Incident causation

Incident causation understandin" rel="nofollow">ing of the importance of usin" rel="nofollow">ing in" rel="nofollow">incident causation theories to guide in" rel="nofollow">incident in" rel="nofollow">investigation and analysis understandin" rel="nofollow">ing of different in" rel="nofollow">injury causation models ability to identify the suitability of in" rel="nofollow">injury causation models for analysis of an in" rel="nofollow">injury event understandin" rel="nofollow">ing of the process of learnin" rel="nofollow">ing from in" rel="nofollow">incidents ability to assess guidelin" rel="nofollow">ines for in" rel="nofollow">incident reportin" rel="nofollow">ing, in" rel="nofollow">investigation and analysis in" rel="nofollow">in relation to the learnin" rel="nofollow">ing from in" rel="nofollow">incident process Background This assignment is particularly related to modules 7 and 8. You should read the material and do the exercises related to these two modules before you attempt to do the assignment. For this assignment you need to read and analyse the case “Construction – fall from a buildin" rel="nofollow">ing”. The case describes an in" rel="nofollow">incident that resulted in" rel="nofollow">in a serious in" rel="nofollow">injury where a 19 year old man falls from a buildin" rel="nofollow">ing. It first gives an overview and then notes from four in" rel="nofollow">interviews with the people in" rel="nofollow">involved in" rel="nofollow">in the in" rel="nofollow">incident. These notes are from a real event made by an in" rel="nofollow">investigator. This case study can be found as an appendix to the assignment. When you write the assignment you should imagin" rel="nofollow">ine that you have been asked to help identify the causes of the in" rel="nofollow">injury event with the purpose of identifyin" rel="nofollow">ing how in" rel="nofollow">injury events like this can be prevented in" rel="nofollow">in the future. The purpose of the analysis is to help learnin" rel="nofollow">ing from the in" rel="nofollow">incident and to identify how preventive measures can be implemented in" rel="nofollow">in the two organisations. Imagin" rel="nofollow">ine that you are writin" rel="nofollow">ing this report to the two organisations. Tasks Write a report that addresses the followin" rel="nofollow">ing eight poin" rel="nofollow">ints. Describe the importance of usin" rel="nofollow">ing in" rel="nofollow">injury events to learn from and improve safety Arguments for usin" rel="nofollow">ing in" rel="nofollow">injury causation theories and models for the analysis of the in" rel="nofollow">injury event Discussion of the in" rel="nofollow">injury event usin" rel="nofollow">ing different in" rel="nofollow">injury causation models to illustrate how they identify different types of causes which can guide the effort to prevent similar events Recommend one or more models for the analysis of this in" rel="nofollow">injury event (Construction – fall from a buildin" rel="nofollow">ing) Use the model(s) to identify the causes Describe and justify a process that the two organisations can implement to learn from events like the fall from a buildin" rel="nofollow">ing. Discuss if ACC’s guidance (or part of the guidance) on in" rel="nofollow">injury in" rel="nofollow">investigation described in" rel="nofollow">in the document ACC366 “How to implement safer workplace practices” can be used to guide the learnin" rel="nofollow">ing from in" rel="nofollow">incident process you have recommended above. Describe the preconditions that both organisations needs to establish for the learnin" rel="nofollow">ing from in" rel="nofollow">incident process to be effective. The report needs to have: Front page Table of content Introduction (purpose of the report) Sections with appropriate headin" rel="nofollow">ings that cover poin" rel="nofollow">int 1 to 8 (described above) Conclusion References (use APA style see this Admin" rel="nofollow">inistration Guide or OWLL) Appendices if appropriate e.g. Worksheets when analysin" rel="nofollow">ing the event. Construction - fall from a buildin" rel="nofollow">ing Overview Who was in" rel="nofollow">injured? And what was his job Raymond, a 19 year old who had been workin" rel="nofollow">ing for Superiorsteel Limited for 15 months. It was his first job sin" rel="nofollow">ince leavin" rel="nofollow">ing school and he had no prior experience in" rel="nofollow">in the construction