Você está na página 1de 36




-on time/- late
(MEM 603)

No Name Student ID

Guidelines Level Poor Satisfactory Good Excellent

Scale 0-4 5-6 7-8 9-10

Assessment Criteria (Report) Weight (w) Scale (y) Total= w * y

Introduction 5
Content/ Diagrams/Figures/ Discussion and Conclusion
Part A- Accident Investigation 40
Part B- Preventative Action 20
Part C - Identification 20
Format, Language and Organization 10
References and citation 5
TOTAL 100%


1 | P a ge

First of all, I would like to thank ALLAH S.W.T. for giving me the opportunity to finish this
project on time. Without His blessing, I would never be able to finish this task.

Secondly, it is a genuine pleasure to express our deep sense of thanks and

gratitude to my lecturer Pn. Nurul Syuhada who guide, teach and help me to complete
my mini project in Occupational Safety and Health (MEC603) which make a report for
accident investigation and prevention action.

Next, it is my privilege to thank all friends for their kind help and cooperation
throughout completion of this project.

Finally, I would like to thank my family for their understanding, encouragement

and support, towards the completion of my project. Thank you so much.

2 | P a ge

The objective of this project is to identify ethical principles and commit to professional
ethics and responsibilities and norms of engineering practice. In order to complete this
task, we are asking to select a particular Case Study as listed in Appendix 1. The step
that should be taken to complete this task listed below :-

1. Imagine you are safety officer; you received the information regarding the
accident as listed in Appendix 1.
2. Part A- You is required to explain each step in order to carry out the accident
investigation with professionally ethics, fill the suitable form and prepare the
accident report.
3. Part B- Provide suggestions for preventive action, especially in term of
engineering control in order to avoid similar accidents happen in the company.
( supported with relevant photo/technical diagrams/drawings/ form)
4. Part C- Identify the ethical principles and professional ethics exist/ potential to
happen to the case study that you have chosen. Example: construction industry
– ethical issues: corruption, materials used are out of specification etc.

3 | P a ge












4 | P a ge


Nowadays, there are lot cases of accident happened in Malaysia involving the
safety and health of workers at the workplace. Based on the definition, the word
“accident" can be defined as an unplanned event that interrupts the completion of an
activity, and that may or may not include injury or property damage [1]. Ideally, the
accident can cause many problem including injuries, death, loss of equipment, trauma
and others. The main point for accident investigation is to help the investigator identified
the root causes and hazard of the accident. When the causes are established, the next
step is identified the precautions and implemented to prevent a recurrence. As a step-
by-step guide, it will help all organization, particularly smaller businesses, to carry out
their own health and safety investigations. Investigating accidents and incidents
explains why we need to carry out investigations and takes you through each step of the
process [4]:

Step 1: Gathering the information

Step 2: Analyzing the information
Step 3: Identifying risk control measures
Step 4: The action plan and its implementation

Investigators must always keep in mind that effective accident investigation means fact-
finding, not fault-finding [2]. Based on the finding obtained from the investigation
process, it is easier to take steps control to minimize or eliminate the possible causes of
an accident. This practice can help prevent similar accident from happening in the
future. Below is the criteria of effective incident investigation program that listed by
OSHA [3]

5 | P a ge
Effective Incident Investigation Programs:

Clearly state easy‐ to‐ follow written procedures

Provide for personnel to be trained on incident investigation and company


Offer collaboration between workers, worker representatives, and management

Focus on identifying root cause(s), not on establishing fault

Emphasize correcting root cause(s)

Implement timely corrective actions based on investigation findings

Provide for an annual program review to identify and correct program deficiencies
and identify incident trends

In general, the investigation process need to conduct by someone who has fully
knowledgeable of the work processes, someone who has experienced in accident
causation and experienced in investigative techniques. In most cases, the supervisor
should help investigate the event [4]. Other members of the team can include:

1. Safety officer

2. Employees with knowledge of the work

3. Health and safety committee

4. Union representative, if applicable

5. Employees with experience in investigations

6. Representative from local government

6 | P a ge
7 | P a ge
1. Safety officer
A safety officer is assign to monitors workplace activities in ensure that the
workers comply with company policies and safety regulation. The duties scopes
for safety officer are varying including safety inspection and accident
investigation. Other specific responsibilities of safety officer are:

1. Responsible for monitoring and assessing hazardous and unsafe situations

2. Responsible to correct unsafe acts through the regular line of authority
3. Responsible to maintain awareness of active and developing situations.
4. Responsible to ensure the Site Safety and Health Plan is prepared and
5. Responsible to ensure there are safety messages in each accident Action

Generally, when come to the accident investigation, only one safety officer will be
assigned for each site. The safety officer may have assistants if necessary and
that assistance may represent assisting agencies. Some action plan for safety
officer when involves in accident investigation are:

1. From initial response, the safety officer needs to document the hazard
analysis process, identification of hazard, exposure assessment and controls.
2. Safety officer need to participate in planning meetings to identify any health
and safety concerns inherent in the operations daily work plan.
3. Safety officer must review the Incident Action Plan for safety implications.
4. Exercise emergency authority to prevent or stop unsafe acts.
5. Investigate accidents that have occurred within incident areas.
6. Ensure preparation and implementation of Site Safety and Health Plan
7. Assign assistants and manage the incident safety organization.
8. Review and approve the Medical Plan (ICS 206).

On top of that, the investigation also gives some benefits for specific person, community
and organization. Below is the list of benefits arising from an investigation ;-

8 | P a ge
 The prevention of further similar adverse events. If there is a serious accident,
the regulatory authorities will take a firm line if you have ignored previous
 The prevention of business losses due to disruption, stoppage, lost orders and
the costs of criminal and civil legal actions.

 An improvement in employee morale and attitude towards health and safety.

Employees will be more cooperative in implementing new safety precautions if
they were involved in the decision and they can see that problems are dealt with.

 The development of managerial skills which can be readily applied to other areas
of the organization.

Phase by Phase to health and safety investigations [4].

Generally, accident investigation process can be divided in three major phases. The first
phases plays a crucial role in protect the evidence necessary to conduct the
investigation. The second phases more to collecting evidence and gather the
information. Action and correction is the last phase in accident investigation.


At the phase 1, the role and responsibilities are more focused on the supervisor. The
supervisor is the one who can lead their worker during the emergency accident
before safety officer take a place on investigation process.

There are seven steps of investigation enable in phase 1:

1. Take control of the accident scene:

The supervisor plays a crucial role in this step where he need to take charge and
act fast when accident is happened. Usually people are tend to react differently

9 | P a ge
as they are curios and confused probably effect from immediate accident.
Supervisor is the one who should lead his worker during emergency situation.

2. Provide first aid and call for emergency services:

The supervisor also needs to provide first aid and call for emergency services if
necessary. The act must depend on the current situation.

3. Control potential secondary accidents:

The supervisor must be able to spot potential problem and warn other. There
might be another accident if the situations become uncontrolled.

4. Identify sources of evidence at the scene:

At this step, the supervisor needs to identify evidence at the scene to ensure that
the evidence not be removed during emergency response.

5. Preserve evidence from alteration or removal:

The supervisor need to ensure the evidence must be preserved. He need to

inform his worker to keep the evidence not being moved from the original places.

6. Investigate to determine the loss potential:

The supervisor need to state how serious the accident and the potential it is likely
to occur again. The safety officer can then decide how in-depth the investigation
should be.

7. Notify appropriate managers:

The supervisor needs to notify the appropriate manager about the accident.

10 | P a g e

At the second phase, the role are likely focus on responsibility of safety officer. Safety
officer is the one who has the responsibility to conduct accident investigation. He need
to find the causes of the accident in this phase, then entering the last phase which is
action and implement. This phase has 3 steps as a guidelines to conduct the accident
investigation successfully:

STEP 1: Information gathering

The first step when come to accident investigation is gathering as much as

possible the required information. The safety officer need to find out what actually
happened and what conditions and actions influenced the accident. All the
information relevant need to be collect including opinions, observation,
measurement, photograph, sketch, check sheets, permit-to-work and detail of the
environmental conditions at the time. This information must be recorded and kept
in note form from initial investigation until the investigation is complete.

