10 questionnaires have been distributed to Safety Officers/Supervisors at the Senai – Pasir Gudang – Desaru Expressway project site and various other project sites in Melacca and Kuala Lumpur to gauge the accident investigation and reporting mechanism. Out of the 10 questionnaires given out, 8 responded. The sample of the questionnaire can be found in Appendix I.
Respondence Background
All of the respondence are qualified Safety Officers and Safety Supervisors appointed by their respective companies and are registered with the Department of Safety and Health Malaysia (DOSH) or at least have attended courses conducted by the National Institute of Occupational Safety and Health (NIOSH), Malaysia. They were chosen as respondence base on their vast experience and knowledge on Construction Safety and Health issues. It is hoped that their valuable feedback could improve the accident reporting and investigation procedures practiced at their respective site.
Research Outcome
Response from the questionnaires is tabulated and the result is shown in the spreadsheet below.
No
Description
Respondent
YES
NO
YES %
1
Written Safety
a. Management commitment
8
8
100
b. Safety performance standard
8
5
3
62.5
c. Employee involvement
8
8
100
d. Written safety rules/procedures
8
8
100
e. Safety inspection
8
7
1
87.5
f. Loss prevention
8
8
100
g. Regulatory compliance
8
8
100
h. Safety and health training
8
8
100
i. Accident reporting/investigation
8
6
2
75
j. Safety and health promotion
8
8
100
k. Return to work policy
8
1
7
12.5
Average YES
85.2
2
Do Managers:
a. Conduct/attend safety meetings
8
6
2
75
b. Review serious accidents/near misses
8
8
100
c. Ensure supervisors accountable
8
4
4
50
d. Conduct safety inspection
8
6
2
75
e. Recognize safety performance
8
2
6
25
f. Attend safety training session
8
2
6
25
g. Talk to employees about safety
8
6
2
75
h. Follow safety rules and procedures
8
7
1
87.5
i. Require supervisors to complete one safety project/year
8
8
j. Encourage supervisors to attend outside safety training
8
6
2
75
k. Provide adequate resource for accident prevention
8
5
3
62.5
l. Include safety in supervisor’s job description/performance
8
4
4
50
m. Review the quality of accident investigation reports
8
6
2
75
Average YES
59.6
3
Do Safety Officers/Supervisors:
a. Conduct safety meetings with their employees
8
8
100
b. Perform safety inspections of their department
8
8
100
c. Take appropriate action(s) to correct safety rules
8
8
100
d. Talk to their employees
8
8
100
e. Promptly complete and submit accident investigation reports
8
8
100
f. Attend supervisory safety training programs
8
8
100
g. Conduct periodic planned safety observations
8
8
100
h. Identify and complete at least one safety project annually
8
3
5
37.5
i. Review and respond promptly to employee suggestions
8
8
100
j. Initiate immediate action(s) to correct unsafe conditions/acts
8
8
100
Average YES
93.75
4
Do Safety Manager:
a. Conduct formal safety and health inspections
8
4
4
50
b. Encourage employees to submit safety suggestions
8
8
c. Attend at least one departmental safety meeting each quarter
8
8
100
d. Participate in investigation of serious injuries/near misses
8
8
100
e. Coordinate regulatory compliance activities
8
4
4
50
f. Conduct safety training for employees/supervisors
8
2
6
25
g. Conduct induction training
8
8
100
h. Attend 1-2 professional development courses annually
8
8
100
i. Review accident statistics and worker’s compensation costs
8
8
100
j. Serve as Chairperson or member of the Safety Committee
8
8
100
Average YES
72.5
5
Do employees:
a. Follow all established safety rules and procedures
8
6
2
75
b. Report unsafe conditions/accidents to their supervisor
8
7
1
87.5
c. Attend all required safety training programs
8
8
100
d. Submit safety suggestions
8
2
6
25
e. Maintain proper housekeeping at their work place
8
6
2
75
Average YES
72.5
6
Safety Committees
a. Do your company have an active safety committee
8
8
100
b. If yes, does the Safety Committee
i. Perform safety inspections
8
8
100
ii. Meet at least quarterly
8
8
100
c. Review all serious accidents
8
8
100
i. Recommend safety program improvement
8
8
100
ii. Monitor safety program effectiveness
8
8
100
iii. Take timely action on safety suggestion
8
6
2
75
iv. Maintain and publish minutes of each meeting
8
8
100
Average YES
96.9
7
Injury/Illness Prevention Activities
a. Does your company use engineering controls and/or administrative controls to prevent or control workplace injuries and illnesses
8
8
100
