Incident Investigation - Report Example

Name of the university College name Name of student Student number Course number Course title INCIDENT INVESTIGATION REPORT THE ARM AMPUTATION OF THE SAW MILL MACHINE OPERATOR Date of submission Signature of student Name of supervisor Date Signature of the supervisor TABLE OF CONTENTS Introduction 3 Objectives of carrying out the incident investigation 4 Causative agents 5 Conditions necessary for prevalence of causative agent 5 Outcomes of unguarded mechanical machinery following incident 6 Methods through which injuries occur in unguarded machines 7 Legislations and regulations that control occupational health and safety incidents 7 List of policies that would assist in investigation 8 Assessment of necessary procedures 8 List of documents that would assist in investigation 9 Reasons why the documents would be of use 10 Strategies towards reduction of occurrence of incidents 10 Requirements of machine guarding 10 Measures to prevent and control occurrence of incidents 11 Requirements of occupational health and safety (plant) regulation 1995 12 Threats and weaknesses of effecting guarding of a machine 12 A case of old machine 12 Guidelines for conforming to guarding of machines 13 Resources required for carrying out the investigation 13 People to be involved in the investigation 13 Reasons for involving the nominated persons in the investigation 14 Appropriate areas of intervention 15 References 15 Table 1: action plan template 17 Table 2: Analysis of the causal factors contributing to the incident 18 Introduction NOHSC (2003) suggests that occurrence of incidents results into great losses like loss of life and limbs, loss of earning to the victims, loss of breadwinner to the family members, loss of revenue in case the company is closed due to lack of enforcing occupational health and safety regulation and legislation. The company incurs expenses through employing staff or seeking expert counsel from consultants for assessing loss of earning of the victims of incident, eligibility of benefits of the victims, calculating benefits that the company will extend to the victims. The company also pays legal expertise in appeals, claims management according to occupational health and safety guidelines and adhering to compensation insurance policies or being sued for health and safety negligence. The company incurs costs in carrying out assessment for alternative employment opportunities for the victims, carrying out employment placements, and in rehabilitation programs and rehabilitation assessments that outline employability of the victims, functional assessment, skills analysis of the victim and potential of their application, funding rehabilitation plans, funding work adjustment training for the victims and determination of return to work formulas of the victims1. Objectives of carrying out the incident investigation a. To determine events that contributes to occurrence of incidents b. To compare and contrast related incidents to determine common patterns surrounding occurrence of the incidents c. To determine measures outlined by occupational health and safety regarding management of incidents d. To access measures that should be implemented to prevent occurrence of incident e. To evaluate effectiveness of the proposed preventive measures for compliance and conformity with occupational health and safety legislation Causative agents A causative agent is an event or happenings that results into direct or basic cause of a specified outcome of an incident. The causative agent is predisposed by underlying factors that create an environment for the direct cause of an incident to prevail. For instance, outbreak of electrical fire as a result of electric short circuit predisposed by lack of repairs of frayed electrical wires or worn out wires and failure to carry out routine inspections or risk assessment that could possibly show possibility of outbreak of an incident that threatens health and safety of employees or user of the premises2. Conditions necessary for prevalence of causative agent a. Failure to carry out routine inspection or risk assessment of an incident or outcome in order to determine position of the workplace to outbreaks of incidents b. Failure to comply with part 3 of occupational health and safety and welfare regulation 1995 that is against use of unsafe machines by government health and safety inspectors3. c. Failure to comply with occupational health and safety (plant) regulation 1995 that requires all systems of machinery to be functionally certified d. Poor machine guarding practices that are responsible for workplace injuries like loss of fingers and limbs or death. e. Failures to carry out routine inspections that can indicate and identify hazards through management oversight risk tree (MORT) and conform to risk assessment guidelines on safety of machinery f. Failure to take control and preventive measures by determining critical control points that can predispose occurrence of an incident g. Failure to carry out machinery safety audits and facilitate safety systems conformity to occupational health and safety through analysis of possible behavior based actions that can compromise safety Outcomes of unguarded mechanical machinery following incident Onguard (website, 2007, June) indicates the outcome of a mechanical machinery incident following exposure to unguarded machinery depends on the surface of machinery that comes into contact with the body and the following injuries are likely to be observed a. Amputation of the limbs b. Sprains c. Fractures d. Open wounds e. Electrocution and burns Methods through which injuries occur in unguarded machines a. Through contact or entanglement with machinery b. Following victim’s trapping between machine and material or fixed structure or point c. Through coming into contact with moving parts of the machine d. By being struck