1.

0 INTRODUCTION

Occupational Safety and Health Act (OSHA) 1994 was enacted on 25 th February
1994 after being gazette on the parliament. OSHA 1994 was enacted due to inadequacy
of Factory & Machinery Act (FMA) 1967 on factors pertaining to its scope in which limited
to machinery sector and dependency on government for regulatory process. To be more
precise, FMA 1967 only covers occupational safety and health in the manufacturing,
mining, quarrying and construction industries where if converted into figure only cover 23
% of industry in Malaysia. Introduction of OSH 1994 cover all workers in all economy
related activities, excluding those working on board ships that administered by Merchant
Shipping Ordinance 1952 and armed forces. The main objective of Occupational Safety
and Health Act (OSHA) 1994 are as listed below;

a) To secure the safety and health of persons at work

b) To protect persons at a place of work other than employees
c) To promote an appropriate and suitable environment for persons at work
d) To enable previous legislative to be replaced by regulations and approved
industry codes of practice operating in combination with the OSH Act 1994.

According to the statistic provided on DOSH Malaysia official website until October
2019, there are approximately 6562 numbers of occupational accidents recorded by
Department of Occupational Safety and Health Malaysia (DOSH) in all sector. From the
figure stated most of the cases involves accidents on manufacturing sector that is 4070
cases recorded. However, the highest case recorded that involving death are in
construction sector which is 72 death had been recorded. Even with the presence of
OSHA 1994, the number of accidents reported each year shows no signs of decreasing.
Hence, continuous studies on how to improve safety at workplace have to be done.
Thus, the risk of occurrence of accidents at workplace can be reduced. The OSHA 1994
has been amended few times due to some improvements made to ensure it covers all
area of sector regarding safety at workplace.

This study is conducted to investigate an accident that occurred on 25th of

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January 2019 at one of the factory in Kedah where the victim (general worker) was died
on a concrete wall that fell while the victim was pushing the iron door in the factory area.
Purpose of this case study is to show procedure on reporting accidents at work place,
the necessary investigation as well as preventive actions to avoid future accidents from
occurring.

2.0 PART A - ACCIDENT INVESTIGATION

As the safety officer assigned to investigate an accident happened in the factory there
are several action and standard operation procedures that have to be done quickly whenever
an accident happened. One of the procedure is to ensure proper information is being
collected, so that the purpose of the investigation which to help reduce or prevent any future
incidents from happening is satisfied. Safety officer has to find the root cause of the accident
and analyse the details of the event. Information obtained from the investigation is really
useful to prevent the accident from re-occurring. The investigation process should begin after
attending first aid or medical treatment towards the injured person(s). Steps of the
investigation process are as the followings;

1. Secure the area where the accidents happens and preserve the area.
2. Gather all the evidences and information needed
3. Gather witness and perform interviews
4. Determine the root cause
5. Prepare the incident report and notify to Department of Safety and Health (DOSH)

2.1 Secure and Preserve the Scene

Part III of Occupational Safety And Health (Notification Of Accident, Dangerous

Occurrence, Occupational Poisoning And Occupational Disease) Regulations 2004
later written as NADOPOD states that there should be no interference at accident or
dangerous occurrence scene stated where the accident or dangerous occurrence
causes the death of any person or serious bodily injury to any person or serious
damage and dangerous to plant or other property, no person shall, unless authorized

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 to do so, remove or in any way interfere with or disturb any plant, substance, article or
thing related to the incident except to the extent necessary to ;
(a) Save the life of, prevent injury to, or relieve the suffering of any person;

(b) Maintain the access of the general public to an essential service or utility; or

(c) Prevent further damage to or serious loss of property or environment.

Therefore, the safety officer in charge should mark the scene with something
clear such as yellow tape or barricade the scene with cone. The safety officer then
have to inform all personnel not to remove any thing from the accident scene and
prevent unauthorised personnel to cross the restricted area.

