FACULTY OF HOTEL AND TOURISM MANAGEMENT

MARA UNIVERSITY OF TECHNOLOGY (UiTM)

CAMPUS PERMATANG PAUH, PENANG

BACHELOR OF SCIENCE (HONS.) IN CULINARY ARTS MANAGEMENT

OCCUPATIONAL SAFETY AND HEALTH (MEM603)

INDIVIDUAL ASSIGNMENT - ACCIDENT INVESTIGATION

(WORKER DIES STUCK TO MACHINE)

PREPARED BY:
NUR IZZAH IMAN BINTI MOHD HANAFI (2021196127)
PHM2455B1

PREPARED FOR:
SIR RASDI BIN DERAMAN

SUBMISSION DATE:
13 MAY 2022

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 FACULTY OF MECHANICAL ENGINEERING,

UNIVERSITY TEKNOLOGI MARA (UiTM)

INDIVIDUAL ASSESSMENT FORM

OCCUPATIONAL SAFETY AND HEALTH (MEM 603)

LECTURER NAME DUE DATE SUBMISSION DATE REMARKS

ENCIK RASDI BIN 13 MEI 2022 13 MEI 2022 -on time/- late
DERAMAN

GROUP NO HM2455B1

No Name Student ID
1 NUR IZZAH IMAN BINTI MOHD HANAFI 2021196127

GENERAL LEVEL POOR MARGINAL ACCEPTABL GOOD EXCELLENT

GUIDELINES E
:
Scale 1-2 3-4 5,6 7,8 9,10

Assessment Criteria (Report) Weight (w) Scale (y) Total= w * y

Introduction 10
Content/ Diagrams/Figures/ Discussion and Conclusion

Part A- Accident Investigation 40

Part B- Preventative Action 20
Part C - Identification 20
Format, Language and Organization, 10
References and citation
TOTAL 100%

REMARKS:

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TABLE OF CONTENTS

TABLE OF CONTENTS PAGE

Cover Page i

Table of contents 1

1.0 Introduction 2

2.0 Selected Serious Case Accident 3

3.0 Part A : Accident Investigation 4-9

4.0 Part B : Preventive Actions 10-13

5.0 Part C : Ethical Principles and Professional Ethics 14-15

6.0 Conclusion 16

7.0 References 17

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1.0 INTRODUCTION

One of the employees of a hand glove manufacturing plant in Bercham died as a result
of poor workplace safety practises on 21st of November 2020 at approximately 4 p.m. It was
reported that the worker was from Burma and was a production line operator for the company.
A media statement issued on 23rd November, by Ir. Zamzurin Maarof, director of the Perak
Department of Occupational Safety and Health (DOSH), revealed that the poor worker was
washing the excess mix out of the gloves mould when he was killed.

After that, the victim proceeded under the transfer line machine, where his head became
trapped between the machine and the chargement line machine of the automated production
line system. This resulted in severe damage to the victim’s brain, which resulted in his
immediate death. Immediately following the incident, a team of investigative officers from
DOSH Perak was sent out to the location and issued a disturbance prevention notice of the
production line to the factory mentioned until further investigations and improvement works
were completed by the employers in question. Not only that, but a restriction notice was also
issued for failing to provide a secure production line working system. Those found guilty of
violating the Occupational Safety and Health Act of 1994 will face severe consequences.

Employers are accountable for identifying and analysing any potential hazards in the
workplace and developing an effective risk control strategy before workers begin their work
responsibilities. Such incidents may have been avoided if employers had followed the Hazard
Identification, Risk Assessment, and Risk Control (HIRARC) approach.

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2.0 SELECTED SERIOUS ACCIDENT CASE

Date : 21st November 2020

Title Case : A worker was fatally injured after being trapped in machinery.

Location : Manufacturing, Perak

Summary Case : An employee was killed after the victim's head got trapped in a moving
machine that was operating automatically.

Observation :

1. The failure to offer SOP and HIRARC for all operations in the appropriate workplace
division is a common occurrence among employers.
2. The employer does not ensure that a barrier is provided at the base of the machine.
3. There is no cautionary notice indicating that employees are not permitted to access the area
below the machine

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3.0 PART A : ACCIDENT INVESTIGATION
In every safety management system, accident investigation is the most critical
component of the overall process. During this part of the process, we can have an explanation
on what are the causes of the accidents and what do we do in order to prevent them from
happening again in the future. The major objective of conducting accident investigations is to
enhance health and safety performance by uncovering both the immediate and core causes of
the incident. Not only that, but the objective can also be achieved by providing solutions to
improve the health and safety management system by enhancing risk control, deterring
recurrence, and minimizing financial losses.

