1. Fatal accidents in hot work Padasjoki 26.8.2010
Hannu Tarvainen, dr.
FEDERATION OF ACCIDENT INSURANCE INSTITUTIONS (FAII), FINLAND
Hannu Tarvainen

2. F E D E R A T I O N O F A C C I D E N T I N S U R A N C E
I N S T I T U T I O N S
LABOUR MARKET INSURANCE: THE TRIPARTITE PRINCIPLE
Labour market organisations
Ministry of Social Affairs and Health
Insurance companies
Federation of Accident Insurance Institutions
Hannu Tarvainen

3. Investigation of Fatal Accidents
Over 800 fatal investigations since 1985
Coordinator : Federation of Accident Insurance Institutions
Cooperation:
Insurance companies
Employers
Employees
Relevant authorities and institutions
Hannu Tarvainen

4. Example 1. Maintenance worker died from burns after his clothes and overalls caught fire
(Fatal accident at work. Investigation report no. TOT 9/08)
INVESTIGATIONS FOR SAFETY SINCE 1985
FEDERATION OF ACCIDENT INSURANCE INSTITUTIONS (FAII), FINLAND
Hannu Tarvainen

5. The accident place and the front of repair shop of the earthwork company
Hannu Tarvainen

6. Course of events The dump truck tailboard after the accident.
A tailboard of a dump truck was being modified in a yard of an earthwork company’s repair shop.
The work was being done by an experienced 62-year-old part-time maintenance worker NN.
NN had been trained to have a valid hot work licence.
NN was working to add extra weight to the tailboard.
Prior to adding extra weight NN was wielding an angle grinder to cut away the heads of two hollow metal bars from the tailboard.
Sparks from the metal cutting ignited NN’s safety footwear, woollen overalls and other clothing.
NN did not notice burning of his clothing in time.
It is possible that NN lost his awereness because of toxical emissions.
NN died from extensive burn injuries
The dump truck tailboard after the accident.
Red arrows and lines illustrate the parts that were
to be cut off.
Hannu Tarvainen

7. Factors of accident Inadequate preparation of sparkling work:
no fire extinguisher in hot work site
working alone
no guidance to call for help or first aid
no guarding for hot work
Incorrect choice for workwear and footwear.
Ignition and fierce burning of workwear and footwear.
The emission of burning footwears were toxic, NN lost his awareness.
Extensive (whole body) burn injuries.
NN’s ”safety footwear” after the accident.
(Shoes could not be identified afterwards.)
Hannu Tarvainen

8. (Fatal accident at work. Investigation report no. TOT 13/08)
Example 2. Metal worker died from burns after his clothes and overalls caught fire
(Fatal accident at work. Investigation report no. TOT 13/08)
Hannu Tarvainen

9. The ship and shipyard were the fatal accident happened
Hannu Tarvainen

10. Course of events
One metal worker, NN, was grinding a metal handle of a water tank in a shipyard.
The work was being done by an experienced and healthy 70-year worker (retired) NN.
NN had been trained to have a valid hot work licence.
During the grinding work (30 seconds) a cleaning sheet under his safety footwear went suddenly up in flames.
NN tried to extinguish the fire by stepping the cleaning sheet .
His woollen overalls and other clothing went up in flames.
His fellow workers shut down the flames using a blanket .
NN died from extensive burn injuries.
The air used for ventilation of the water tank leaked out a hole of a pipeline decreased the flash point of the sheet (hydrocarbon compound was found).
The workplace after the accident.
Red arrows and lines illustrate the passage of NN after the accident.
Hannu Tarvainen

11. Factors of accident Inadequate preparation of sparkling work:
NN did’t know the location of the fire extinguisher (the distance around 20m)
NN tried alone to extinguish the fire by an incorrect way, that is by stepping
Inadequate guarding for hot work
Incorrect choice and fierce burning of workwear.
The air used for ventilation decreased the flash point of the sheet (hydrocarbon!)
Extensive (whole body) burn injuries.
NN’s overalls and footwear” after the accident.
Hannu Tarvainen

12. Example 3. Metal worker died when his overalls caught fire
(Fatal accident at work. Investigation report no. TOT 13/08)
Hannu Tarvainen

13. The workplace were the fatal accident happened
Hannu Tarvainen

14. Course of events
A metal cooler was being cutted using a gas burner in a car scrap yard.
The work was being done by an experienced 51-year-old and experienced metal worker NN.
NN had been trained to have a valid hot work licence.
The gas (propane) leaked out through the connector and tranferred into and under his overalls .
Sparks from the metal burning ignited very quickly NN’s woollen overalls and other clothing.
No fire extinguisher in hot work site.
NN’s fellow worker tried to extinguish the fire.
NN died from extensive burn injuries.
The cutted metal cooler and work environment after the accident.
Hannu Tarvainen

15. Factors of accident Inadequate preparation of sparkling work:
No fire extinguisher in hot work site
Inadequate guarding for hot work
Incorrect choice for workwear.
The worktools for burning were inspected insufficiently
Ignition and fierce burning overalls.
Extensive (whole body) burn injuries.
After the accident the amount of propane leakage was tested .
Hannu Tarvainen

16. Prevention of similar work accidents
Following the instructions given for hot work and a (temporary) hot work site
Hot work planning, hazard identification, preparation of the hot work site (e.g. fire extinguishing, guarding, methods for calling help), inspection of the hot work site
Using overalls and shoes that are resistant to sparks and hot particles
Overalls should conform to the standards for the protective clothing
Requirements should be considered to footwear also
The employer must supervise the use of appropriate protective clothing and personal protective equipment
The employer must inspect the safety of worktools frequently enough
Directing sparks away from worker(s) and combustible materials when using an angle grinder
When washing or repairing the workwear the effects to the heat and flame resistance treatment/attribute should be observed and taken into account
Hannu Tarvainen

17. Main surroundings of all fatal work accidents
Experienced workers
The average age 45 years
Risk taking personally
Poor supervison
Multi-employer wokplace
Poor introduction to the work
Hannu Tarvainen

18. Conclusions of fatal investigated accidents: Root causes
Organisation 49%
Environment 18%
Machine 12%
Worker 11%
Others 10%
Hannu Tarvainen

19. Investigation of Fatal Accidents: Poor actitivity of the organisation
Management:
Safety management,
Economical role of safety
Supervision:
Dangerous work methods and machines,
Poor training and instructions
Workers:
Poor attitude, risk taking (PPE)
Hannu Tarvainen

20. The safety of multi-employer workplaces 1. OSHA
The host employer's responsibility is to provide information about hazards and their controls, safety and health rules, and emergency procedures to all employers at the workplace.
In addition, the host employer must ensure that assigned safety and health responsibilities are appropriate to other employers at the workplace.
Hannu Tarvainen

21. The safety of multi-employer workplaces 2. OSHA
The contract employer responsibility is to ensure that the host employer is aware of hazards associated with the contract employer's work and how the contract employer is addressing them.
The contract employer must advise the host employer of any previously unidentified hazards (near accidents) at the workplace.
Hannu Tarvainen

22. Safety card since 2003 Started in paper and metal industry
Outsourcing has increased
Cooperation: Enterprises, contractors, employees, insurance companies
Voluntary, in practice necessary
Requirement of the orderer
Over safety cards accepted
Hannu Tarvainen