by extruded products from the machinery e. Following a fall while accessing or opening or maintaining the machinery Legislations and regulations that control occupational health and safety incidents a. Occupational health and safety (plant) regulation 1995 b. Occupational health, safety and welfare Section 19 act 1986 c. Occupational health and safety legislation section 21 (1) act 1985 d. Occupational health and safety legislation 2007 e. Magistrate’s court (occupational health and safety) rules 2005 f. Accident compensation regulation 2001 g. Occupational health and safety act 2004 h. Occupational health and safety act 1985 i. Accident compensation (workcover authority) Act 1993 j. Accident compensation (occupational health and safety) act 1996 List of policies that would assist in investigation a. Occupational health and safety risk management procedures b. Incident reporting policy c. Training policy d. Contractor management policy e. Risk management processes Assessment of necessary procedures a. Assessment of required resources b. Guidelines for developing recommendations c. Training qualification of investigation officers d. Personnel responsible for carrying out investigation e. Reporting incident procedures f. Investigation procedures List of documents that would assist in investigation a. The ARD timber company was declared unsafe by government inspector because of its unquarded condition b. The machine is 15 years old c. The Sawmill management had a guard of the saw manufactured and fitted by a consultant engineering company d. The saw operator was not consulted when designing of the guard was done by the consulting engineering firm to make the guard more effective (the guard is hydraulically operated and its designed such that the only time the saw can operate with the guard not fully in position) e. The request by the maintenance fitter for the guard to be repaired f. Risk assessment by the maintenance fitter to determine the area of machine that caused failure (the hydraulic ram) g. The order of the hydraulic ram from Europe via the sea and conditions surrounding the import of the hydraulic ram via the sea h. Decision to repair the guard over the Christmas i. Documentation of pressure from the management to complete the contract j. Documentation of maintenance fitter persuading the machine operator to continue operations without the guard on k. Documentation of removal of the guard by maintenance fitter l. Documentation of the machine operator events towards the incident where upon the saw amputates him Reasons why the documents would be of use The documents will show position of the company to implement occupational health and safety regulations. The documents will help to illustrate if the company has working occupational health and safety programs and if the occupational health and safety regulations are compromised and for what reasons are they compromised. The documents will show if the company health and safety management consults with its employees regarding health and safety. The documents will show if the procurements procedures factor urgency of the health and safety of the employees4. Strategies towards reduction of occurrence of incidents Requirements of machine guarding a. Preventing access to dangerous points of the machine b. Ensuring the physical barrier or guard can be altered or removed with recommended tools by qualified person c. Guarding of the machinery should not be easy to by-pass or disable accidentally d. The guarding should not be a health and safety hazard Measures to prevent and control occurrence of incidents a. The machine should be serviced regularly by certified machine setter and this should be followed by retesting the machine before production is started by the machine operator b. Organization should develop framework with employees and health safety representatives for updating on recently researched safe operations of the machines c. The organization occupational health and safety personnel should ensure procedures for operating the machine guarding are reviewed weekly and their report complied to form part of risk assessment d. The workers should be equipped with knowledge, training and information relevant to safe working procedures of working with machines e. The machine should have visible signage to act as an alert to employees on dangers of operating the machine f. The machine safety systems should be inspected and tested daily before and after close of a working day or shift g. The machine should be equipped with dual interlock safety systems as a control measure for ensuring machine moving parts are stopped when access is required to trapping spaces Requirements of occupational health and safety (plant) regulation 1995 a. Employer should create safe workplace to protect employees’ health and safety from risks of health and safety by ensuring the machine or machine systems are safely operational b. A guarding should be fitted as a measure to control and prevent risks of operator or any user to any machinery, equipment or appliance in order to minimize contacts of the person with danger points of the machine Threats and weaknesses of effecting guarding of a machine A case of old machine Schaffer (website) indicates that there may occur a scenario where the machine signage is not visible and therefore users or machine operator does not have a constant reminder of dangers associated with the machines and this predisposes laxity of safety rules and regulations The costs of installing machine guards to very old machines is very high and the organization may be subject to laxity to install them because the machine operator or other users have in the past been operating the machine without a guard leading into compromise of occupational health and safety regulation and regulations Guidelines for conforming to guarding of machines a. Australian standard AS 4024.1-2006 on