2.2 Gathering Evidences and Information.

After the victim has been treated or send to the hospital and ensure the
condition of the victim stable, the Safety Officer must immediately investigate and
record all the detail about the incident. Before investigation starts, all running work
are put to stop to give way for investigation and to preserve the scene where the
accident occurred. All the object involve and the place of falling are recorded
either in video or picture form. The information gathered can be used during
investigation session.

General Information
Case Title: Died, crushed by brick wall
Location: Factory in Kedah
Date: 25th of January 2019
Case Summary: The victim of a general worker was died on a concrete wall that fell
while the victim was pushing the iron door in the factory area.
Case Classification: Fatality
Contributing Factor: Serious injury to head
Preliminary Observation: The victim safety helmet has been open and the brick hitting his head.
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 2.3 Gather Witnesses and Perform Interviews

I. Observing Construction Site Logbook.

Date Name Position Time In Time Out

25/01/2019 Nabil Worker 7.30 am

From the logbook it can be seen that the victim is a registered and authorized
worker in the factory.

I. Perform Interview.

2 other workers are being interview in order to gather information, the first
interviewee are the worker that work on the same shift with the victim.

Interviewee’s name: Muhammad Razlan Date: 25th of January 2019

Time: 3.00pm

Relation: Victim’s Colleague

1. When was victim go inside the construction site? At 7.30 am.

2. Does the victim shows any sign of sickness? No. The victim is in healthy condition.

3. Did the victim wear PPE?

Yes, he wore required PPE: safety helmet, safety boot, glove and safety jacket.

4. What was the weather? Cloudy weather, 25 C.

5. What happened to the victim?

The victim had been crushed by brick wall during closing the iron door.

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 Table 2.3.1 : Interview script with victim’s colleague.

From the interview session, it can be seen that the victim abide rule by wearing
PPE inside the factory. The victim is also in good condition and shows no sign of
sickness. The second interview have been conducted with the safety officer on duty.

Interviewee’s name: Zharif Rahizi

Date: 6th January 2019
Time: 2.00pm

Relation: Operational engineer

1. What happen on that day?
The victim was working at the factory that day.
2. Did you perform daily meeting with all workers before they start
working? Yes, each worker will be given daily briefing before they
start working.
3. Did the victim wear PPE?
Yes, he wore required PPE: safety helmet, safety boot, glove and safety jacket.
4. Did the victim receive training about safe work in the factory?

Yes, each worker has been given training appropriately.

5. Did the written instructions, procedures and risk assessments have been
placed at the worksite?
Yes, there is written instructions, procedures and risk assessments for all the
machinery that need to be used.
6. Why the victim need to push the iron door on that
day? The weather are cloudy and in order to avoid
rain from entering the factory site the door must be
closed.
.
7. When is the iron door and brick structure of the factory last
inspect? It last inspect around 2009 it was around the time the
factory first open.
8. Where are you during the accident? I am attending the meeting with other
manager about this month sales.

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Table 2.3.2 : Interview script with site supervisor.

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 From the interview session with the operational engineer on duty, it can be
seen that the victim is working as usual and wear complete PPE. He also have
been given briefing before the work start. The factory also have safety signs as
reminder for the worker to practice safe working ethics. However, the working
condition at the victim area does not comply with OSHA 1994, where the wall
structure and the iron gate does not inspect and maintain properly. The brick wall
suddenly fell to the victim when the worker pushing the iron gate. The victim died
on the way to the hospital.

2.4 Determine the Root Cause

According to the information and evidence gathered during investigation, the root
cause of the incident can be determined. The victim wore complete PPE such as
safety helmet, safety boot, gloves and safety jacket during the accident. He also
does not have any health issue that may cause the accident. The victim has been
provided with sufficient training related to OSHA 1994. Therefore, it can be conclude
that the cause of the accident does not come from the victim.
Further investigation of the accident shows that the cause of the accident came
from the building structure of the factory which itself and due to no standard working
procedure (SOP) and HIRARC for opening and closing the iron gate. Based on the
evidence obtained from the scene, it can be seen that the condition of the wall
structure of the factory are not properly maintain. The brick wall was very old and
have a lot of crack on it and the iron gate itself has rust.