Some guideline what should be done by safety officer are:

1. Safety officer and his assistance need to explores all reasonable lines of enquiry
2. They need to setting out clearly what is known, what is not known and records
the investigative process
3. The next step is questioned 5W 1H about the problem including where, when,
what, who, why and how. For example of relevant question are:
 Where and when did the adverse event happen?
 Who was injured/suffered ill health or was otherwise involved with the
adverse event?
 How did the adverse event happen? Note any equipment involved
 What activities were being carried out at the time?
 Was there anything unusual or different about the working conditions?
 Were there adequate safe working procedures and were they
 What injuries or ill health effects, if any, were caused?

STEP 2: Analysis

11 | P a g e
The next step after gathering all the relevant information is by doing the analysis
to find the cause of the adverse event. This analysis involves examining the fact
and determining what happened and why. The safety officer need to ensure that
all the information is examined thoroughly to avoid missing information. In
addition, the analysis must be free from bias, so all the possible cause is fully
considered. During the analysis process, the safety officer need to identify some
of the issue including:

1. The sequence of events and conditions that led up to the adverse event
o Understanding the relationships between factors, root causes and the
defined problem.
2. The immediate causes of the accident
o Failure to warn the potential hazard.
3. The underlying causes
o actions in the past that have allowed or caused undetected unsafe
4. The root causes
o organizational and management health and safety arrangements
o supervision, monitoring, training, resources allocated to health and

In accident investigation, there are some methods that are applicable in

analyzing the information gathered to find immediate, underlying and root
causes. One of the suitable methods is:

12 | P a g e
 What happened and why?

Victim breaks his



Victim is on ladder Falling due to victim falls of


The ladder slips
Access to the roof


The ladder is not

From the diagram we can see the hierarchy of the problem and its respective
reasons. The best practice in understanding what happened and why is by
organize the information gathered. The concept is simple by questioned ‘why’ over
and over until the answer is no longer meaningful. From this example we can see
that the starting point is the ‘event’, eg Izzat has broken his leg. Following the line
below, set out the reason why Izzat has broken his leg. This first line should
identify the vulnerable person, the hazard and the circumstance that brought them
together. Then ask ‘why’ for each reason and continue down asking ‘why’ until the
answer is no longer meaningful. During this stage, do not care on how many times
the question ‘Why’ is asked to the problems because at the end the real causes of
the accident will be found. By collecting the relevant information and determine
what happened and why, the investigator can analyses the cause of the accident

13 | P a g e

At the last phase, it is essential to come out with the solution of the problem and
implementation to control safety and health. This phase can be dividing into two steps
including risk control measure and action plan from overall accident investigation.

STEP 1: Identifying suitable risk control measures

One need to identify the risk control measure and set out what need to be done, when
and by whom. This practice is to ensure the timetable for implementation is monitored.
Ideally, measures that rely on engineering risk control measures are more reliable than
those that rely on people. The role of safety officer at this phase including:

1. Identify the additional measures needed to address the immediate, underlying

and root causes.
2. Identify and compare the practice underlined as required by codes of practice
and guidance.
3. Provide meaningful recommendation that can be implemented at the workplace.

In order to decide which risk control measure are more recommend and more priority,
the following measure need to be identified:

1. Measures which eliminate the risk

 Use inherently safe products, such as a water-based product rather
than a hydrocarbon-based solvent.
2. Measures which combat the risk at source.
 Provision of guarding.
3. Measures which minimise the risk by relying on human behavior
 Safe working procedures and the appropriate use of personal
protective equipment.