All accidents, regardless of severity, must be taken into account and must be
investigated rigorously. Serious accidents have the same underlying causes as minor accidents,
as do occurrences with the potential to result in severe loss. It is these underlying reasons that
lead to the accident. The results of accident studies have constantly revealed that the number of
less serious accidents outnumbers the number of catastrophic accidents and that there is a
higher number of incidents than there are accidents.

There are several steps that we need to go through in order to carry out the accident
investigation with professional ethics and this includes five steps. The steps mentioned are to
deal with immediate risks, select the level of investigation, investigate the event, record and
analyze the results, and the last one, review the process.

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 Deal with immediate risks

Select the level of investigation

Investigate the event

Record and analyse the results

Review the process

Figure 1 Accident Investigation Process

1. Deal with immediate risks.

Industrial types of machinery are quite hazardous. Workers who must operate them on a
daily basis are in danger of a variety of injuries. When accidents and events happen, quick
action may be required to make the situation safe and avoid additional injuries. Assist, treat,
and, if necessary, rescue injured individuals.

The safety of the employees is supposed to come paramount, and it is vital that an
injured employee receives prompt medical care. In the event of an emergency, make sure to
reach out to Malaysia Emergency Response Services (MERS) at number 999. In non-
emergency cases, send the wounded employee to a medical institution.

2. Select the level of investigation.

Those cases that include severe injuries, illness, or loss should receive the highest
amount of attention and effort. Additionally, those that had the potential to inflict much more
injury or damage must also be taken into consideration. Accidents and incidents of this type
require a greater amount of meticulous investigation and more management effort.

In most cases, this may be accomplished by taking a more in-depth look at the factors
that ultimately led to key occurrences. Furthermore, it might be accomplished by delegating the

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duty of conducting investigations into more significant incidents to managers in higher-level
positions.

3. Investigate the event.

The following are some of the things that investigations are conducted to determine:

1. The past state of events and the processes that led to their occurrence.

2.What transpired is the series of occurrences that lead up to the conclusion that was reached.

3. An explanation of why things transpired in the manner in which they did, including an
investigation into both the direct and underlying reasons.

4. What steps need to be taken to prevent the same mistake from happening again, and how can
it be accomplished.

There are three variations of sources that the investigators can retrieve information
regarding the accident and incidents from, which are through observation, documents, and also
interviews.

I. Observation.

In order to facilitate an investigation, the scene of any significant accident has to be

secured as soon as possible. The person in charge should restrict access to the location of the
incident to prevent other mishaps, and then we also should lock up and store any machinery or
supplies that were involved in the incident.

It is important to conduct a thorough investigation of the accident scene as soon as

possible after it has occurred. Particular attention needs to be paid to positions of individuals,
Personnel Protective Equipment (PPE), tools and materials, plants, or substances that are being
utilized.

The investigators can obtain information regarding the accidents from physical sources
such as premises and workplace, access and exit, plants and substances being used, the location
and relationship of physical particles, and any post-event checks, sampling, or reconstruction.

II. Interview

As for the interview, the information related to the incidents and accidents can be
obtained from those who related to the accidents and their line managers, witnesses, and also

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those who witnessed or participated in the event prior to it taking place, such as inspection and
maintenance employees.

It is of the utmost essential to conduct interviews with the individuals involved in the
accident as well as any witnesses to the incident. Ideally, these interviews should take place in
the individual's normal environment so as not to make the individual feel uncomfortable. It is
crucial to conduct the interview in a manner that places more focus on prevention than it does
on assigning blame. Rather than the investigators providing a narrative of what took place, the
individual or persons involved should provide their own perspective on the events. In order to
prevent people from having an effect on one another during interviews, there should be some
separation between them. When questions are posed, they should not be threatening since
otherwise the investigator may be perceived as confrontational and reflecting a blame culture.

III. Documents

Another type of sources that the investigators can find information from are written
instructions of procedures, risk assessments, and policies also documentation of previous
investigations, screenings, investigations, and surveys. The documentation that needs to be
found for the investigation purpose is the documentation of the inspections, tests,
examinations, and surveys that were carried out prior to the event. These give information on
how and why the conditions that led up to the incident arose in the first place.

4. Record and analyse the results.

The next step in the accident investigation process is to record the information prior to
the case and analyse the results after obtaining the information. All of the information about the
accidents and incidents that occurred must be documented using a methodical approach that is
consistent throughout the investigation process. Moreover, the person in charge also needs to
create a record of the accidents and events’ history for future reference. In addition, the cause
and effect analysis should also be analysed as well as a list of suggested protective and
preventative actions. The documentation and analysis should be finished as quickly as possible
after the accident took place.

The details of the accident and any corrective steps taken should be notified to all of the
supervisors so that they can take a note of what has happened to the employees under their
supervision and things that they should do to prevent the same accidents from occurring again.
It is possible that such supervisors will also be required to put appropriate preventative
measures into effect. Investigation reports and accident statistics should be analysed on a
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regular basis in order to find common causes, characteristics, and patterns that may not be
obvious when occurrences are viewed in isolation.

