Chapter 12 - Lecture notes 12 PDF

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Lecture 12...

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Indicate whether the statement is true or false. 1. An investigation is conducted primarily to determine if cognitive failure was to blame and to ensure it doesn’t happen again in the future. a. True b. False 2. Incidents that result in minor injuries do not need to be investigated. a. True b. False 3. Personal factors should be included on the incident investigation form to assist in entry, recordkeeping, and analysis. a. True b. False 4. If the other members of the injured worker’s work group are unharmed and not experiencing emotional distress, they can continue with their work immediately after the incident. a. True b. False 5. The theory of normal incidents says that it is one normal incident that goes wrong that is at the heart of most incidents. a. True b. False 6. It is recommended that incidents be reported to a workers’ compensation board, normally within three days a. True b. False 7. When using re-enactments as an investigative method, filming the witness is prohibited. a. True b. False 8. Interviewing the witness on the spot as soon as possible after the event is one of the basic rules of interviewing as an investigative method. a. True b. False 9. Incident investigations can start while everyone is waiting for the ambulance to arrive. a. True b. False 10. Both the federal and provincial/territorial levels of government can order an investigation into a workplace incident. a. True b. False

Indicate the answer choice that best completes the statement or answers the question.

11. Evelyn from HR is doing a walkthrough shortly after an incident in the shipping area and needs to know how the conveyor belt is operated. Whom should she ask? a. the injured worker b. the plant manager c. coworkers of the injured worker d. the injured worker’s supervisor 12. Why can witnesses’ recall become distorted if investigation is not begun in a timely manner? a. There are changes at the incident site. b. There is removal of important evidence. c. They may suffer memory loss. d. They discuss the incident with others. 13. Who is more likely to experience a cognitive failure? a. an older worker b. a young worker c. a working parent d. a dissatisfied worker 14. What is the most important criterion in choosing which computer to use for incident investigation? a. portability b. processing speed c. database capabilities d. graphical and CAD software 15. What question should be asked when investigating situational factors contributing to an incident? a. What shift was being worked? b. Was the work being performed to standards? c. Was a supervisor present? d. Did some unsafe act contribute to the event? 16. As a result of the investigation, it was revealed that Kyle had been suffering from depression for several months. What theory explicitly mentions mental problems? a. bow-tie analysis b. Swiss cheese model c. domino theory d. theory of normal incidents Read the following scenario and answer questions 21–25. On Friday, August 23, 2016, a construction worker fell 55 floors to his death while working on what will become Toronto’s tallest condominium building. Despite a variety of safety precautions, this type of incident is not uncommon in the construction industry. Three days earlier, on Tuesday, August 20, 2016, a 26-year-old construction worker in Las Vegas, Nevada also died in a fall from a building under construction.

17. What would be an example of the fourth level of defence from the Swiss cheese model, which might have prevented this fatality? a. safety training b. a strong safety culture c. a safety-conscious supervisor d. rails along the edge of open floors 18. What organization would have the legal right to demand a mandatory investigation into the Toronto worker’s death? a. Ontario Ministry of Labour b. City of Toronto Building Department c. Workers Insurance Safety Board (Ontario) d. the construction firm for whom he worked 19. Which of the following personnel would NOT be responsible for incident investigation? a. supervisor b. technical adviser and specialist c. front-line employee d. safety and health committee 20. The theory of normal incidents would be more likely to be used in investigating incidents in what type of industry? a. agriculture b. oil refineries c. healthcare d. light manufacturing 21. What different types of falls are considered under incident type classification? a. fall to same level, fall to lower level, fall to higher level b. fall on upper body, fall on lower body c. fall backwards, fall forwards d. fall vertically, fall horizontally 22. What piece of information is found on both the long and short supervisor report? a. type of injury b. type of accident c. suggested corrective action d. sketch/diagram of accident scene 23. Which set of three factors strongly influences incident investigations? a. timing, severity, and legal requirements b. costs, causes, and timing c. severity, causes, and costs d. legal requirements, causes, and severity