b. Does your company use safety posters, health fairs etc to promote health and safety
8
8
100
c. Has a Job Safety Analysis (JSA) been completed for each hazardous job
8
8
100
d. Has your company developed an effective ergonomics program
8
2
6
25
e. Are safety and health requirements and concerns considered when purchasing new machines, equipment and chemical products
8
8
100
Average YES
85
8
Accident Reporting and Investigation
a. Are all workplace injuries and illnesses reported and investigated
8
8
100
b. Are near misses and vehicle-related accidents reported and investigated
8
8
100
c. Have all supervisors and managers been trained in accident investigation procedures
8
8
100
d. Are Safety Officers/Supervisors required to complete a separate Accident Investigation Report
8
8
100
e. Are incomplete reports returned to the appropriate Safety Officers/Supervisors
8
8
100
f. Are accident prevention programs and activities based upon an analysis of accident reports and injury and illness rates
8
6
2
75
Average YES
95.8
9
Emergency Preparedness
a. Does your company have a current Emergency Response Plan
8
8
100
b. Are emergency phone numbers and building maps/site maps posted
8
8
100
c. Do all personnel know how to respond to an emergency such as fire
8
6
2
75
d. Do your company conduct periodic disaster drills
8
4
4
50
e. Are alarms tested at least once per month
8
8
100
Average YES
85%
Main Elements Studied
The main elements studied are the Accidents Investigation and Reporting procedures. The targeted questions with respect to this area are as below:-
Does your company have a current written safety and health program that addresses the following elements?
i. Accident reporting and investigation? (75% answered ‘YES’)
Do managers
m. Review the quality of accident investigation reports? (75% answered ‘YES’)
3. Do safety officers/supervisors
e. Promptly complete and submit accident investigation reports? (100% answered ‘YES’)
4. Do safety managers
d. Participate in the investigation of serious injuries and near misses? (100% answered ‘YES’)
5. Do employees
b. Report unsafe conditions and accidents to their safety officers/supervisors? (87.5% answered ‘YES’)
6. Safety committees
c. Review all serious accidents? (100% answered ‘YES’)
8. Accident reporting and investigation
All questions in this section are relevant to the topic discussed. (Average ‘YES’ – 95.8%)
9. Emergency Preparedness
All questions in this section are relevant to the topic discussed. (Average ‘YES’ – 85%)
Generally almost all of the respondents reported positively on aspects of accident investigation and reporting in their respective companies. From having a clear written policies to having an emergency response plan in place are sure signs that accident investigation and reporting are taken seriously and thus, the standards of safety and health could only improve.
Chapter 5 Conclusion
Introduction
With every company taking a serious stand on aspects of safety and health at the work site, so does accident investigation and reporting procedures. From the feedback gathered through questionnaires, the accident investigation and reporting mechanism are properly in placed and practiced.
Discussion
Accidents are usually complex. An accident may have 10 or more events that can be causes. A detailed analysis of an accident will normally reveal three cause levels: basic, indirect, and direct. At the lowest level, an accident results only when a person or object receives an amount of energy or hazardous material that cannot be absorbed safely. This energy or hazardous material is the DIRECT CAUSE of the accident. The direct cause is usually the result of one or more unsafe acts or unsafe conditions, or both. Unsafe acts and conditions are the INDIRECT CAUSES or symptoms. In turn, indirect causes are usually traceable to poor management policies and decisions, or to personal or environmental factors. These are the BASIC CAUSES.
In spite of their complexity, most accidents are preventable by eliminating one or more causes.
Accident investigations determine not only what happened, but also how and why. The information gained from these investigations can prevent recurrence of similar or perhaps more disastrous accidents. Accident investigators are interested in each event as well as in the
sequence of events that led to an accident. The accident type is also important to the investigator. The recurrence of accidents of a particular type or those with common causes shows areas needing special accident prevention emphasis.