2.5 Prepare Incident Report and Notify Department of Occupational Safety and
Health

After all the data were obtained and the root cause has been determined, safety
officer should prepare a report regarding the accident and submit to DOSH
Malaysia. The report should include all the findings from the incident scene, the
interviews and the data. The report should show the timeline of the incident and the
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cause of the incident whether it is direct or indirect. It is crucial to include all the
details of the incident including photos and diagrams so that the person that review
the report can know every details of the incident.

When an accident happens in workplace, it is required under Occupational Safety

And Health (Notification Of Accident, Dangerous Occurrence, Occupational
Poisoning And Occupational Disease) Regulations 2004 later written as NADOPOD
for the safety officer in- charged to report the accident to DOSH but first the safety
office must identify who was injured in this case it was one of the employee. This
case involved fatality. Both this factor then require the safety officer to first notify
nearest DOSH state office immediately, therefore the nearest DOSH state office is
at Menara TJB, Tingkat 9,Jabatan Keselamatan dan Kesihatan Pekerjaan Johor,
Jalan Dato' Mohd Mufti, Taman Dato Onn, 80534 Johor Bahru, Johor. Next, step is
the written report need to be send using form JKKP 6 within seven working days.
For the last all the collected data about the employee and accident need to be fill in
the form JKKP 8 & JKKP 9 then submit the letter to DOSH and the record must be
kept at the workplace for 5 years. Form JKKP 6, JKKP 8 and JKKP 9 are shown in
the appendix.

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3.0 PART B - PREVENTIVE ACTION

Preventive actions are measures taken to ensure the risk of accidents either can be
reduce or eliminate. So that, the same accidents will not happen again in the future. If
the accident involved fatality, preventive actions have to be implement immediately.
Preventive actions can be classified into hazard control. There are a total number of 5
types of control which are elimination, substitution, engineering control, administrative
control and personal protective equipment (PPE). The effectiveness of the controls
method increase going up the chart as shown below.

Figure 1: Hierarchy of controls

For instance, this type of case is better to be approach using administrative control,
engineering control and the personal protective equipment as the preventive actions to
effectively reduce the occurrence of accident.

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3.1 Engineering Control

Engineering controls are methods that are built into the design of a plant,
equipment or process to minimize the hazard. Engineering controls are a very
reliable way to control worker exposures as long as the controls are designed, used
and maintained properly. For this type of accident it will be recommended that to
install the automatic door in order to avoid the same accident happen again.

3.2 Administrative Control

Administrative controls (or work practice controls) are changes in work

procedures such as written safety policies, rules, supervision, schedules, and
training with the goal of reducing the duration, frequency, and severity of exposure to
hazardous chemicals or situations. Administrative control is more effective compared
to PPE. This is due to the method involves some method of earlier planning and
avoidance while PPE only aids only as a final barrier between the hazard and
worker. Administrative control requires workers and employers to dynamically think
or comply with regulations and they do not offer everlasting solutions to problems
makes the method is in second last position in term of effectiveness. In general, cost
involved to apply this method is more economical in early stage but might become
more expensive over time as higher failure rates and the need for constant training
or re-certification eclipse the initial investments of the three more desirable hazard
controls in the hierarchy.
In the summary of this case, administrative control can be taken by providing
performing the inspection and maintenance on the brick wall to ensure the concrete
wall construction in a safe and sound state. Besides, by providing SOP and HIRARC
for the opening and closing of iron gate also can help to avoid this accident from
repeating. Besides, by giving inspecting all the workers so that they wear their PPE
properly.