in" rel="nofollow">industry. He was origin" rel="nofollow">inally hired by Superiorsteel Limited for two months as an assistant welder. He then worked for them as a labourer in" rel="nofollow">in their workshop for six months. At the time of the in" rel="nofollow">incident he was workin" rel="nofollow">ing as a labourer on a buildin" rel="nofollow">ing site. (Superiorsteel was subcontracted by Bigconstruction Limited to do all the steelwork). Raymond’s job was to pick up and place concrete treads on the in" rel="nofollow">internal stairway and he also did the heavy liftin" rel="nofollow">ing usin" rel="nofollow">ing a hand operated electric hoist. He occasionally assisted and directed the site crane driver to lift material and equipment to different floors. But this was not part of his job description. What was the in" rel="nofollow">incident? Raymond was directin" rel="nofollow">ing a crane driver to move a gas bottle set and trolley from the fifth to the seventh floor. The wheels of the trolley caught on the guardrail. Raymond tried to free it by pullin" rel="nofollow">ing on it but the guardrail snapped and the trolley and Raymond swung out beyond the edge of the buildin" rel="nofollow">ing. Raymond fell 14 metres on to the concrete floor below. assignment 2 accident 1 Drawin" rel="nofollow">ings of scene of accident: assignment 2 accident 2 What was the damage? Raymond’s in" rel="nofollow">injuries were as follows: Seven fractures to his pelvis Extensive in" rel="nofollow">internal in" rel="nofollow">injuries in" rel="nofollow">includin" rel="nofollow">ing a ruptured spleen Punctured lung Compound and multiple fractures of both legs His right leg was amputated below the knee Interview 1: Raymond, the in" rel="nofollow">injured person (Superiorsteel) Raymond These are the notes from an in" rel="nofollow">interview with Raymond. The in" rel="nofollow">interview was held five weeks after the in" rel="nofollow">incident. It was held in" rel="nofollow">in the hospital a week after he had come out of a coma. Introduction Thanks for talkin" rel="nofollow">ing to me today Raymond. I know the fall has had a serious effect on you, and you have a great deal to cope with right now, so I appreciate your willin" rel="nofollow">ingness to talk to me. What I am tryin" rel="nofollow">ing to do is to fin" rel="nofollow">ind out exactly what happened, so that we can ensure somethin" rel="nofollow">ing like this doesn’t happen again" rel="nofollow">in. I’ll show you my notes after I have written them up, so that you can check that I have all the in" rel="nofollow">information right. Questions Replies 1. Raymond please describe what happened on the day of the in" rel="nofollow">incident. There was a bolt missin" rel="nofollow">ing on the main" rel="nofollow">in steel frame on level seven, so Barry (my supervisor) told me to get the gas weldin" rel="nofollow">ing equipment from level five and cut a hole for a bolt. 2. How do you get the gas weldin" rel="nofollow">ing equipment from one floor to another? We hook the gas equipment on to a chain" rel="nofollow">in on the crane and the crane driver lifts it up for us. I don’t do it very often because it’s not my job. 3. Was Barry goin" rel="nofollow">ing to supervise you doin" rel="nofollow">ing this lift? No, he believes that we learn by “trial and error” on the job. I was OK with that. 4. So what did you do next? I went and asked Matt (the dogman for Bigconstruction) to help me to get the gas equipment from level five to level seven. He said okay, and I went back up to level five and waited for him to come up. In the meantime Stan, another employee of Bigconstruction, wanted to use the crane too, so Matt stayed on the ground level. 5. What difference did it make with Matt not bein" rel="nofollow">ing on the same floor as you? Well, it really meant he left the job up to me. He still called out in" rel="nofollow">instructions to me and the crane driver, but he wouldn’t have been able to see very well from down there. 6. What happened next? The crane driver presented the hook and chain" rel="nofollow">in to me and I attached the chain" rel="nofollow">in to the gas equipment. I pulled the gas equipment trolley towards the edge of the buildin" rel="nofollow">ing, which was protected by a guardrail. Then I thin" rel="nofollow">ink the crane driver got fed up with me takin" rel="nofollow">ing too long because he could not see me and I could not see him. I thin" rel="nofollow">ink he took the load up without knowin" rel="nofollow">ing that I was still holdin" rel="nofollow">ing onto the bottles. 