14 | P a g e
STEP 2: Action plan and implementation:

The next step in phase two after identify risk control is action plan and implementation. This
second practice can be said as the desired outcome of a thorough investigation. The point that
need to be consider in action plan including [5]:

1) Provide an action plan with SMART objectives

 S-Specific
 M-Measurable,
 A-Agreed
 R-Realistic
 T-Timescale
2) Ensure that the action plan deals effectively with immediate, underlying and root causes.
3) Ensure the finding and recommendations are correct, address the issues and realistic.
4) include lessons that may be applied to prevent other adverse events,
 assessments of skill and training in competencies may be needed for other
areas of the organization;
5) Should be fed back into a review of the risk assessment.
 The Approved Code of Practice5 attached to the Management of Health and
Safety at Work Regulations 1999 regulation 3 (paragraph 26), states that
adverse events should be a trigger for reviewing risk assessments); [6]
6) The result of the investigation and the action plan must to be share with everyone who
need to know.
7) Include arrangements to ensure the action plan is implemented and progress monitored.


It is a good practice to document what you find from your risk assessment. This includes noting
the hazards, how people might be harmed by them, and what's already in place to control the
risk. This documentation doesn't need to be complicated, but it can help you communicate and
manage risks in your workplace.

15 | P a g e
Accident Investigation Report

Date of investigation Investigator

Date of injury Injured worker
Project location Project Supervisor
M.O.L. notified? No Yes Joint H & S Committee in place? No Yes

Injured worker’s
Nature of injury reported (injured body

Factors that led up to accident:

Project Safety Representative:


Names and addresses of witnesses and their comments (please use back for additional

Recommendations for corrective measures:

Corrective measures taken? N/A Yes To follow up on (Date)

Investigator Signature President

16 | P a g e
Accident Investigation Report

Name: Address:
Type of business:

Injured Employee
Last name: First name: Occupation:
Age: Experience at work involved:
Nature of injury:

Accident / Injury
First aider: Medical treatment:
Name and address of doctor:
Date and time of accident:
Project and location of accident:
Date and time accident reported to supervisor:
Date and time accident reported to MOL:
Name of MOL representative who took the call:
Date and time accident reported to head office:
Names and addresses of witnesses:

Who made the work assignment?
Directions the employee received before starting work:

17 | P a g e
Were any specific procedures involved? Yes No N/A
Description of machinery or equipment involved:

Accident Description
Explain what happened (what, where, when, who, how).

Sketch / Diagram

18 | P a g e
19 | P a g e
Immediate Cause Underlying Causes

How can the accident be prevented from happening again?

20 | P a g e
What steps have been taken to prevent a recurrence of the accident?

Action By: Report Prepared By:

21 | P a g e
Accident Report

Injured Worker’s Last Name First Name Occupation

Location where injury/accident occurred First Aid Provider

Hospital or Clinic Attended for Medical Aid Treating Physician's Name

Project Location of
Nature of Injury

Person who transported

No Yes
Will this be a lost time injury? No Yes Is injury work-related?
Were any subcontractors No Yes
No Yes Was the MOL called1?
Injury Details
Date and Hour of Injury Date and Hour Reported to Employer
Day Month Year Time Day Month Year Time
a.m. a.m.
p.m. p.m.
Date and Hour Last Worked Normal Working Hours
Day Month Year Time from to
a.m. a.m. a.m.
p.m. p.m. p.m.
Who was the injury
reported to?
What caused the injury? Describe the injury, the body part involved and specify left or right
side (use back of sheet if necessary).

Describe the worker's activities at the time of the injury. Include details of equipment or
materials used (use back of sheet if necessary).

1 Reasons to call the MOL: fatality, critical injuries (defined as an injury of a serious nature that: places life in jeopardy, produces
unconsciousness, results in substantial loss of blood, involves the fracture of a leg or arm, involves the amputation of a leg, arm, hand
or foot, consists of burns to a major portion of the body, causes the loss of sight in an eye), fire, explosion or hazardous material
release, lost time injuries or accident requiring medical treatment, occupational illnesses, any worker who has had their fall arrested,
any 'prescribed incident', or property damage >$500.

22 | P a g e
Did anyone else witness the accident or know more about the injury?



