Table of Contents

1 INTRODUCTION .......................................................................................................................... 1
2 PART A- ACCIDENT INVESTIGATION .................................................................................... 2
3 PART B- PREVENTATIVE ACTION .......................................................................................... 6
4 PART C IDENTIFICATION ....................................................................................................... 9
5 CONCLUSION ............................................................................................................................. 10
6 REFERENCES ............................................................................................................................. 11
7 APPENDICES .............................................................................................................................. 12
1 INTRODUCTION
An accident is the final event in an unplanned process that results in injury or illness
to an employee and possibly property damage. It is the final result or effect of a number of
surface and root causes. An accident may be the result of many factors that have interacted in
several ways. Workplace accidents are part of events that lead to a physical or psychological
injury. In reality, there are different types of accidents involving physical, chemical,
biological and many more.

Deaths and injuries can occur from hazardous substance exposures that appear to be
entirely preventable. A high proportion of these incidents are caused by hazardous substances
used in everyday domestic and workplace situations. A total of 57,975 chemical incidents
were reported during the 10-year surveillance period. In 4,621 (8%) of these incidents,
15,506 persons were injured. Among them, 354 deaths occurred. The most commonly
reported category of injured persons included employees of the responsible party (7,616
[49%]), members of the general public (4,737 [31%]), students exposed at school (1,730
[11%]), and responders to the incident (1,398 [9%]). Deaths occurred among members of the
general public (190 [54%]), employees (154 [44%]), and responders (10 [3%]). The most
frequent health effects experienced as a result of these incidents included respiratory irritation
(7,443), dizziness or central nervous system problems (3,186), and headache (3,167). The
three chemicals associated with the largest number of persons injured were carbon monoxide
(2,364), ammonia (1,153), and chlorine (763) [1].

For example, in 13 September 2014 an accident was happened and the worker was
died due to the exposure of hazardous chemical in Tapak bina, Johor. Victim was found
unconscious after got out of the cabin. During the incident, he was carrying out the air-
conditioner maintenance works. After going through an autopsy, the worker was found to be
died due to Acute Pulmonary Disease. Pulmonary Disease is a progressive lung disease
characterised by increasing breathlessness or need for air which usually occur due to long
term smoking or air pollution. In this case, the worker was diagnosed to be attack by Acute [3]
Pulmonary disease which is because the exposure to the hazardous chemical. This statement
was being proved as during the investigation process there was a chemical spill found in the
cabin where he performing his maintenance works. This accident has been chosen as my case
study and the objective for this case study is basically to identify the ethical principles and
commit to professional ethics and responsibilities and norms of engineering practice.

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2 PART A- ACCIDENT INVESTIGATION
An incident investigation is a formal or systematic process which involves the
documentation and analysis of a workplace event that resulted in a loss or the potential for
loss, including a thorough examination of contributing factors. As responsible employer, we
should act fast to the accident by having a proper accident investigation. Accident
investigations are used as a finding to the root cause and implement corrective action. The
investigation process should begin after arranging for first aid or medical treatment for the
injured person(s). In getting started, remind everyone involved especially workers the
investigation is to learn and prevent, not find fault. Steps of the investigation process include:
1. Preserve/Document the Scene
2. Collect Information
3. Determine Root Causes
4. Implement Corrective Actions

Preserve/Document the Scene

When a serious incident occurs, the emergency response is clearly the most important
first step to take which by informing the higher level management personnel. However,
when the decision is made to conduct an investigation, the investigation should be
commenced quickly as well. One of the first and most important actions to take is to
secure the location of the incident. The decision to secure the scene of the incident may
best be made by local or management personnel. Securing the scene may be done even
before the formal decision to investigate is taken. Securing the scene of the incident is
important to make sure that evidence is not moved or removed, which can easily happen
after an incident. Securing the scene of the incident quickly is a great help for the
investigation team in the fact-finding phase. Investigation team can use cone, tapes or
even guard to secure the scene. If the incident is quite serious, the public authorities may
also order that the scene of the incident be secured. As a guideline for the employers,
United States Department of Labor Occupational Safety and Health Administration
(OSHA) have prepared several tools that can be used while doing the investigation. The
tools are as listed:
Appendix A: Incident Investigation Form
Appendix B: Incident Investigators Kit
Appendix C: Tips for Video/Photo Documentation
Appendix D: Sketch the Scene Techniques