7. I see, and then? The bit of the trolley the bottles sit on got caught on the guardrail. I was tryin" rel="nofollow">ing to pull and push the trolley back down so it would release and then I would be able to brin" rel="nofollow">ing it back out. Before I knew it I was at the edge of the buildin" rel="nofollow">ing and I don’t know how I got there. It all happened so fast. I looked down and then up and saw the gas bottles were actually hangin" rel="nofollow">ing out in" rel="nofollow">in the air outside the buildin" rel="nofollow">ing. I let go at the last min" rel="nofollow">inute. My body went forward and I couldn’t grab onto anythin" rel="nofollow">ing because there was nothin" rel="nofollow">ing to grab onto. I thought if this is it then this is it. I remember fallin" rel="nofollow">ing and my whole body goin" rel="nofollow">ing forward. I remember hittin" rel="nofollow">ing the ground with my right leg first. The next thin" rel="nofollow">ing I remember is wakin" rel="nofollow">ing up and bein" rel="nofollow">ing told I had been in" rel="nofollow">in hospital for four weeks. 8. You said you were presented with the hook and chain" rel="nofollow">in by the crane driver – is that normal practice? Well not really, but I used to do it occasionally when we were very busy. 9. What was the usual procedure? Usually the dogman is on the same floor as me, and he gives in" rel="nofollow">instructions backwards and forwards between the crane driver and myself. 10. Why was the dogman not on level five with you on this occasion? Well, we were in" rel="nofollow">in a bit of a rush that day as we were behin" rel="nofollow">ind schedule. He had another load to supervise as soon as min" rel="nofollow">ine had fin" rel="nofollow">inished, so I suppose he thought he would save time by stayin" rel="nofollow">ing on the ground level where the next load was goin" rel="nofollow">ing to be loaded. 11. Why were you all in" rel="nofollow">in a rush? All Superiorsteel employees had received a notice that mornin" rel="nofollow">ing statin" rel="nofollow">ing that if we did not fin" rel="nofollow">inish the job by a certain" rel="nofollow">in date, we would lose our jobs. So it had been rush, rush, rush all day 12. Had you been given any train" rel="nofollow">inin" rel="nofollow">ing on workin" rel="nofollow">ing with a crane and movin" rel="nofollow">ing heavy loads? No, not really. 13. Is there anythin" rel="nofollow">ing else you would like to tell me about the in" rel="nofollow">incident? No, that’s all I can remember at the moment. 14. Thanks Raymond, I appreciate you talkin" rel="nofollow">ing to me. No problem. I only hope it helps prevent somethin" rel="nofollow">ing like this happenin" rel="nofollow">ing to someone else. Interview 2: Matt, the dogman (Bigconstruction) Matt These are the notes from an in" rel="nofollow">interview with the dogman. The in" rel="nofollow">interview was held on site in" rel="nofollow">in the smoko room, the day of the in" rel="nofollow">incident. Introduction Thanks for takin" rel="nofollow">ing the time to talk to me today Matt. As you know, I’m here to fin" rel="nofollow">ind out what happened today when Raymond was in" rel="nofollow">injured. It’s important we talk to everyone who was there, so we can fin" rel="nofollow">ind out exactly what happened. That way we can make sure it doesn’t happen again" rel="nofollow">in. Questions Replies 1. Matt, what is your position on this buildin" rel="nofollow">ing site? I’m employed by Bigconstruction as a dogman. 2. What exactly does a dogman do? The dogman loads and unloads material moved around the site by the crane driver. It’s a very skilled job. You need to be able to give clear directions to the crane driver and be able to structure a load correctly takin" rel="nofollow">ing in" rel="nofollow">into consideration the weight, and balance of the load. 3. What happened on the day of the in" rel="nofollow">incident? Raymond came and asked me for help and I told Lyall, the crane driver, to take the hook to level five for Raymond to load the equipment. I saw Lyall drop the chain" rel="nofollow">ins at level five over the handrail. Raymond hooked up the chain" rel="nofollow">ins onto the gas set by puttin" rel="nofollow">ing the chain" rel="nofollow">ins through the eye of the gas set. Lyall then started to lift the load. I saw the gas set get stuck on the handrail. I told Lyall to stop liftin" rel="nofollow">ing and I shouted to Raymond to pull the gas set off the rail. The handrail then snapped and the gas set and Raymond came out from the face of the buildin" rel="nofollow">ing. Raymond swung out holdin" rel="nofollow">ing onto the gas bottle. He then just let go while he was in" rel="nofollow">in the air and he fell to the concrete floor below. I was about 15 metres away from where he landed. 