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Incident causation

understanding of the importance of using incident causation theories to guide incident investigation and analysis
understanding of different injury causation models
ability to identify the suitability of injury causation models for analysis of an injury event
understanding of the process of learning from incidents
ability to assess guidelines for incident reporting, investigation and analysis in relation to the learning from incident process
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 building”. The case describes an incident that resulted in a serious injury where a 19 year old man falls from a building. It first gives an overview and then notes from four interviews with the people involved in the incident. These notes are from a real event made by an investigator. This case study can be found as an appendix to the assignment.
When you write the assignment you should imagine that you have been asked to help identify the causes of the injury event with the purpose of identifying how injury events like this can be prevented in the future. The purpose of the analysis is to help learning from the incident and to identify how preventive measures can be implemented in the two organisations. Imagine that you are writing this report to the two organisations.
Write a report that addresses the following eight points.
Describe the importance of using injury events to learn from and improve safety
Arguments for using injury causation theories and models for the analysis of the injury event
Discussion of the injury event using different 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 injury event (Construction – fall from a building)
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 building.
Discuss if ACC’s guidance (or part of the guidance) on injury investigation described in the document ACC366 “How to implement safer workplace practices” can be used to guide the learning from incident process you have recommended above.
Describe the preconditions that both organisations needs to establish for the learning from incident process to be effective.
The report needs to have:
Front page
Table of content
Introduction (purpose of the report)
Sections with appropriate headings that cover point 1 to 8 (described above)
References (use APA style see this Administration Guide or OWLL)
Appendices if appropriate e.g. Worksheets when analysing the event.
Construction – fall from a building
Who was injured? And what was his job
Raymond, a 19 year old who had been working for Superiorsteel Limited for 15 months. It was his first job since leaving school and he had no prior experience in the construction industry. He was originally hired by Superiorsteel Limited for two months as an assistant welder. He then worked for them as a labourer in their workshop for six months. At the time of the incident he was working as a labourer on a building 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 internal stairway and he also did the heavy lifting using 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 incident?
Raymond was directing 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 pulling on it but the guardrail snapped and the trolley and Raymond swung out beyond the edge of the building. Raymond fell 14 metres on to the concrete floor below.
assignment 2 accident 1
Drawings of scene of accident:
assignment 2 accident 2
What was the damage?
Raymond’s injuries were as follows:
Seven fractures to his pelvis
Extensive internal injuries including a ruptured spleen
Punctured lung
Compound and multiple fractures of both legs
His right leg was amputated below the knee
Interview 1: Raymond, the injured person (Superiorsteel)
These are the notes from an interview with Raymond. The interview was held five weeks after the incident. It was held in the hospital a week after he had come out of a coma.
Thanks for talking 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 willingness to talk to me. What I am trying to do is to find out exactly what happened, so that we can ensure something like this doesn’t happen again. I’ll show you my notes after I have written them up, so that you can check that I have all the information right.
Raymond please describe what happened on the day of the incident.
There was a bolt missing on the main steel frame on level seven, so Barry (my supervisor) told me to get the gas welding equipment from level five and cut a hole for a bolt.
How do you get the gas welding equipment from one floor to another?
We hook the gas equipment on to a chain 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.
Was Barry going to supervise you doing this lift?
No, he believes that we learn by “trial and error” on the job. I was OK with that.
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.
What difference did it make with Matt not being on the same floor as you?
Well, it really meant he left the job up to me. He still called out instructions to me and the crane driver, but he wouldn’t have been able to see very well from down there.
What happened next?
The crane driver presented the hook and chain to me and I attached the chain to the gas equipment. I pulled the gas equipment trolley towards the edge of the building, which was protected by a guardrail.
Then I think the crane driver got fed up with me taking too long because he could not see me and I could not see him. I think he took the load up without knowing that I was still holding onto the bottles.
I see, and then?
The bit of the trolley the bottles sit on got caught on the guardrail. I was trying to pull and push the trolley back down so it would release and then I would be able to bring it back out. Before I knew it I was at the edge of the building 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 hanging out in the air outside the building. I let go at the last minute. My body went forward and I couldn’t grab onto anything because there was nothing to grab onto. I thought if this is it then this is it. I remember falling and my whole body going forward. I remember hitting the ground with my right leg first.
The next thing I remember is waking up and being told I had been in hospital for four weeks.
You said you were presented with the hook and chain by the crane driver – is that normal practice?
Well not really, but I used to do it occasionally when we were very busy.
What was the usual procedure?
Usually the dogman is on the same floor as me, and he gives instructions backwards and forwards between the crane driver and myself.
Why was the dogman not on level five with you on this occasion?
Well, we were in a bit of a rush that day as we were behind schedule. He had another load to supervise as soon as mine had finished, so I suppose he thought he would save time by staying on the ground level where the next load was going to be loaded.
Why were you all in a rush?
All Superiorsteel employees had received a notice that morning stating that if we did not finish the job by a certain date, we would lose our jobs. So it had been rush, rush, rush all day
Had you been given any training on working with a crane and moving heavy loads?
No, not really.