safety of machine to its operator or user b. Victorian worksafe authority occupational health and safety act 2004 chapter 5 addresses the concerns of employers with old machines where the cost of installation of machine guards if prohibitive by stating, “The duty-holder must do what a reasonable person would do in the particular circumstances by putting in place reasonable practicable measures to prevent occurrence of incidents” c. 1983 NSW occupational health and safety Act S18 for manufacturers and suppliers of spares and equipment to conform with AS 4024.1-1996 Resources required for carrying out the investigation a. Human resources I. Internal occupational health and safety representatives II. External occupational health and safety personnel b. Financial resources c. Equipment resources I. Digital cameras II. Recorder People to be involved in the investigation a. The company occupational health and safety representatives b. The machine operator work group members c. The company senior management d. The company occupational health and safety advisory committee e. Organizational legal advisers on occupational health and safety f. Occupational health and safety specialists g. The politicians Reasons for involving the nominated persons in the investigation In order for the nominated persons to assist in advising on legal aspects and implication concerning the incident, to help in evaluation of possible existence of secondary standards on the incident, to bridge in resolving any conflict of interest that may arise, to help in shedding light on level of public interests and political interest on the incident and its economical costs and impacts and for the persons to provide guidance on international convections on accepted standards for occupational health and safety. Appropriate areas of intervention Adequately guarding drive belts and pulleys Providing information, instruction and training on machinery guarding and safety regulations involved Guarding the machines with dual interlocking systems Adhering to occupational health and safety regulation and legislation Ensuring machine signage is visible to alert employees on dangers of running it Carrying out routing inspection and risk assessment Carrying out routing repairs of the guarding system to comply with minimum standards for operation Ensuring employees abide by occupational health and safety guidelines depending on their workplace policies References National Occupational Health and Safety Commission (NOHSC). (March, 2003). Australian Occupational Health and Safety Thesaurus (3rd edition ed.). Canberra: National Occupational Health and Safety Commision , Canberra (common Wealth of Australia). Schaffer, R.M.H. (Occupational health and safety environment management consultants. (2008). when machine guarding is impossible. Retrieved February 12th, 2009, from http://www.environmentdiy.com.au/index.php?=articles/machine_guarding Onguard. (2007, June). ONGUARD. Retrieved February 12th, 2009, from Plant/machine and workshop safety newsla letter 19 2007: http://www.docs.sa.gov.au/docs/files/communities/documen/a/2007_05_15_on_guard_19.pdf Footnotes 1. Australian OHS Thesaurus, 3rd edition, March 2003 2. CIS Thesaurus. Occupational Safety Health. International Occupational Safety and Health Information Centre, International Labour Office, Geneva, 1976 3. CCH Occupational Health and Safety, Glossary CCH International: The information Professionals 4. Australian and New Zealand Standard Industrial classification (ANZSIC) Table 1: action plan template INCIDENT DATE LOCATION DETAILS AND CONTACT CURRENT JOB POSITION OF INVESTIGATOR QUALIFICATION PROFILE OF INVESTIGATOR INVESTIGATION TEAM ISSUE ACTION REQUIRED PERSON RESPONSIBLE TIMEFRAME STATUS SITE INSPECTION RECORDS OF COMPLIANCE AND REPAIRS RISK ASSESSMENT ASSESSMENT OF OCCUPATIONAL HEALTH AND SAFETY KNOWLEDGE ASSESSMENT OF CERTIFICATION FOR USE OF MACHINE ASSESSMENT OF RISK FACTORS DOCUMENTATION OF EVENTS LEADING INTO THE INCIDENT Table 2: Analysis of the causal factors contributing to the incident The investigation of the machine operator incident evaluates different causal factors that will be assessed by the nominated investigators for their contribution to laxity of occupational health and safety incidents in organizational workplace. organization Causal factors Comments Possible corrective action Recommended corrective action The ARD Timber company Has the management taken any step towards improving health and safety of its employees after the saw was declared unsafe by government inspector because of its unguarded condition? The management should consult with occupational health and safety officials on safety standards and what need be done. The machine should be certified for safety after What is the implication of the guard being hydraulically operated and designed such that the only time that the saw can operate with the guard not fully in position? Efficiency of the guard is decreased The guard is a healthy hazard The guard should be removed and replaced by fixed ones The consulting engineering company license should be revoked Why was the machine operator not consulted on design of the guard for the purpose of making it more effective? Consulting the machine operator on appropriate design for the guard Why did the store clerk opt to consider economical factors as a aspect when the store clerk ordered the hydraulic ram to be shipped by sea. Ensuring repair tools arrive at the required time Making efforts to ensure the company has enough spare parts for the machinery Why did the maintenance fitter not repair the guard during the Christmas break as he promised when he persuaded the machine operator to continue with operations without the guard? Repair of the guard on time or stopping operations until the hydraulic ram is fitted Not to run the saw mill without guarding regardless of the risk of employment Read More

