“Those who do not learn from their

mistakes, are bound to repeat them”

KNU1053
SAFETY MANAGEMENT AT WORKPLACE
By: Assoc Prof Dr Rubiyah Baini
Department of Chemical Engineering & Energy Sustainability
Faculty of Engineering, University Malaysia Sarawak
Any unplanned event that results in
 Personal injury
 Property damage
 Fatality
 Short & long term Health deterioration
 Incident
◦ An unplanned event that does not result in personal
injury but may result in property damage or is worthy of
recording.
 Near-Miss
◦ An event that does not result in an injury or damage. It is
important to record and investigate near-misses to
identify weaknesses in the SMS that could possibly lead
to an injury or damage.
 Example : Incident

An incident disrupts the work process, does not result in injury or damage, but should
be looked as a “wake up call”. Could lead to a situation that cause harm or damage.
o Human error, equipment failure, lack of
awareness on the dangers at workplace,
lack of knowledge and etc.
What can you say about this ?
We like to think that accidents are unexpected
or unplanned events, but sometimes, that's not
necessarily so. Some accidents result from
hazardous conditions and unsafe behaviors that
have been ignored or tolerated for weeks,
months, or even years.
• Why accident investigation is conducted?
o To collect facts
o To improve the work system
o To prevent similar accidents from happening again
o To protect workers
• An accident investigation is not about blaming people,
but to find the root causes of the accident.
• An accident investigation is the analysis and account of
an accident based on information gathered by a
thorough and conscientious examination of all factors
involved.
 “Well that’s an
accident waiting to
happen…”
 “Someone ought to do
something…”

That someone is YOU!

As a general guideline, a report would be expected
when:
 The incident resulted in an injury which required
immediate medical attention beyond the level of
service provided by a first aid attendant, or injuries
to several workers which require first aid.
 The incident resulted in a situation of continuing
danger to workers, as when the release of a
chemical cannot be readily or quickly cleaned up.
Who are they?
 Supervisor

 Safety committee

 Qualified personnel

-those who have been trained, expert in accident causation,

experienced in investigative techniques, fully knowledgeable of
◦ work processes
◦ procedures
◦ persons and industrial relations environment
- and those who are unbiased
 Secure the accident scene
 Collect facts about what had happened
 Develop the sequence of events
 Determine the causes
 Recommend improvements
 Write the report
 Follow-up
o Take measurements
o Take pictures
o Evaluate equipment
 Secure the accident scene
Sample Accident Investigator's Kit
• Camera
• Tape recorder
• Measuring tape
• Clipboard, paper, pencils, etc.
• Plastic bags with ties
• String
• Personal Protective Equipment
o Eye protection
o Hand protection
o Clothing
o Respirators
o Hearing protection
Make personal observations.
 What do you see? What equipment, tools, materials, machines, structures appear to
be broken, damaged, struck or otherwise involved in the event? Look for gouges,
scratches, dents, smears. If vehicles are involved, check for tracks and skid marks.
Look for irregularities on surfaces. Are there any fluid spills, stains, contaminated
materials or debris?
 What about the environment? Were there any distractions, adverse conditions
caused by weather? Record the time of day, location, lighting conditions, etc. Note
the terrain (flat, rough, etc.)
 What is the activity occurring around the accident scene?

 Who is there: Who is not? You'll need this information to take initial statements and
interviews.
 Measure distances and positions of anything and everything you believe to be of any
value to the investigation.
Look for witnesses
 If you're fortunate there will be one or more eye-witnesses to
the accident. Ask them for an initial statement giving a
description of the accident. Also try to obtain other information
from the witness including:
 Names of other possible witnesses for subsequent interviews.

 Names of company rescuers or emergency response service.

 Materials, equipment, articles that were moved or disturbed during

the rescue.
Take photos of the accident scene. Some important points to remember
about taking photos include:
 Take distance and close shots photos

 Take photos at different angles

 Take notes on each photo. These will be included in the appendix of the
report along with the photos. Identify the type of photo, date, time, location,
subject, weather conditions, measurements, etc.

Videotape the scene. The video recorder will pick up details and
conversations that can add much valuable information to your
investigation.