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Collect Information
The next step is to gather useful information about what contributed to the accident
directly and indirectly. In this phase the investigation team should be present as planned
in the investigation plan. Some steps they may take are:
Create a thorough and complete overview of the positions and directions of all
relevant physical objects and circumstances at the location of the incident, for
example, using; photographs, physical samples, position measurements, and (air)
samples, or by retrieving electronic data such as cctv or photographs already
taken.
Interview eyewitnesses as soon as possible after the accident. Eventually
memories will fade and sometimes through discussion with the other workers will
change their perspective towards the real situation, thus immediate interview will
give a better and accurate statement.
Retrieve and review documents related to the incident such as; maintenance
records, work procedures, training procedures, training records, permits to work or
relevant audit reports.
Conduct additional interviews with involved personnel to explore the
organisational factors relevant for the incident.
There can be no prescribed order or sequence in which to gather information. In general
one should attempt to retrieve the most vulnerable information first. If it is not yet clear
whether some information will eventually be needed to conduct the analysis, the general
advice is to retrieve and include the information anyway and evaluate its relevance later.it
is also important to bear in mind that all this procedure is to learn and prevent, not to find
fault. Appendix E provides a checklist to use to help ensure all information pertinent to
the incident is collected.

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Determine Root Causes
Root Cause Analysis is essentially a deeper investigation of all potential causes of an
incident. The process involves a team in gathering and analysing of data to identify root
causes and effective corrective actions that would prevent future incidents. Root causes
generally reflect management, design, planning, organizational and/or operational
failings. Cause and effect diagram are the continuous improvement support tools for
identifying the root cause of the incident, visualizing the possible relationship between
causes, provide focus for discussion and to aid in development if incident prevention
plan. Examples of the tools are 5-why stairway and fishbone diagram. The 5-why
stairway is basically a continuous asking Why until more contributing factors are
discovered. All the question must always focussed on finding the root cause instead of
putting blame on someone or something. Additional examples of questions to ask to get
to the root causes are listed in Appendix F. The fishbone is just a simple diagram
consisting possible cause and the problem.
After information has been gathered, the next step is to conduct the actual analysis and to
determine the cause(s) of the incident. In many cases, the gathering of information and
the analysis of the incident will need to take place as an iterative process [4]. Starting the
analysis may, for example, clarify the need to gather additional information via new
interviews. The first step in conducting an analysis will generally be the development of a
detailed timeline. The goal of using a timeline during the investigation is to structure
events and actions in time accurately. Doing this helps the investigator to evaluate
potential causal pathways. After the timeline is developed there are many models and
methods available that can help the investigator to analyse, structure and communicate
the findings.

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Implement Corrective Actions
An investigation will not be completed without implementation of the corrective actions
addressing the root cause of the incident. The implementation should be involving and
supported by the senior management. Corrective actions will be like preventive value if
they dont properly address the root of incident. Throughout the workplace, the findings
and how they are presented will shape perceptions and subsequent corrective actions.
Outermost conclusion and weak corrective action are unlikely improve the culture or to
prevent future incidents.it takes time and lots of perseverance to find corrective actions
yet the outcome will always give an opportunity to reduce risk and eventually improve
the companys safety, morale and its bottom line. Some samples of global corrective
actions to consider are:
Strengthening/developing a written comprehensive safety and health management
program
Revising safety policies to clearly establish responsibility and accountability
Revising purchasing and/or contracting policies to include safety considerations
Changing safety inspection process to include line employees along with
management representatives

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3 PART B- PREVENTATIVE ACTION
Effective controls protect workers from workplace hazards and help avoid injuries,
illnesses, and incidents; minimize or eliminate safety and health risks; and help employers
provide workers with safe and healthful working conditions. The processes described in this
section will help employers prevent and control identified hazards [5]. Below is the sequence
of implementing preventive action:

1. Identify control options

2. Select controls
3. Develop and update a hazard control plan
4. Select controls to protect workers during no routine operations and emergencies
5. Implement selected controls in the workplace
6. Follow up to confirm that controls are effective

This case study is about an accident involving spill of hazardous chemical which then
causing the victims to die due to acute pulmonary disease. Based on that, here are a
references aid in controlling workplace hazards associated with chemical hazards and
toxic substances. Controlling exposures to chemical hazards and toxic substances is the
fundamental method of protecting workers. A hierarchy of controls is used as a means of
determining how to implement feasible and effective controls.