Figure 2 Example of Accident Report Form

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5. Review the process
After recording and analysing the results of the investigation, the last step that is left to
do is to review the process. The things that need to be taken into consideration when
conducting a review of the accident or incident investigation process are the findings of the
investigations and analyses also the functionality of the investigation system in terms of quality
and effectiveness of the investigation system.

Line managers are responsible for following up and putting the findings of
investigations and analyses into action. In areas where it is important to do so, the
establishment of follow-up procedures is recommended in order to keep the pace of
advancement under control. The investigative system should be checked regularly to ensure
that it consistently delivers data in compliance with the specified objectives and criteria.

Typically, this involves the responsible party reviewing samples of investigation forms
to confirm the quality of the investigation and the causation and remedial action
recommendations. In addition, we must verify the number of incidents, near-misses, injuries,
and illnesses, as well as document all the documents of the accidents that occurred.

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4.0 PART B: PREVENTIVE ACTION
As mentioned before, after providing any necessary medical aid to a worker who has
been hurt while working under supervision, the next step is to conduct an investigation and
identify the root and the causes of the accidents in the first place. The results of the
investigation and analysis will typically result in additional personal protection equipment,
enhanced training opportunities, or more stringent control measures. Upon knowing the root of
the problems and accidents, the best thing to do in order to prevent the same thing from
happening again is by eliminating the possible existing risk that exists within the workplace
that may cause harm to the employees.

The hierarchy of control is a pyramid of steps that should be reviewed in order when
evaluating the approaches to eliminate or decrease an identified risk. Each step in the hierarchy
should be taken into consideration before moving on to the next. Although each level of the
pyramid should be taken into consideration, priority should be given to control measures that
are located higher up in the hierarchical structure rather than to those that are located lower
down. Implementing all those levels of the hierarchy at the same time is often going to result in
the most efficient risk control.

Figure 3 Hierarchy of Risk Controls

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1. Eliminating the risk.

The most crucial and efficient step in the hierarchy of control is to remove all the
potential hazards from the workplace to ensure that there is no possibility of a subsequent
occurrence. Even if it might not be possible to eliminate the risk entirely in the majority of
situations, this should always be the first control measure that needs to be considered. For
instance, things that can be eliminated in order to prevent the same accidents from happening
again are removing any potentially harmful activities, tools, processes, equipment, machinery,
or substances that can bring harm to the employees and staff.

2. Substituting the risk.

The next step down in the hierarchy is risk substitution. Risk substitution is the process
of changing one risk for another that is less likely to happen or has less serious possible
outcomes. Substitution is not as good as getting rid of the risk completely because it still exists,
even though it is much fewer. As an example of risk substitution, you could replace loud
equipment with quieter equipment or a highly dangerous substance with a less dangerous one.
After the change has been made, a detailed risk assessment should be carried to find out if the
new approach has created any possible risk.

3. Isolate the risk.

The employee is protected from the risk factor by a process known as risk isolation,
which involves putting a barrier of some kind between the worker and the risk factor. The
barrier is the sole thing protecting the worker from danger, which means that the risk is still
there. This is the primary distinction between this level and level one, which eliminates all
risks. The danger would once again be uncontrollable if the barrier were to become ineffective
or be required to be circumvented. It is possible to isolate risks by establishing remote control
systems and relocating potentially hazardous machinery to a room that is physically different
from the one in which it is operated.

4. Engineering controls.

The process of engineering risk control entails the planning, design, and installation of
supplementary safety measures to equipment used in the workplace. The installation of more
strict ventilation systems in harmful workplaces and the installation of guardrails on elevated
walkways are both examples of safety elements that might be implemented.

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5. Administrative Controls.

The administrative controls level represents level five of the hierarchy. These are the
preventative actions that may be taken by management and higher-ups in the chain of
command to lessen the chances of an incident taking place. The provision of specialised
training that is specifically geared toward the danger or the organisation of work schedules in
such a way as to restrict the amount of time spent in potentially dangerous surroundings are
two examples of possible countermeasures.

Figure 4 & 5 Examples of Hazard notices

6. Personal Protective Equipment (PPE)

The utilisation of personal protective equipment is the lowest stage in the hierarchy of
risk control (PPE). However, despite the fact that it is likely to be utilised regardless of what
other levels are also being used to control risk, it continues to be placed at the bottom of the
hierarchy due to the fact that it does not eliminate or significantly lower the risk itself. Instead,
the focus of this level is on preparing for the possibility that an incident may take place and
preventing the employee in from harm. Personal safety equipment includes things like hard
helmets, ear protection that reduces noise, cut-resistant gloves, and many more. 