Occupational safety and health professionals use the hierarchy of control (shown in the
figure below) to determine how to implement feasible and effective controls. This
approach groups actions by their likely effectiveness in reducing or removing the falling

23 | P a g e

Eliminate the hazards completely always comes to priority as the first choice. Then, the
substitution comes next involves replacing the material or process with a less
hazardous one. [7]

There are question needs to consider regarding these options including:

1. Is there any safer ways to perform the task?

o If falling is a hazard, eliminate the risk by storing stock at lower heights so

workers don't have to climb ladders to reach the goods.

2. Can the task perform at another place?

o Don’t do the job at height if you can do it on the ground.

3. Can workers use something less harmful?

o If construction-heavy industrial equipment are a hazard, consider

substituting with new or safer equipment.

24 | P a g e
25 | P a g e

If the hazards cannot be eliminate or substitute, the best options is engineering control.
These involve using work equipment or other means to prevent workers from being
exposed to a hazard. Engineering controls are physical changes to the workplace and
may include equipment guarding, guardrails, traffic control lanes and barriers between
vehicles and pedestrians, and many other options. For example, while working at
heights cannot be avoided in construction, guardrails can be installed to prevent falls
from happening. Guardrails are an example of an engineering control.

Engineering controls examples including:

1. Use places that are already safe which equip with permanent or temporary
guardrails and built scaffold.

2. Put on edge protection, guardrails and screens before erecting a structure.

26 | P a g e
3. Reduce the number of personnel that have to go near the edge and the
number of times they have to go.

4. Put up debris netting to catch any falling objects. A lot of the risk involved in
working at heights can be de- signed out. Often you can make structural
changes to the work systems or work environment that would prevent falls
and make for a safer workplace.

27 | P a g e
Risk management- working at height

STEP 1: Determine responsibilities

in managing falling prevention

STEP 2: Identify all situation where

someone might fall from height.

STEP 3: Undertake a risk assessment

on those situation identified

STEP 4: Consider what safety

measures are needed to eliminate

STEP 6: Ensure emergency

STEP 5: Implement safety measure procedures are in place in case of
a fall.

STEP 7: Check safety measures are

adequate. STEP 8: Ensure all plant and
safety measures are adequately
designed and maintained.

STEP 9: Check risk assessment

safety measures at every site and

28 | P a g e

Administrative controls involve identifying and implementing safe work procedures so

your workers can perform their job duties safely. The findings of your risk assessment
will form the basis of these safe work procedures.

Examples of administrative controls include

1. Implementing person-check procedures and prohibiting the use of mobile phones

while workers are driving.

2. Create an exclusion zone to restrict access to areas where there is work taking
place above.

3. Put up clear signage to warn people of fall areas, open pits and unsafe

29 | P a g e
4. Give employees information and training on the standard procedures and safety

5. Regularly undertake and record maintenance, inspection and testing of systems

and equipment to ensure it is suitable as well as sufficient.


Using personal protective equipment (PPE) is another important control to protect

workers. PPE should be in good condition and be used by trained workers.

1. Footwear that is suitable to prevent slips.

2. Sunglasses to make sure that an employee at height is not at risk due to glare or

3. Safety helmets that will remain in place in the event of a fall.

4. Wear safety harnesses as secondary fall protection.

30 | P a g e
31 | P a g e


Identify the ethical principles and professional ethics exist/ potential to happen to the
case study that you have chosen. Example: construction industry – ethical issues:
corruption, materials used are out of specification etc.


CASE: Died falling from height Location

PLACE: Tapak bina, Johor

ACCIDENT: The victim fell from the roof as the roof installation works is being
carried out

INJURIES: Fatal Serious bodily injury

MAIN CAUSE: No safe work procedure

Roofing is generally considered as construction activity and so the factors affecting

roofing and how these can be structured are largely similar to those for the construction
industry as a whole.

Domestic as well as industrial roofing, and new construction as well as

repair/maintenance were covered in the workshop including the following activities:

• SLATING AND TILING; including clay, concrete, natural and man-made slate,
steel, bitumin and wooden shingles and shakes.