4. Can you suggest any reasons why this happened? Inexperience and shortage of train" rel="nofollow">ined staff. 5. What do you mean by in" rel="nofollow">inexperience? Well, this is Raymond’s first job on a buildin" rel="nofollow">ing site and assistin" rel="nofollow">ing the crane driver to lift equipment from one floor to another is not actually part of his job. So he doesn’t get to do it very often. 6. Tell me more about the shortage of train" rel="nofollow">ined staff? Superiorsteel’s contract states that they are supposed to provide us with only train" rel="nofollow">ined workers but they don’t. They tell us that they are train" rel="nofollow">ined but it is obvious they are not. Train" rel="nofollow">ined workers cost more and we all know that they are tryin" rel="nofollow">ing to keep costs as low as possible. 7. How do you thin" rel="nofollow">ink this type of in" rel="nofollow">incident could be prevented? By havin" rel="nofollow">ing a landin" rel="nofollow">ing platform, or a cage (which would be grappled to the buildin" rel="nofollow">ing), or a safety harness. 8. Is there anythin" rel="nofollow">ing else you would like to say? No, I still keep replayin" rel="nofollow">ing the event over and over in" rel="nofollow">in my head and can’t stop thin" rel="nofollow">inkin" rel="nofollow">ing about it. He was an okay sort of kid and didn’t deserve to have that happen to him. I hope he’s goin" rel="nofollow">ing to be all right. Interview 3: Barry, Raymond’s supervisor (Superiorsteel) Barry These are the notes from an in" rel="nofollow">interview with Raymond’s supervisor. The in" rel="nofollow">interview was held on site in" rel="nofollow">in the smoko room on the day of the accident. Introduction Thanks for takin" rel="nofollow">ing the time to talk to me today, Barry. As you know, I’m here to fin" rel="nofollow">ind out what happened today when Raymond was in" rel="nofollow">injured. It’s important we talk to everyone, who was there, so we can fin" rel="nofollow">ind out exactly what happened. That way we can make sure it doesn’t happen again" rel="nofollow">in. Questions Replies 1. Barry, what is your job on this buildin" rel="nofollow">ing construction? I am a supervisor for Superiorsteel. 2. I’d like to begin" rel="nofollow">in by askin" rel="nofollow">ing you to describe exactly what happened. I didn’t actually see what happened. I was in" rel="nofollow">in the office at the time. I have been concerned about Raymond bein" rel="nofollow">ing on the site for quite some time. 3. Could you tell me a bit more about your concerns? I have been to see Bill, the managin" rel="nofollow">ing director of Superiorsteel Limited, twice to complain" rel="nofollow">in about Raymond. On those two occasions, I asked Bill to remove Raymond from the site because I felt he wasn’t capable of doin" rel="nofollow">ing the work competently and safely. Raymond is in" rel="nofollow">inclin" rel="nofollow">ined to wander off without notifyin" rel="nofollow">ing anybody. 4. What did Bill say? He flatly told me that Raymond was stayin" rel="nofollow">ing. I was told it was a matter of economics. I guess that Raymond was on a cheap rate and that they could not afford to hire another person. 5. Had you discussed your concerns with Raymond? I had also warned Raymond about his lack of care and sometimes clumsy performance, which could in" rel="nofollow">injure him or others. 6. Tell me about the job Raymond was doin" rel="nofollow">ing at the time of the in" rel="nofollow">incident? Raymond should not have been doin" rel="nofollow">ing that job. That particular load was only for an experienced dogman. I have confidence in" rel="nofollow">in Raymond performin" rel="nofollow">ing simple lifts but that was not a simple lift. After attachin" rel="nofollow">ing the gas equipment and positionin" rel="nofollow">ing it near the rail, he should have leant back holdin" rel="nofollow">ing the load until it was above the rail, then he should have let it go. 7. Was Raymond suitably train" rel="nofollow">ined to do that job? Well, I believe people learn by trial and error and if they do it wrong, you correct them. 8. Was someone supervisin" rel="nofollow">ing Raymond at the time? No. 9. Is there anythin" rel="nofollow">ing else you would like to say about this in" rel="nofollow">incident? No, not really, I’m just annoyed because we’re already behin" rel="nofollow">ind schedule and this is only goin" rel="nofollow">ing to put us under more pressure. 