Is there anything else you would like to tell me about the incident?
No, that’s all I can remember at the moment.
Thanks Raymond, I appreciate you talking to me.
No problem. I only hope it helps prevent something like this happening to someone else.
Interview 2: Matt, the dogman (Bigconstruction)
These are the notes from an interview with the dogman. The interview was held on site in the smoko room, the day of the incident.
Thanks for taking the time to talk to me today Matt. As you know, I’m here to find out what happened today when Raymond was injured. It’s important we talk to everyone who was there, so we can find out exactly what happened. That way we can make sure it doesn’t happen again.
Matt, what is your position on this building site?
I’m employed by Bigconstruction as a dogman.
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 taking into consideration the weight, and balance of the load.
What happened on the day of the 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 chains at level five over the handrail. Raymond hooked up the chains onto the gas set by putting the chains 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 lifting 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 building. Raymond swung out holding onto the gas bottle. He then just let go while he was in the air and he fell to the concrete floor below. I was about 15 metres away from where he landed.
Can you suggest any reasons why this happened?
Inexperience and shortage of trained staff.
What do you mean by inexperience?
Well, this is Raymond’s first job on a building site and assisting 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.
Tell me more about the shortage of trained staff?
Superiorsteel’s contract states that they are supposed to provide us with only trained workers but they don’t. They tell us that they are trained but it is obvious they are not. Trained workers cost more and we all know that they are trying to keep costs as low as possible.
How do you think this type of incident could be prevented?
By having a landing platform, or a cage (which would be grappled to the building), or a safety harness.
Is there anything else you would like to say?
No, I still keep replaying the event over and over in my head and can’t stop thinking about it. He was an okay sort of kid and didn’t deserve to have that happen to him. I hope he’s going to be all right.
Interview 3: Barry, Raymond’s supervisor (Superiorsteel)
These are the notes from an interview with Raymond’s supervisor. The interview was held on site in the smoko room on the day of the accident.
Thanks for taking the time to talk to me today, Barry. As you know, I’m here to find out what happened today when Raymond was injured. It’s important we talk to everyone, who was there, so we can find out exactly what happened. That way we can make sure it doesn’t happen again.
Barry, what is your job on this building construction?
I am a supervisor for Superiorsteel.
I’d like to begin by asking you to describe exactly what happened.
I didn’t actually see what happened. I was in the office at the time.
I have been concerned about Raymond being on the site for quite some time.
Could you tell me a bit more about your concerns?
I have been to see Bill, the managing director of Superiorsteel Limited, twice to complain about Raymond.
On those two occasions, I asked Bill to remove Raymond from the site because I felt he wasn’t capable of doing the work competently and safely. Raymond is inclined to wander off without notifying anybody.
What did Bill say?
He flatly told me that Raymond was staying. 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.
Had you discussed your concerns with Raymond?
I had also warned Raymond about his lack of care and sometimes clumsy performance, which could injure him or others.
Tell me about the job Raymond was doing at the time of the incident?
Raymond should not have been doing that job. That particular load was only for an experienced dogman. I have confidence in Raymond performing simple lifts but that was not a simple lift. After attaching the gas equipment and positioning it near the rail, he should have leant back holding the load until it was above the rail, then he should have let it go.
Was Raymond suitably trained to do that job?
Well, I believe people learn by trial and error and if they do it wrong, you correct them.
Was someone supervising Raymond at the time?
Is there anything else you would like to say about this incident?
No, not really, I’m just annoyed because we’re already behind schedule and this is only going to put us under more pressure.
Thank you Barry.
Interview 4: David, Site Manager (Bigconstruction)
These are the notes from an interview with David, the site manager. The interview was held on site in David’s office on the day of the accident.
Thanks for being available to answer my questions so promptly. As you know, this was a serious harm incident, and we need to investigate it thoroughly to ensure another such incident doesn’t happen again.
Did you see the accident today, David?
No, I heard a scream and ran out of my office just after Raymond hit the ground.
Raymond worked for your subcontractors, Superiorsteel Limited?
Yes, that is correct.
Were you aware that Raymond was not a trained or experienced dogman?
No. The contract we have with Superiorsteel Limited states that they must use only properly trained dog-men for loading and unloading.
Was Raymond given any training in lifting loads?
No. We offered to train Superiorsteel staff. They said their staff didn’t need training.
Did you think Raymond needed training?
No, I have watched Raymond 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 the duties he could do.
Is there anything else you would like to say about the incident?
Access to New Zealand Standards On-line
You have access to New Zealand Standards on-line 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 links to statistics
ACC 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 Handling
WorkSafe NZ’s Material on Stress and Fatigue in the workplace
WorkSafe NZ’s webpage on Workplace Health and Safety strategy for New Zealand
Web links to the NOHSAC reports
The Australian and New Zealand Society of Occupational Medicine
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
Link to New Zealand legislation
Link to the Health and safety at Work Act 2015.
Link to Health and safety 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 introduction to managing for health and safety
"A Guide to measuring 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
Investigating accidents and incidents (HSE)
ACC’s web page on Discomfort, pain and injury

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