EMS responded to an accident scene at your plant. The report states that Jim was injured on Aug. 1 in the power press shop area of ABC Tool, LLC. The accident occurred on a mechanical power press and Jim lost two fingers when he reached into the press to extract a part that had fallen.
The press was foot pedal operated but, was not guarded. There was a plexi-glass point of operation guard, but it was left flipped up. Jim was removing a piece of metal that was stuck in the die and hit the unguarded foot pedal. Jim screamed and employees came running to his aid. A supervisor was called as well as 911. Reporting does not stop here. Sometimes, the emergency response team at a facility will participate in the accident investigation.
Every near miss is a practice for the minor incident and every minor is a practice for a serious incident. Serious incidents lead to fatalities. Every time we let a near miss go by without an investigation, we are practicing for the big one.
Theories of the Cause of Accidents
- Single Event Theory is to blame the victim. It's simple right, Jim on one occasion reached into the machine without a tool. It’s convenient to blame the victim and all responsibility goes to him. Blaming is a short-term fix, but in the long run blaming is expensive to implement and maintain.
- The Domino Theory says that injury results from a series of related occurrences which lead to a final event, resulting in injury or illness. Also referred to as a chain of related events. It’s assumed that by eliminating any one action or event the chain will be broken.
- Multiple Cause Theory uncovers root causes because accidents are not assumed to be simple events. They are the result of a series of random related or unrelated acts/events that somehow interact to cause the accident. This is a systems approach, which takes into account the dynamics of systems that interact within the overall safety program.
- Get everyone safe
- Preserve and document scene
- Collect information
- Determine root causes
- Implement corrective actions
Once you gather information, you must conduct a structured analysis to determine the unique events that occurred prior to and including the injury event. You must accurately determine the sequence of events and start by separating (breaking down) the incident into its component parts. This is looking at pre-incident, during incident and post-incident parts so that each can be seen as hazardous conditions, unsafe behaviors or system weaknesses.
Sequence of Events
- Employee was hired and received orientation
- Maintenance man removes guard to work on press
- Maintenance does not have a part and is then called away for another broken machine
- Maintenance fails to secure guard and post a “Do Not Use” sign
- Part jams in press
- Employee fails to lock out the press before clearing the jam
- Employee bypasses unsecured guard
- Employee reaches into press without a hand tool
- Employee steps on unguarded foot pedal activating press
- Press dies close on employee’s hand (the injury incident)
- Supervisor and 911 is called
- 911 medics provide treatment at scene
- 911 medics transport employee to hospital
Causes of Accidents
When looking at the injury or illness we must look below the direct cause of amputation injury. We must look at the indirect causes (behaviors and conditions) that led to the injury. Conditions would include: unguarded machine, broken tools or equipment, defective PPE or an untrained worker. Behaviors would include ignoring a hazards, fails to enforce or inspect, failing to train. The basic root cause of accidents pre-exist indirect includes: inadequate training, no discipline or procedures, no orientation process, inadequate training, no inspections that recognize hazards, no labeling or signage to warn employees.
The injury analysis for Jim’s accident:
- Injury Analysis – amputation of two fingers caused by being caught in the dies of press.
- Indirect Cause Analysis – hazardous conditions, foot pedal unguarded, and unsafe employee/manager/maintenance behaviors, employee bypasses unsecured guard, employee failed to lockout tagout, employee reaching unguarded die without hand tool and maintenance failed to secure guard.
- Basic Root or Systems Analysis – press operator not trained, maintenance man had too much work and was in hurry, press operater working too fast, supervisor too busy, supervisor not conducting safety inspections of area and failed to train press operator.
Employers must control hazards in the workplace and keep employees safe from harm. The intention of the OSHA standards is they are minimum requirements. If a specific rule cannot be sited, the General Duty Clause says, “employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees...”
Sherrie Wilson is Industrial Fire World's EMS editor.
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