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Figure 6 List of PPE

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5.0 PART C: ETHICAL PRINCIPLES AND PROFESSIONAL
ETHICS
Maintaining good standards and proper work ethics is essential to the success of any
organisation. They must also be practising a high system of ethics while doing their job. This is
to prevent any misunderstandings between management and staff. If safety is not taken into
consideration, the organisations themselves will suffer a loss in profit. They, as well as the
organisation, will profit much if they continue to sustain this element of their work. Several
ethical issues are associated with the case study shown below :

1. Not providing an appropriate standard operating procedure (SOP)

According to the findings of the investigation, the company did not adhere to the
requirements imposed by Department of Occupational Safety and Helath (DOSH) on its
employees. The company did not provide the appropriate standard operating procedure (SOP)
for working for them. This will have a significant effect on the workers' safety, and as a result,
it demonstrates that the organisation mentioned does not give consent regarding the workers'
safety. Due to the fact that the workers are not provided with appropriate training by the
company, such as safety training, the level of risk associated with that activity will significantly
increase. The workers will then be exposed to a hazardous working environment as a result of
this.

2. Corruption

One of the unethical problems that are associated with the operations of this
organization's business is that it does not provide its employees with what is undoubtedly their
main right, which is to provide a safer working environment for its employees. . This is due to
the fact that this company does not provide the establishment of Safety Health and Committee,
which is a fundamental component that any organisation must have. This demonstrates that the
emphasis of this firm is entirely on producing greater profits, even if it means sacrificing the
safety of its own employees to achieve this goal. We all know that having a Safety and Health
Committee in a company is crucial because it will keep an eye out for and investigate any
possible risks that can result in an accident. 

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3. Does not comply with the laws and acts as specified

This demonstrates that the organization does not fully commit to and obey the
guidelines that have been established by the Department of Safety and Health (DOSH), which
are outlined in the OSHA Act of 1997. According to the act, every company needs to establish
the Safety and Health Committee within the organization but the company, in this case, does
not bother to form one which is why they are considered as not abiding by the law. Moreover,
the company also did not provide an appropriate standard operating procedure that had resulted
in their employees being injured severely. Without a proper standard operating procedure, this
might be one of the variables that contributed to the occurrence of the accident.

4. Lack of awareness of the hazard.

This happens because of the fact that the organization did not take the safety ad health
of the workers as a serious matter. They ignore the laws and do whatever they think is enough
without thinking about the fact that the workers will get hurt because of their carelessness. As
a result of their reckless behaviour, the employers became less conscious of the risks and
hazards at work, hence increasing the chance of them getting harmed.

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6.0 CONCLUSION
In conclusion, every employer needs to make sure the safety and health of the
employees and staff working under their supervision. The employees have the right to work in
a safe organization regardless of their scope of job and ranks. There is risk everywhere in the
workplace but we can always be prepared for any possible situation by following the guidelines
and legislation provided by the Department of Occupational Safety and Health (DOSH). As
mentioned before in the previous parts, the act of taking preventative measures is important for
the sake of the safety and health of everyone in the organization. If the higher us and employers
do not take the safety and health of the employees as a serious matter, accidents will keep on
occurring and the numbers of people getting injured while working there will be increased and
never decreased. If only they, the organizations abide by the laws and legislation made by
DOSH, the rates of accidents at the workplace can decrease and the workers also feel safe to
work without having to worry about getting injured working.

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7.0 REFERENCES
A. (2020, September 25). Hierarchy of Control | Workplace Health and Safety. Conserve®.

https://conserve.com.au/how-the-hierarchy-of-control-can-help-with-workplace-health-

and-safety/

Farris, R., & Pitt, L. L. P. (2019, May 9). 8 Most Common Workplace Injuries for Factory

Workers. Farris, Riley & Pitt, LLP Personal Injury Attorneys.

https://www.frplegal.com/industrial-accidents/8-most-common-workplace-injuries-for-

factory-workers/

Graham, T. (2022, April 4). The Hierarchy of Controls: What It Is and How to Use It. KPA.

https://www.kpa.io/blog/the-hierarchy-of-controls-what-it-is-and-how-to-use-it

Quezada, D. (2015, May 6). Steps to take when an injury happens at work. The Business

Journals. https://www.bizjournals.com/bizjournals/how-to/human-resources/2015/05/

steps-to-take-when-an-injury-happens-at-work.html

Teh, C. (2020, November 23). Employee Dead Due to Negligence of Work Safety. Ipoh Echo.

https://www.ipohecho.com.my/2020/11/23/employee-dead-due-to-negligence-of-work-

safety/

Wahab, B. N. A. (n.d.). Official Website Department of Occupational Safety and Health -

Fatal Accident Case. Official Website Department of Occupational Safety and Health.

https://www.dosh.gov.my/index.php?

option=com_content&view=article&id=955:accident-

case&catid=352&Itemid=757&lang=en

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