• SHEETING AND CLADDING; including profiled self-supporting fiber cement,

steel, aluminium and fully supported metals with fillers, sealants, fixings and
fasteners and roof lights.

32 | P a g e
• FLAT ROOFING; including built up felt roofing, single ply, mastic asphalt, liquid
applied waterproofing and dry seal.

Roofers as a trade are those who have been trained to undertake specialist roof work.
This is distinct from people who happen to work on roofs, for example, joiners. It was
suspected that many of the latter cases will be classed as roofers in accident statistics
even though technically they are not. Even within the roofing trade there are different
levels of qualification.

• The younger and older workers are at most risk of falls from height due to
lack of awareness in the former case and complacency in the latter (D4).

• Fatigue among roofers, for example through alcohol or having more than
one job, may be a significant factor which in some cases warrants more
attention (D5).

• The provision of information / advice (D8) to roofers is an area where

improvements are needed. The main issue appears to be that information
is not pitched at the level that workers need, either being too complicated
or too generic.

• The eyesight of the workforce is a health area that has been overlooked
and needs further investigation (D6).

• Compliance in the industry was thought to be poor with even skilled

people taking unnecessary risks (D9). This seems to be ingrained in the
culture, and people are allowed to get away with safety violations too

• Many accidents have been seen which are due to the weather and
perhaps more control is needed in this area (D11).

33 | P a g e
• Training was seen as indispensable for any roofing work (D1). A major
problem area is that the self-employed are unlikely to have any formal
training (O2).

• Incident management and feedback (O5) is an area that has the potential
to raise awareness of the hazards involved in work at height. Companies
are doing nothing in this respect, and it is being left to the NFRC to drive
this area.
• Supervision (O6) was identified as a key area for improving safety in work
at height. Supervision at the moment does not carry enough safety

• HSE have an important role to play in improving safety in the industry

(E2). The key activities were thought to be more site visits and warnings
along with dissemination of information in order to raise awareness. It was
recognized that HSE are under resourced at present, and this limits how
much they can do in these areas.

Ethical Issue

There are top five categories of fatalities in the construction industry namely falls,
electrocutions, vehicle rollover, personnel run over by vehicle and excavation caveins
[7]. Accident is not happened without any reason, there should be caused by unsafe act,
unsafe condition or both. The causes of accidents in Tapak Bina Johor were found are
failure of workers to obey work procedures, work at high elevation, poor site
management and poor workers attitude about safety.

In the construction project, money is absolutely the important thing. To get the
success project, we must consider on quality, time and cost. All these three main
objective are related with safety. Accident will be happen anytime if worker and the

34 | P a g e
company did not follow the safety regulation. If safety is negligible, it may affect the time
of completing the project, and also can increasing the cost.

Training should provide workers with the necessary knowledge, skills and hands-
on work experience to carry out their work efficiently and safely. The fact that someone
has been doing the same job for a long time does not necessarily mean that they have
the necessary skills or experience to do it safely.

Some of the ethical problems that might arise at Tapak Bina Johor follow:

1. Lack of instruction and training may mean that tasks are not done properly;
2. Misunderstandings, which arise more easily when employees lack understanding
of the usual routines and procedures in the organization;
3. A lack of respect for the risks involved, due to ignorance of the potential
4. Problems due to the immaturity, inexperience and lack of awareness of existing
or potential risks;
5. Poor handling of dangerous materials or tools, due to employees not being
properly informed about how things should be done correctly

35 | P a g e

1. (https://www.ccohs.ca/oshanswers/hsprograms/investig.html)
2. http://www.ihsa.ca/resources/accident_investigation.aspx
3. Risktec. (2008), 44(14), 611232.
4. http://www.hse.gov.uk/pubns/hsg245.pdf
5. Safety, O. (n.d.). Preserve / Document Scene Collect Information Root
Implement Corrective Actions.
6. https://www.worksafebc.com/en/health-safety/create-manage/managing-
7. C.R. Asfahl, Industrial Safety and Health Management, 5th ed. Upper Saddle
River, NJ: Prentice Hall, 2004.

36 | P a g e