For instance, outbreak of electrical fire as a result of electric short circuit predisposed by lack of repairs of frayed electrical wires or worn out wires and failure to carry out routine inspections or risk assessment that could possibly show possibility of outbreak of an incident that threatens health and safety of employees or user of the premises2. Conditions necessary for prevalence of causative agent a. Failure to carry out routine inspection or risk assessment of an incident or outcome in order to determine position of the workplace to outbreaks of incidents b.

Failure to comply with part 3 of occupational health and safety and welfare regulation 1995 that is against use of unsafe machines by government health and safety inspectors3. c. Failure to comply with occupational health and safety (plant) regulation 1995 that requires all systems of machinery to be functionally certified d. Poor machine guarding practices that are responsible for workplace injuries like loss of fingers and limbs or death. e. Failures to carry out routine inspections that can indicate and identify hazards through management oversight risk tree (MORT) and conform to risk assessment guidelines on safety of machinery f.

Failure to take control and preventive measures by determining critical control points that can predispose occurrence of an incident g. Failure to carry out machinery safety audits and facilitate safety systems conformity to occupational health and safety through analysis of possible behavior based actions that can compromise safety Outcomes of unguarded mechanical machinery following incident Onguard (website, 2007, June) indicates the outcome of a mechanical machinery incident following exposure to unguarded machinery depends on the surface of machinery that comes into contact with the body and the following injuries are likely to be observed a.

Amputation of the limbs b. Sprains c. Fractures d. Open wounds e. Electrocution and burns Methods through which injuries occur in unguarded machines a. Through contact or entanglement with machinery b. Following victim’s trapping between machine and material or fixed structure or point c. Through coming into contact with moving parts of the machine d. By being struck by extruded products from the machinery e. Following a fall while accessing or opening or maintaining the machinery Legislations and regulations that control occupational health and safety incidents a.

Occupational health and safety (plant) regulation 1995 b. Occupational health, safety and welfare Section 19 act 1986 c. Occupational health and safety legislation section 21 (1) act 1985 d. Occupational health and safety legislation 2007 e. Magistrate’s court (occupational health and safety) rules 2005 f. Accident compensation regulation 2001 g. Occupational health and safety act 2004 h. Occupational health and safety act 1985 i. Accident compensation (workcover authority) Act 1993 j. Accident compensation (occupational health and safety) act 1996 List of policies that would assist in investigation a.

Occupational health and safety risk management procedures b. Incident reporting policy c. Training policy d. Contractor management policy e. Risk management processes Assessment of necessary procedures a. Assessment of required resources b. Guidelines for developing recommendations c. Training qualification of investigation officers d. Personnel responsible for carrying out investigation e. Reporting incident procedures f. Investigation procedures List of documents that would assist in investigation a.

The ARD timber company was declared unsafe by government inspector because of its unquarded condition b. The machine is 15 years old c. The Sawmill management had a guard of the saw manufactured and fitted by a consultant engineering company d. The saw operator was not consulted when designing of the guard was done by the consulting engineering firm to make the guard more effective (the guard is hydraulically operated and its designed such that the only time the saw can operate with the guard not fully in position) e.

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