Read the following scenario and answer questions 21–25. On Friday, August 23, 2016, a construction worker fell 55 floors to his death while working on what will become Toronto’s tallest condominium building. Despite a variety of safety precautions, this type of incident is not uncommon in the construction industry. Three days earlier, on Tuesday, August 20, 2016, a 26-year-old construction worker in Las Vegas, Nevada also died in a fall from a building under construction. 24. Although possibly not a cause of the Toronto incident, what factor might explain a cognitive failure to reattach a safety tether/harness to a safety hook after moving from one floor to the next floor of a building under construction? a. uncomfortable equipment b. a careless attitude toward safety c. a fight at home that morning d. hand–eye coordination problems 25. Forklift trucks belong to what agent group? a. tools b. lifting devices c. motive power sources d. materials-handling systems Read the following scenario and answer questions 21–25. On Friday, August 23, 2016, a construction worker fell 55 floors to his death while working on what will become Toronto’s tallest condominium building. Despite a variety of safety precautions, this type of incident is not uncommon in the construction industry. Three days earlier, on Tuesday, August 20, 2016, a 26-year-old construction worker in Las Vegas, Nevada also died in a fall from a building under construction. 26. What is the action that should have been taken by the site manager immediately after the incident? a. taking photographs of the job site b. securing and protecting the scene(s) c. documenting any personal protective equipment in use d. talking to coworkers who were in the immediate area 27. Which analytic model, used in incident analysis, combines a fault tree with an event tree? a. the domino theory b. the bow-tie model c. the Swiss cheese model d. the normal incidents theory 28. What is the key element in cognitive interviews that elicits more accurate information from eyewitnesses? a. developing rapport b. asking probing questions c. encouraging active participation d. focusing on the eyewitnesses’ mental images 29. Who generally has primary responsibility for incident investigation? a. the worker’s immediate supervisor b. a management member of the JHSC c. an investigator from the Ministry of Labour d. a technical expert from the industry association

30. Besides the supervisor, who else should sign the supervisor’s accident/incident report? a. the senior manager b. the Ministry of Labour inspector c. the employee (if/when available) d. the chair of the Joint Health and Safety Committee 31. Incident investigation is a vital component of an organization’s RAC program. What does RAC stand for? a. recognition, approval, and change b. requirements, attribution, and control c. recognition, assessment, and control d. requirements, approval, and change 32. What incident investigation method can reveal unsafe conditions that may have contributed to the incident but not unsafe acts? a. interviews b. simulations c. reenactments d. walkthroughs Read the following scenario and answer questions 21–25. On Friday, August 23, 2016, a construction worker fell 55 floors to his death while working on what will become Toronto’s tallest condominium building. Despite a variety of safety precautions, this type of incident is not uncommon in the construction industry. Three days earlier, on Tuesday, August 20, 2016, a 26-year-old construction worker in Las Vegas, Nevada also died in a fall from a building under construction. 33. According to the textbook, what should coworkers who witnessed the incident be offered prior to being interviewed? a. legal advice b. trauma counselling c. the opportunity to go home to calm down first d. the opportunity to retrieve tools left at the incident site 34. The investigator asked Hamish what personal protective equipment he was wearing. What type of factors was the investigator interested in at that moment? a. human factors b. cognitive failures c. situational factors d. environmental factors 35. Which of the following is an optional procedure in conducting a re-enactment? a. filming cognitive interviews with witnesses b. inviting a qualified observer to watch the re-enactment c. taking photos and/or making sketches and drawings of the scene d. having witnesses describe what they saw before they act out what happened

36. Using the case at the end of the chapter as your source material, describe the concepts, methods, and personnel you would use to implement and perform an effective investigation of this incident. Use the domino theory or Swiss cheese model as your theoretical foundation to help you classify the causes and determine what can be done to ensure that incidents of this type do not occur in the future. In addition to writing up the foregoing, prepare a Supervisor’s Accident/Incident Report (long form), filling in as much information as you can (similar forms to the example in the textbook can be downloaded from the Internet). 37. Define “incident investigation” and describe the aim and benefits of incident investigations. 38. Compare and contrast the domino theory with the theory of normal incidents. 39. Explain how timing, severity, and legal requirements strongly influence incident investigations. 40. Describe each of the three types of cognitive failure (human factor) and relate each to relevant incident types listed in the chapter. Provide examples to support your answer. 41. Read OH&S Notebook 12.3, Analysis of an Incident, and identify the human, situational, and/or environmental factors that contributed to the incident.