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 Elimination/Substitution

-the highest hierarchy and most effective preventive control are the Elimination or
Substitution. Through this level, we eliminate the exposure before it can or start to occur. The
solution is by substitute the chemical used with a safer alternative. This level is the hardest
part to be performed as it is not common to find an alternative solutions or chemical to match
with the conventional used chemical.

Engineering Controls

The second most effective control is Engineering control. This type of control will
implement physical change to the workplace, which then will eliminates or reduces the
hazard on the job or task. Based on the case study, the spill of the chemical can be avoided or
reduced if we were providing a second container to the chemical solutions. Secondary
containment simply means that when a chemical spill develops, the spill will be contained
and controlled in a secondary area (OSHA 1910.1450). Second we can change process to
minimize contact with hazardous chemicals by changing the way we handle the process.
Next, use of wet methods such as water spray to reduce generation of dusts or other
particulates. Lastly by using application of engineering control equipment such as local
exhaust system and general ventilation to improve indoor air quality and generally to provide
a safe, healthful atmosphere.

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 Administrative and Work Practice Controls

In this level the control will be more establish efficient processes or procedures design
by the administrative department of an organization. A practice about how to handle a spill of
hazardous chemical should be done in order to avoid the same incidents happen again in
future. Next is to start a rotate job assignments where we can reduce the total time a worker is
exposed to the hazardous chemical and probably he will be more alert and attentive. The
department also can adjust work schedules so that workers are not overexposed to a
hazardous chemical for a long and frequent time. Besides that, Job Hazard Analysis (or JHA)
is also a valuable technique that can be utilized in companies of all sizes, to routinely
examine and analyse safety and health hazards associated with individual jobs or processes.

Personal Protective Equipment

Last but not least, the worker should have the responsibility to use protection to
reduce exposure to risk factors. This is for their own safety and prevention to the problem
that cant be solving from the upper level of control. Several personal protective equipment
that can be use while handling hazardous chemical are by use chemical protective clothing,
wear respiratory protection, use proper gloves and wear eye protection.

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4 PART C IDENTIFICATION

Not Professional

How the task or job is conducted reflects the professionalism of the company. Always
professionally handle your job by following all the SOP and instructions provided. The
victim was supposed to be aware of the fumes produce by the hazardous chemical while
doing his job, yet he was not informing anyone or leaves the scene. It is not a failure of
professionalism to admit that you need guidance or other assistance to complete your task or
job whenever you feel something is not right happen to your surrounding and yourself.

Lack of awareness to the surrounding

If he had discovered the spill before it suffocating him, he will still be able to stay survive.
All he had to do is clean up the spill by following the regulation and it wont take him more
than 5 minutes to do so.

Not Independent

By all the knowledge and experience the worker had, he should be able to take care of
himself better than others. His decision to remain doing his job in that kind of accident had
killed him.

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5 CONCLUSION

An incident investigation is a formal or systematic process which involves the

documentation and analysis of a workplace event that resulted in a loss or the potential for
loss, including a thorough examination of contributing factors. The goal of the incident
investigation is the generation of recommendations which will eliminate the potential for
future loss. Not to forget, the objective of investigation is to identify cause and prevent it, not
to find fault and put the blame on anyone or anything.

Based on this case study we were exposed that chemical substances can be dangerous to
man and his environment. Depending on the quantities involved, their degree of toxicity,
corrosive power, explosive force, inflammability or even radioactivity, they can cause
considerable damage. It is therefore important to know the risks linked to chemical
substances, to keep to the prescribed directives for handling them and to establish prevention,
protection and intervention measures in order to prevent these risks from developing. The
chemical substances used in the home and workshop are not generally dangerous, as long as
the instructions for their use and storage, which usually come with the original container, are
followed.

Later on ,if your air conditioner smells like paint thinner, formaldehyde or other
chemicals, its always better being safe than sorry. Many fluids are used within your HVAC
system that could result in an assortment of chemical odours with system malfunction,
making prompt attention advisable. Bad smells are never a good sign. If youve smelt it, get it
dealt with the help from the professional ones.

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6 REFERENCES

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7 APPENDICES

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