10. Thank you Barry. Okay. Interview 4: David, Site Manager (Bigconstruction) David These are the notes from an in" rel="nofollow">interview with David, the site manager. The in" rel="nofollow">interview was held on site in" rel="nofollow">in David’s office on the day of the accident. Introduction Thanks for bein" rel="nofollow">ing available to answer my questions so promptly. As you know, this was a serious harm in" rel="nofollow">incident, and we need to in" rel="nofollow">investigate it thoroughly to ensure another such in" rel="nofollow">incident doesn’t happen again" rel="nofollow">in. Questions Replies 1. Did you see the accident today, David? No, I heard a scream and ran out of my office just after Raymond hit the ground. 2. Raymond worked for your subcontractors, Superiorsteel Limited? Yes, that is correct. 3. Were you aware that Raymond was not a train" rel="nofollow">ined or experienced dogman? No. The contract we have with Superiorsteel Limited states that they must use only properly train" rel="nofollow">ined dog-men for loadin" rel="nofollow">ing and unloadin" rel="nofollow">ing. 4. Was Raymond given any train" rel="nofollow">inin" rel="nofollow">ing in" rel="nofollow">in liftin" rel="nofollow">ing loads? No. We offered to train" rel="nofollow">in Superiorsteel staff. They said their staff didn’t need train" rel="nofollow">inin" rel="nofollow">ing. 5. Did you thin" rel="nofollow">ink Raymond needed train" rel="nofollow">inin" rel="nofollow">ing? No, I have watched Raymond in" rel="nofollow">in the past and he showed a reasonable degree of expertise on whatever he did. He was no better or worse than some of the others on site. He was employed as a labourer, so he was limited in" rel="nofollow">in the duties he could do. 6. Is there anythin" rel="nofollow">ing else you would like to say about the in" rel="nofollow">incident? No. Access to New Zealand Standards On-lin" rel="nofollow">ine You have access to New Zealand Standards on-lin" rel="nofollow">ine through the library use the Article Databases listed under Standards New Zealand or from the library Catalogue record: http://kea.massey.ac.nz/record=e1000460~S1 ACC's website useful lin" rel="nofollow">inks to statistics ACC in" rel="nofollow">injury statistics 2008/2009 Statistics New Zealand, Injury statistics European Agency for Safety and Health at Work WorkSafe NZ’s web-page on Glossary of terms and acronyms WorkSafe NZ's & ACC's Code of Practice for Manual Handlin" rel="nofollow">ing WorkSafe NZ’s Material on Stress and Fatigue in" rel="nofollow">in the workplace WorkSafe NZ’s webpage on Workplace Health and Safety strategy for New Zealand Web lin" rel="nofollow">inks to the NOHSAC reports The Australian and New Zealand Society of Occupational Medicin" rel="nofollow">ine New Zealand Occupational Health Nurses Association New Zealand Institute of Safety Management New Zealand Occupational Hygiene Society Human Factors and Ergonomics Society of New Zealand HASANZ Health and Safety Association New Zealand Lin" rel="nofollow">ink to New Zealand legislation Lin" rel="nofollow">ink to the Health and safety at Work Act 2015. Lin" rel="nofollow">ink to Health and safety in" rel="nofollow">in Employment Regulations 1995 ACC's publication: How to implement safer workplace practices: A guide to workplace health and safety Guidance on risk assessment at work (1996) ACC's publication: How to implement safer workplace practices: A guide to workplace health and safety HSE, UK: Plan, Do, Check, Act. An in" rel="nofollow">introduction to managin" rel="nofollow">ing for health and safety "A Guide to measurin" rel="nofollow">ing Health and Safety Performance" , HSE, UK 2001 Summary guide to safety climate tool, HSE, 1999 ACC's publication: How to implement safer workplace practices: A guide to workplace health and safety Investigatin" rel="nofollow">ing accidents and in" rel="nofollow">incidents (HSE) ACC's web page on Discomfort, pain" rel="nofollow">in and in" rel="nofollow">injury