Sketch the accident scene

Some records you might want to review are:
 Maintenance records - to determine the maintenance history of the tools, equipment or machinery
involved in the accident.
 Training records - to determine the quantity and quality of the training received by the victim and
others.
 Standard operating procedures - to determine the formally established steps in the procedures.
 Safety policies, plans, rules - to determine their presence and adequacy.
 Work schedules - to determine if the victim might have been fatigued or otherwise overworked.
 Disciplinary records - if discipline is considered justified, to determine if disciplinary actions have
occurred previously.
 Medical records - if permission granted, or otherwise allowed, to determine potential
physical/mental contributing factors.
 Accidents records
 Safety Committee Minutes - to determine the history of any discussion of related hazardous
conditions, unsafe behaviors or program elements.
 Gathering data through interviews
 Who to be interviewed., and what questions to use. Some people you may want to consider for an
interview include:
• The victim. To determine specific events leading up to and including the accident.
• Co-workers. To establish what actual vs. appropriate procedures have been used. Preferably ones who
perform the same task.
• Direct supervisor. To get background information on the victim. He or she can provide procedural
information about the task that was being performed.
• Manager. Can be the main source for information on related systems.
• Training department. To get information on quantity and quality of training the victim and others have
received.
• Personnel department. To get information on the victim's and others' work history, discipline, appraisals.
• Maintenance personnel. To determine background on equipment/machinery maintenance.
• Emergency responders. To learn what they saw when they arrived and during the response.
• Medical personnel. To get medical information (as allowed by law.)
• Other interested persons. Anyone interested in the accident may be a valuable source of information.
• The victim's spouse and family. They may have insight into the victims state of mind or other work
issues.
 The investigation process is "fact-finding" not "fault-finding". Not to place blame.
Effective Interviewing Techniques - establish a cooperative relationship to obtain facts
 Keep the purpose of the investigation in mind: To determine the cause of the accident so that similar accidents will
not recur. Make sure the interviewee understands this.
 Approach the investigation with an open mind and calm. It will be obvious if you have preconceptions about the
individuals or the facts.
 Conduct the interview at appropriate location - "neutral" location.
 Interview the people involved (victim, witnesses, people involved with the process, i.e., forklift driver, mechanic).
 Put the person at ease. Explain the purpose and your role. Sincerely express concern regarding the accident and
desire to prevent a similar occurrence.
 Ask background information, name, job, what had happened
 Ask open ended questions to clarify particular areas or get specifics. Try to avoid yes and no answer (closed
ended) questions. Try to avoid asking "why" as these types of questions tend to make people respond defensively.
Example: Do not ask: "Why did you drive the forklift with under-inflated tires? Rather, ask: What are forklift
inspection procedures? What are forklift safety hazard reporting procedures?
 Repeat the facts and sequence of events back to the person to avoid any misunderstandings.
 Use atape recorder with permission.
 Ask for their suggestions as to how the accident/incident could have been avoided.
 Conclude the interview by thanking them for their contribution. Ask them to contact you if they think of anything
else. If possible, tell these people personally of the outcome of the investigation before it becomes public
knowledge.
The challenge at this point is to accurately determine the sequence of
events in the accident process, to effectively analyze the accident
process, and to determine related:
• Hazardous conditions. Things and states that directly caused the
accident.
• Unsafe behaviors. Actions taken/not taken that contributed to the
accident.
• System weaknesses. Underlying inadequate or missing programs,
plans, policies, processes, and procedures that contributed to the
accident.
Worker Error - The worker makes a choice to work in an unsafe manner. It implies that there are
no outside forces acting upon the worker influencing his actions and that there are simple
reasons for the accident. This thinking results may result in in blaming and short-term fixes.
Systems Approach - Accidents happen due to the defects in the system. People are only one part
of a complex system composed of many complicated processes This thinking results in long-
term fixes.
Other Theories - Explained the interaction among conditions, behaviors and systems that result in
an accident.
• Single Event Theory- The accident happens as a result of a single cause; It's convenient to
simply blame the victim when an accident occurs, such as lack of attentiveness may be
explained as the cause of the accident.
• The Domino Theory – The accident happens as a result of a series of related occurrences which
lead to a final event that results in injury or illness. The accident investigator will assume that
by eliminating any one of actions or events, the chain will be broken and future accidents
prevented. In the example above, the investigator may recommend removing the sharp edge of
the work surface (an engineering control) to prevent any future injuries. This explanation still
ignores important underlying system weaknesses or root causes for accidents.
• Multiple Cause Theory – The accident happens as a result of a series of random related or
unrelated acts/events that somehow interact to cause the accident. Unlike the domino theory,
the investigator will realize that eliminating one of the events does not assure prevention of
future accidents. Removing the sharp edge of a work surface does not guarantee a similar
injury will be prevented at the same or other workstation. Many other factors may have
contributed to an injury. An accident investigation will not only recommend corrective actions
to remove the sharp surface, it will also address the underlying system weaknesses that caused
it.
Cause levels
Management Safety Policies & Decisions
Basic Personal Factors Environmental Factors
Causes

Indirect
Causes Unsafe Act Unsafe Condition

Direct
Causes Unplanned Release of Energy
and/or Hazardous Material

Incident
(Source: http://www.labtrain.noaa.gov/osha600/refer/menu16a.pdf)
Direct Cause -Injury analysis
The cause that directly resulted in the occurrence. Example: in the case of a leak, the direct cause could have
been the problem in the component or equipment that leaked. In the case of a system misalignment, the direct
cause could have been operator error in adjustment of the alignment.