The actual procedures used in a particular investigation depend on the nature and results of the accident. The agency having jurisdiction over the location determines the administrative procedures. In general, responsible officials will appoint an individual to be in charge of the investigation. The investigator uses most of the following steps:
1. Define the scope of the investigation.
2. Select the investigators. Assign specific tasks to each (preferably in writing).
3. Present a preliminary briefing to the investigating team, including:
a. Description of the accident, with damage estimates.
b. Normal operating procedures.
c. Maps (local and general).
d. Location of the accident site.
e. List of witnesses.
f. Events that preceded the accident.
4. Visit the accident site to get updated information.
5. Inspect the accident site.
a. Secure the area. Do not disturb the scene unless a hazard exists.
b. Prepare the necessary sketches and photographs. Label each carefully and keep accurate records.
6. Interview each victim and witness. Also interview those who were present before the accident and those who arrived at the site shortly after the accident. Keep accurate records of each interview. Use a tape recorder if desired and if approved.
7. Determine
a. What was not normal before the accident?
b. Where the abnormality occurred.
c. When it was first noted.
d. How it occurred.
8. Analyze the data obtained in step 7. Repeat any of the prior steps, if necessary.
9. Determine
a. Why the accident occurred.
b. A likely sequence of events and probable causes (direct, indirect, basic).
c. Alternative sequences.
10. Check each sequence against the data from step 7.
11. Determine the most likely sequence of events and the most probable causes.
12. Conduct a post-investigation briefing.
13. Prepare a summary report, including the recommended actions to prevent a recurrence.
Distribute the report according to applicable instructions.
An investigation is not complete until all data are analyzed and a final report is completed. In practice, the investigative work, data analysis, and report preparation proceed simultaneously over much of the time spent on the investigation.
As noted earlier, an accident investigation is not complete until a report is prepared and submitted to proper authorities. Special report forms are available in many cases. Other instances may require a more extended report. Such reports are often very elaborate and may include a cover page, a title page, an abstract, a table of contents, a commentary or narrative portion, a discussion of probable causes, and a section on conclusions and recommendations.
The following outline has been found especially useful in developing the information to be included in the formal report:
1. Background Information
a. Where and when the accident occurred
b. Who and what were involved
c. Operating personnel and other witnesses
2. Account of the Accident (What happened?)
a. Sequence of events
b. Extent of damage
c. Accident type
d. Agency or source (of energy or hazardous material)
3. Discussion (Analysis of the Accident – HOW; WHY)
a. Direct causes (energy sources; hazardous materials)
b. Indirect causes (unsafe acts and conditions)
c. Basic causes (management policies; personal or environmental factors)
4. Recommendations (to prevent a recurrence) for immediate and long-range action to remedy:
a. Basic causes
b. Indirect causes
c. Direct causes (such as reduced quantities or protective equipment or structures
Summary
Hundreds of accidents occur daily throughout the Malaysia. These result from a failure of people, equipment, supplies, or surroundings to behave as expected. A successful accident investigation determines not only what happened, but also finds how and why the accident occurred. Investigations are an effort to prevent a similar or perhaps more disastrous sequence of events.
Most accident investigations follow a research technique called the scientific method. This method involves gathering and analyzing facts, and developing hypotheses to explain these facts. Each hypothesis must be tested against the facts, and the most probable explanation of the accident needs to be selected. Any one of several problem solving techniques based on this approach may be used. An investigation is not complete however, until completion of a final report. Responsible officials can then use the resulting information and recommendations to prevent future accidents.
Recommendation
It is recommended that a larger sampling of personnel from the Safety and Health departments of various companies to be included further into the research. It is also recommended that the research is expended to cover the whole working industry i.e. manufacturing factories, forestry department, governmental offices etc.
REFERENCE
WWW.CONSULTNET.IT, Accident Reporting & Investigation
WEB.PRINCETON.EDU, Accident Investigation Procedure
WWW.MANAGEMENTHELP.ORG, Analyzing, Interpreting and Reporting Basic Research Results
WWW.OSHA.ORG, Accident Investigation
WWW.CCOHS.CA, Accident Investigation
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