Answer Key 1. True 2. False 3. True 4. False 5. False 6. True 7. False 8. True 9. False 10. True 11. d 12. d 13. a 14. d 15. a 16. c 17. d 18. a 19. c 20. b 21. a 22. c 23. a 24. c 25. b 26. b 27. b

28. d 29. a 30. c 31. c 32. d 33. b 34. c 35. a 36. The content of the answer should include consideration of human, situational, and environmental factors, discussion of relevant methods (walkthoughs, interviews, re-enactments), and supplementary techniques (measurements, photos, drawings, computers, tools, and records). Discussion of causes should relate to specific elements of the chosen theory (domino or Swiss cheese) but should not confuse elements of one theory with the other. The report should contain all of the relevant facts contained in the case and indicate the various causes of the incident. 37. Incident investigations are a critical component of both an organization’s RAC and OH&S programs. An incident investigation is the analysis and account of an incident based on information gathered by a thorough examination of all the factors involved. A key result of an incident investigation should be to prevent a recurrence of the same incident. When considering the contributing factors, the employer/HRM/investigation team can ask, “What can management, the supervisor, worker, and other employees do to prevent a recurrence of this nature?” The benefits of incident investigation are to determine the root and contributing causes, to prevent a recurrence of similar incidents, to improve safety procedures and practices, to create a permanent report, to determine cost, and to raise the level of safety awareness among employees. 38. According to domino theory, every event, incident, or disaster is composed of a series of happenings that result in some negative condition. The theory is based on a set of five dominos: 1) Background: a lack of control over the management function (planning, organizing, leading, controlling) 2) Personal defects: personal factors such as physical or mental problems, and job factors such as normal wear and tear of equipment 3) Unsafe acts and conditions 4) Incident: a series of undesired events with release of energies that can cause harm 5) Injury: the most undesired result (e.g. trauma or property damage) This theory asserts that if any one of the domino categories does not happen, then the incident probably will not occur. The theory of normal incidents shares the perspective that multiple factors can contribute to an incident; however, rather than discrete factors in a linear sequence, it is the interactive complexities in the technological system that are the issue. Therefore in high-reliability organizations (e.g., chemical plants or nuclear plants) it may be impossible to isolate causal factors.

39. Timing delays may lead to memory loss and distortion of details, changes at the incident site, and removal of important evidence. It is recommended that the following types of incidents, based on severity, be investigated: lost-time injuries, minor injuries that are treated by a doctor, close calls, and incidents with property damage. Mandatory investigations tend to be dictated by the nature and severity of the incident; investigations are always required in the case of a workplace death. Provincial/territorial government agencies may require an investigation if injury-causing incidents are severe or constantly recurring, but specific guidelines vary by jurisdiction. Incidents in which the worker(s) require medical aid or in which there is lost time must be reported to the Workers’ Compensation Board, normally within three days. 40. The three types of cognitive failure are memory/forgetfulness, loss of focus/distractibility, and physical skills (mindbody coordination). The incident types include: Caught-in or caught-between Struck by or struck against Fall to same level, fall to lower level, fall to higher level Abraded, scratched, or punctured Overexertion Contact with an energy Memory failures could result in caught-in or between incidents or contact with an energy if a worker forgets the standard operating procedure. Example: forgetting to lock out a piece of equipment before commencing preventive maintenance. Lack of focus/distractibility could result in similar issues but could also result in being struck by or struck against incidents and falls (with abrasion) if the worker is not aware of their immediate surroundings. Example: falling boxes or other vehicles in motion around them. Physical skills/coordination failures could definitely result in all three types of falls as well as struck-against injuries by falling into furniture, walls, or doors. Coordination issues could also result in contact with an energy, e.g. stumbling and putting a hand down on a hot surface. 41. An example of a human factor was that the work was not being performed according to procedures (a carpenter removed the legally required saw guard). Two examples of situational factors were that the safety measures were not functioning satisfactorily (the supervisor had requested that the company purchase a new saw guard) and the correct equipment was not made available by management. In this particular case, environmental factors (e.g. light or noise) did not seem to have been a contributing factor....