Hazard and Investigation Procedure - Case Study Example

This form is to be completed with reference to the Hazard/Incident Report and Investigation Procedure Incident Date of Incident: 08/ 13/ 2003 Time of Incident: Incident Investigation Date: 08/15/2003 CASES 21 Accident No, IRIS No, eduSafe Reference No: School / Workplace: West Virginia at a logging site 2. Persons Involved in the Investigation Position Name Name of person conducting investigation: Workplace Manager: Management OHS Nominee: Health and Safety Representative: Other: Other: Other: Name of person(s) who were injured –(Note: Due to privacy reasons students’ names are not to be identified in this report) 3. Injury(s) Sustained Multiple crush injuries on the head. 4. Incident Location -(please state exact location) West Virginia at a logging site. Description of Incident –(Provide a brief description) On the fateful day of August 13, the year 2003, a man of age 46 operator of a heavy machinery in this case the victim succumbed to injuries sustained after the equipment he was operating took a wrong turn slid and then rolled downhill finally landing on the victim. The machinery operator (victim) was the only person working in the construction zone at the time. It seemed like the victim had completed the construction of a road that was adjacent to the hillside and afterwards move the equipment towards the steep side of the hill by the end of the newly constructed road. The track marks left by the dozer suggest that the victim tried to move the equipment uphill but he did not succeed as the dozer tracks started digging and spinning. After realising, he would not be able to move forward the victim moved the dozer backwards towards the slope on the hillside. It appeared that the dozer had started sliding backwards into the sloppy side of the hill until it was almost in a vertical position by the edge of the hill. The machinery kept on sliding until it finally tipped over rolled and landing on its side downhill. The victim was not restrained by the seat belts in the dozer hence he ended up being pinned down by the machine. Has a similar incident/near miss occurred previously?  Yes  No Were there procedures in place to minimise the risk?  Yes  No Has a Risk Assessment for the task been completed/reviewed (if applicable) Yes  No 5. Medical Treatment– (Please provide a brief explanation of the medical treatment or first aid that was applied) The paramedics where called to the scene and administered first aid to the victim before transporting him to a medical facility for further treatment. Was an ambulance called?  yes  No 6. Key Contributing Factors –(Provide a brief description of the circumstances that led to the incident/injury occurring and the immediate cause – refer to DEECD’s Hazard/Incident Report and Investigation Procedure) Design of equipment/workplace (e.g. defective or unsuitable equipment, workplace layout) The equipment a heavy machine (bulldozer), the restrains was defective in a rusty condition. The workplace was on a hillside it was sloppy risk of such an incident was high for such an area. Environment (e.g. lighting, ventilation, noise, temperature) The incident occured during the day there was sufficient lighting, it was sunny the temperature was 80 0F There area was open outdoors. There was medium noise emitted by the bulldozer only. Human (e.g. fatigue, lack of understanding) The victim was inexperienced in that field of work Work methods and systems (e.g. training, unclear work procedures, flow of information) There was no indication if the employee was properly trained for safety purposes and he was working alone instead of having a trained supervisor to guide him. Other comments: The seat belt of the machine was not in a good condition to be used, the bulldozer was also not properly maintained and the condition of the workplace was not favourable as the soil was wet and sloppy. 7. Documents Collected - (e.g. interviews, photos, Safe Work Procedures, and risk assessments). Name of Document Attached photos  yes  No Workplace map  Yes  No Death certificate  Yes  No  Yes  No  Yes  No ) 8. Corrective Actions - (Provide a detailed description of what actions are to be taken to reduce the risk of the incident/injury from occurring again – refer eduSafe Action Plan if applicable) Actions Completion Date Person Responsible Actions Completed Insepection of equipment before the commencement of work and ensuring everything is properly maintained.  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No 9. Risk Management –Evaluate the likelihood, consequencesand level of risk Likelihood Descriptor Level Definition Rare 1 May occur, sometime (“once in a life time / once in a hundred years”) Unlikely 2 May occur somewhere within DEECD over an extended period of time Possible 3 May occur several times across DEECD or a region over a period of time Likely 4 May be anticipated multiple times over a period of time May occur once every few repetitions of the activity or event Almost Certain 5 Prone to occur regularly Is anticipated for each repetition of the activity Consequence Descriptor Level Definition Insignificant 1 No injury Minor 2 Injury/ ill health requiring first aid Moderate 3 Injury/ill health requiring medical attention Major 4 Injury/ill health requiring hospital admission Severe 5 Fatality Risk Level Likelihood Consequence Insignificant Minor Moderate Major Severe Almost Certain Medium High Extreme Extreme Extreme Likely Medium Medium High Extreme Extreme Possible Low Medium Medium High Extreme Unlikely Low Low Medium Medium High Rare Low Low Low Medium Medium Key Extreme: Notify Workplace Manager and/or Management OHS Nominee immediately. Corrective actions should be taken immediately. Cease associated activity. High: Notify Workplace Manager and/or Management OHS Nominee immediately. Corrective actions should be taken within 48 hours of notification Medium: Notify Nominated employee, HSR / OHS Committee. Nominated employee, OHS Representative / OHS Committee is to follow up that corrective action is taken within 7 days. Low: Notify Nominated employee, HSR / OHS Committee. Nominated employee, HSR / OHS Committee is to follow up that corrective action is taken within a reasonable time. Risk Level: 5 Workplace Manager and/ or Management OHS Nominee are to maintain completed forms Scene photos Figure 1 This image indicates the newly constructed skid road that the dozer tried to use while backing out of the hillside. The dozer came to an almost vertical incline at the end of dotted line on the right. Figure 2 This image indicates the point at which the bulldozer started sliding before rolling over. Figure 3 The image depicts where the roll over took place and the position where the dozer finally landed. Figure 4 The image shows the position of the victim after the dozer came to a stop from rolling over. Figure 5 This image shows the condition of the restrain that could have saved the life of the operator. Incident map Read More