Indirect Cause - Event Analysis

The cause that contributed to the occurrence but, by it self, would not have caused the occurrence.
Examples: in the case of the leak, the indirect cause could be lack of adequate operator training in detecting the
leak and identifying its source. In the case of the systemmisalignment, an indirect cause could be that the operator
was distracted or that the tools to align the equipment had not been calibrated properly. It is an analysis on the
Interaction of hazardous conditions and unsafe behaviors to produce the injury.

Basic Cause (Root Cause) - Systems analysis

 The cause that, if corrected, would prevent recurrence of this and similar occurrences. Example: in the
case of the leak the root cause could be management not ensuring that the equipment is properly maintained. In
the case of the systemmisalignment, the root cause could be an ineffective training program. It is analysis on the
root causes contributing to the accident, such as inadequate safety policies, programs, plans, processes,
procedures, poor component design result in hazardous conditions and unsafe behaviors. Root cause analysis
(RCA) is a systematic technique that focuses on finding the real cause of a problem and dealing with that, rather
than just dealing with its symptoms. It look into the task, material/equipment, environment, human factors,
management factors
Machinery Methods

EFFECT

Materials People Environment

 Was a safe work procedure used?
 Had conditions changed to make the normal
procedure unsafe?
 Were the appropriate tools and materials
available and used?
 Were safety devices working properly?
 Was there an equipment failure?
◦ What caused it to fail?
 Poor design? …. Poor Maintenance?
 Were hazardous materials involved?
◦ Were they clearly identified?
◦ Was a less hazardous material possible/available?
 Should PPE has been used?
 Weather conditions?
 Housekeeping?
 Temperature?
 Lighting?
 Noise?
 Air contaminants?
 Age
 Experience
 Attitude
 Physical condition
 Health status
 Emotional status
 Had hazards been previously identified?
 Were hazards eliminated or adequately
controlled?
 Had procedures been developed to
address them?
 Were work procedures available/followed?
 Task Structure
 Work organization
 Workplace design/layout
 Equipment availability
 Policies/procedures
 Training program
 Supervision
The symptoms are visible, root causes lie beneath the surface.
◦ Poorly maintained machinery or equipment.
◦ Defective or missing personal protective equipment.
◦ Unguarded machinery or equipment.
◦ Missing or inadequate
warnings or safety and health
signs.
◦ Lack of housekeeping.
◦ Conduct work operations without
prior training
◦ Block or remove safety devices.
◦ Clean, lubricate, or repair
equipment while its in operation.
◦ Working without protection in
hazardous places.
Making system improvements might include some of the following:
 Including "safety" in a mission statement.

 Improving safety policy so that it clearly establishes responsibility

and accountability.
 Changing a work process so that checklists are used that include
safety checks.
 Revising purchasing policy to include safety considerations as well
as cost.
 Changing the safety inspection process to include all supervisors
and employees.
 Recommend control strategies – Hierarchy of control
 Accident
Prevention
 Date and time of accident:
 Person(s) involved/injured:
 Location (campus, building, which room number, which stairs/corridor and floor level, exactly
where in corridor):
 Investigation carried out by:
 Person(s) consulted during investigation (names, job title/company/school/office and dat
 Other sources consulted during investigation (eg manufacturers’ handbooks, risk assessments,
training records):
 Details of accident (factual description of what the individual was doing and what happened, what
injuries sustained):
 Immediate actions taken (eg first aid given, action to make area safe):
 Details of any sick leave taken or alternative duties assigned to the injured person following the
accident:
 Witness and other accounts (attach separate page if necessary):
 Background information (eg brief explanation of the task, purpose and operation of the equipment,
measurements, sketch of the area, environmental conditions at the time):
 Any other relevant information (eg other similar accidents, inspection findings):
 Immediate and underlying causes:
 Action(s) taken or proposed to prevent recurrence (short-term and longer-term measures):
 Signature(s) of investigator(s) and date of report:
 Every employer shall initiate corrective action
without undue delay to prevent recurrence of
similar incidents
 prepare a report of the action taken for
reference by workers.
 Confirm that action has corrected the problem.
http://www.dosh.gov.my/index.php/en/occup
ational-accident-statistics/by-sector

http://www.dosh.gov.my/index.php/en/occup
ational-accident-statistics/by-state

http://www.dosh.gov.my/index.php/en/occup
ational-diseases-and-poisoning-statistic

https://www.nst.com.my/news/nation/2017/0
9/277240/40000-msians-hurt-workplace-
accidents-2016-human-resource-ministry
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