1. WORKER NEARLY KILLED IN WELDING ACCIDENT
ACCIDENT CASE STUDY
WORKER NEARLY KILLED IN WELDING ACCIDENT

2. OVERVIEW OF THE INCIDENT
ACCIDENT CASE STUDY
1 WORK SEVERELY INJURED IN WELDING ACCIDENT
OVERVIEW OF THE INCIDENT
You are a member of the safety committee and have been notified to report to the maintenance department to conduct an investigation of an accident. 1 worker has been taken to the hospital with severe burns and heart arythmia from contact with an electrical source. You and your group must conduct an accident investigation and write a report to determine the root cause and recommend corrective actions.

3. ACCIDENT CASE CHRONOLOGY
7:00am: Maintenance technician Madeline Hurt arrives to work
7:02am: Hurt unlocks tool chest
7:02am: Hurt turns on arc welder without area safety check
7:05am: Hurt notices and ignores water on floor in department
7:05am: Hurt searches for welding gloves, can’t find them
7:09am: Hurt resumes work on a welding job from previous day
7:09am: Table is not adjustable, part cannot be reoriented
7:10am: Hurt stoops over and attempts to weld at odd angle
7:10am: Hurt cannot properly weld hard-to-get-at section
7:11am: Hurt lowers to left knee and contacts water on floor
7:15am: Hurt resumes welding and is knocked unconscious
7:21am: Bill Smith (co-worker) finds her unconscious, calls 911
8:03am: Ambulance arrives, cares for, and transports victim
8:10am: Bill Smith notifies you

4. ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
Date/Time of Incident: Novem, 30, about 715
ACCEPTABLE
Date/Time of Incident: 11/30/96 (Month/Day/Year), 7:15 a.m.
COMMENTS:
Be consistent and accurate with Dates and Times. Accurately reconstructing the accident may depend on accurate timeframes.

5. ACCIDENT INVESTIGATION
REPORT
DEFINITIONS
Accident With Injury - Severity is not a factor
Accident Without Injury - Vehicle or Property Damages Result
Near Miss - Had timing been different Injury or property damage would have resulted
Resulted in Death - Self Explanatory

6. ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
Name: Maddy Hurt
ACCEPTABLE
Name: Madeline B. Hurt
COMMENTS:
Use full legal names only, the use of nick names can sometimes cause confusion. If legal concerns arise, correct names will become important. Review personnel records as needed.

7. ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
Assigned Job: Maintenance Man
ACCEPTABLE
Assigned Job: Maintenance Technician
COMMENTS:
Use the full duty title as it appears in their job description. Review personnel records as needed.

8. ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
Length of Service: Almost 15 Years
About 12 Years on this job
ACCEPTABLE
Length of Service: 14 years 11 Months
11 Years 10 Months on this job
COMMENTS:
Be consistent and accurate with timeframes. Review personnel records as needed.

9. ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
Location of Accident: Maintenance department.
ACCEPTABLE
Location of Accident: Maintenance department, Adjacent to Arc Welding Machine (Serial ) SW corner of room.
COMMENTS:
Fully describe the location and pertinent surroundings. The location can sometimes contribute to the accident. Accuracy is also needed for reconstruction.

10. ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
How Accident Occurred: Maddy was zapped by the green welder (real dirty one) when she put her knee in water leaking from the drinking fountain which Ted was supposed to fix Tuesday. I feel real bad about this.
COMMENTS:
1. Is this sufficient for you to understand what happened?
2. Can the root cause be determined?
3. Can you develop measures to prevent recurrence?
4. Specifically, what is wrong with this narrative?

11. ACCIDENT INVESTIGATION
REPORT
ACCEPTABLE
How Accident Occurred: The employee received a high voltage electric shock (220v) which incapacitated her. At the time of the accident she was welding a T-Joint on mild steel with the voltage regulator set at 110 amps. She knelt on her left knee to obtain a better angle for the weld not realizing that water was leaking from a drinking fountain on the other side of the partition separating the maintenance department from the general facility. The working surface was poured cement. Arc Welding Machine (Serial ) was being used at the time, the nonconductive handle grip was cracked which caused an electrical short causing the injury. The water leak was a contributing factor.

12. ACCIDENT INVESTIGATION
REPORT
How Accident Occurred:
COMMENTS:
1. Preventing recurrence by allowing reconstruction of the accident should be the primary outcome.
2. The use of irrelevant information such as your feelings may disguise the causes of the accident and hinder the investigation.
3. Accuracy is critical for reconstruction.
4. At this point you should not affix blame. The object of the investigation is to determine the root cause not find the fall-guy (or gal).

13. ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
What Factors Led To The Accident:
1. Ted ignored water fountain work order request.
2. Maddy never checks her equipment right.
3. Maddy has trouble following directions.
4. I’ll try and get my points across better in the future.
COMMENTS:
1. Is this sufficient for you to develop preventative measures?
2. Can the root cause be determined?
3. Specifically, what is wrong with these statements?

14. ACCIDENT INVESTIGATION
REPORT
ACCEPTABLE
What Factors Led To The Accident:
1. Possible lack of timely repair of the leaking drinking fountain.
2. Possible lack of training in preoperational equipment checks.
3. Possible lack of policy for preoperational equipment checks.
4. Possible lack of an adjustable welding table/surface.
5. Possible lack of proper inspection of the welding area.
6. Possible lack of a hotwork permit.

15. ACCIDENT INVESTIGATION
REPORT
What Factors Led To The Accident:
COMMENTS:
1. Stick to the facts!
2. If needed break the sequence of events down chronologically.
3. Avoid affixing blame.
4. Think logically and objectively.
5. Think about what was missing from the safety equation.
6. What engineering controls failed or were missing/unavailable?
7. What administrative controls were lacking or unavailable?
8. What PPE was lacking or unavailable?

16. ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
Part of Body Injured: Was shocked real bad.
ACCEPTABLE
Part of Body Injured: Sustained severe electrical burns (2nd degree) to the left knee and left hand (palm, thumb and 1st digit). Minor heart arythmia (confirmed by emergency room) also sustained because of electrical discharge.
COMMENTS:
Fully describe the extent of injuries. Review medical records if needed.

17. ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
Investigators Comments: Bill from maintenance asked me to respond to the accident scene a couple of minutes after it happened. I arrived soon thereafter, and completed this report.
ACCEPTABLE
Investigators Comments: Maintenance Technician (Bill Smith) notified me (11/30/96 - 8:10 a.m.) that a severe electrical injury had been sustained by Madeline B. Hurt. I arrived at the accident scene at approximately 8:15 a.m. The victim had already been transported by ambulance to No Hope Hospital. This report is the result of my investigation.

18. ACCIDENT INVESTIGATION
REPORT
Investigators Comments:
COMMENTS:
1. Describe the facts surrounding your involvement.
2. Identify key names, places, and timeframes.
3. Think logically and objectively.
4. Don’t be afraid to reword in the interest of clarity.
5. Don’t be redundant, save your comments for the proper place in the report.

19. ACCIDENT INVESTIGATION
REPORT
UNACCEPTABLE
Specific Action(s) That Will Be Taken:
1. Get the water fountain fixed.
2. Have Maddy checks her equipment every time.
3. Discipline Maddy for not following directions.
4. Try and get my point across better in the future.
COMMENTS:
1. Is this sufficient to ensure completion of corrective actions?
2. Can estimated completion dates be identified?
3. Have action items be assigned to a specific person?
4. Is anyone held accountable to ensure completion?

20. ACCIDENT INVESTIGATION
REPORT
ACCEPTABLE
Specific Action(s) That Will Be Taken:
1. Establish responsible parties for action items.
2. Ensure a priority system is in place for repair of equipment.
3. Ensure timely repair of facility equipment is accomplished.
4. Determine if training or retraining needs to be conducted.
5. Conduct training or retraining before similar work is performed.
6. Assess if an adjustable welding table/surface is needed.
7. Review & update related safety policies and procedures.
8. Review & update current preoperational welding requirements. (i.e., hotwork permit, safety checklists etc.)
9. Ask co-workers for their input!

21. QUESTIONS TO BE CONSIDERED
What caused the injury to occur?
Do you believe there is a single cause to this accident that, if removed would have prevented it?
Do you believe there are multiple causes?
Are multiple OSHA Standard violations involved?
What could upper management have done?
What could the supervisor have done?
What could the co-workers have done?
To what extent is a lack of written policy responsible?
What written policies need to be developed?
To what extent is a lack of training responsible?
Were the hazards associated with welding fully understood?

22. ACCIDENT CASE FACTS Safety discipline weak
Training deficiencies probably exist
Welding Safety Program not used, non-existent or ineffective
Hotwork permit not used, non-existent or ineffective
Maintenance department allowed “lone-wolf” situation
Hazards associated with welding not fully understood
PPE (lack of welding gloves) may have prevented contact
Repair priority system not used, non-existent or ineffective
Supervisor did not have established “rounds” in department
Written safety procedures not used, non-existent or ineffective
Written safety procedures did not address “lone-wolf” situation
Engineering controls may be a factor (i.e. lack of adjustable table)