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3.3 Personal Protective Equipment (PPE)

Personal protective equipment (PPE) is equipment worn by any employee

that is being expose to any type of hazard and risk to manifestation of accident.
PPE is used to minimize exposure of hazards that can contribute to serious
workplace injuries and illnesses. Either Injuries or illnesses might happen due to
contact with chemical, radiological, physical, electrical, mechanical, or other
workplace hazards. There many type of PPE that have been applied in the
industry according to type of hazard that may expose to the employee. Basic
personal protective equipment may include items such as gloves, safety glasses
and shoes, earplugs or muffs, hard hats, respirators, or coveralls, vests and full
body suits. All personal protective equipment should be design accordingly to the
specifications required and should be maintained in a clean and reliable manner.
PPE should fit comfortably to the wearer. The objective of PPE will not be
achieved if it is not worn properly. Personal protective equipment (PPE) is
considered as the last resort to protect workers from hazard during working.
According to OSHA regulations, employer
should provide sufficient and adequate PPE to worker. Employer also
should ensure their worker wear and use PPE while on duty or do not provide
sufficient protection, employers must provide personal protective equipment to
their workers and ensure its proper use. Employers are also required to train each
worker required to use personal protective equipment and not to charge PPE on
employee (section 26).

Based on investigation and analysis made, the victim had wear all the
necessary PPE but the victim does not wear it properly where the safety helmet
are not tightly wear at the victim head and this cause the helmet suddenly open
during the accident and the brick hit the victim’s head.

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4.0 PART C – ETHICAL PRIINCIPLES AND PROFESSIONAL ETHICS

Professional ethics is a term that encompasses the organizational and personal

standards of behaviour a professional individual is expected to possess. Most organizations
have their own internal code of practice that defines the professional ethics of a certain
profession. This behaviour tends to be good for business and involves demonstrating respect
for key moral principles that include honesty, fairness, equality, dignity, diversity and individual
rights.

For this case of study, the incident happened costs the worker to suffer serious injury on
his head that led to his death. Investigation made shows that it occurs because of the working
environment of the factory containing many hazards. The brick wall fell to the victim since the
wall are not properly maintain and inspect. The situation rises due to lacks of ethical working
practice stated by OSHA 1994. Besides, the authority at the factory does not check their
workers whether their workers wear the PPE properly or not. Most of the workers wear their
safety helmet without tightening their chin strap.

We can conclude that hazard can be found anywhere not only on high speed rotating
machine or electrical appliances but even opening and closing the door can cause injuries to the
people. Safety are the most important things to taken care during works. As a suggestion to this
non-ethical issues, safety officer play big roles to make sure safety in workplaces by double
check that worker provided with proper personal protective equipment (PPE) and always
encourage them to practice OSH.

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5.0 REFERENCES
1. Occupational Accidents Statistics by Sector Until October 2019 (investigated). (n.d.).
Retrieved December 9, 2019, from http://www.dosh.gov.my/index.php/statistic-
v/occupational-accident-statistics-v/occupational-accident-statistic-2019.
2. Wahab, N. B. A. (n.d.). Fatal Accident Case. Retrieved December 1, 2019, from
http://www.dosh.gov.my/index.php/fatal-accident-case.
3. Occupationa Safety and Health (Notification of Accident, Dangerous Occurrence,
Occupational Poisoning and Occupational Disease). Retrieved December 1, 2019,
from http://www.dosh.gov.my/index.php/en/legislation/regulations-1/osha-1994-act-
154/521-02-occupational-safety-and-health-notification-of-accident-dangerous-
occurrence-occupational-poisoning-and-occupational-disease-regulations-2004/file.
4. Dalto, J. (2019, October 31). How to Conduct an Incident Investigation: Convergence
Training. Retrieved from https://www.convergencetraining.com/blog/how-to-conduct-
an-incident-investigation.
5. Occupational Safety and Helath Act 1994 (Act 514). (n.d.). Retrieved December 2,
2019, from http://www.dosh.gov.my/index.php/legislation/acts/23-02-occupational-
safety-and-health-act-1994-act-514.

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6.0 APPENDICES

Figure 2 : JKKP 6 form

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Figure 3 : JKKP 8 form

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Figure 4 : JKKP 9 form

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