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OSH Accident Investigation Study Case

Mechanical (hons) engineering (Universiti Teknologi MARA)

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FACULTY OF MECHANICAL ENGINEERING

EM220

MEM603
OCCUPATIONAL SAFETY AND HEALTH

EMD7M6A

INDIVIDUAL ASSIGNMENT
ACCIDENT INVESTIGATION
“DIED CRUSHED BY KUBOTA TRACTOR”

PREPARED BY:
NUR SYAZREEN BINTI MAHDZIR
2016218556

PREPARED FOR:
DR. ALIAS MOHD SAMAN

26 DECEMBER 2019

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FACULTY OF MECHANICAL ENGINEERING,

UNIVERSITY TEKNOLOGI MARA (UiTM)

INDIVIDUAL ASSESSMENT FORM

OCCUPATIONAL SAFETY AND HEALTH (MEM 603)
LECTURER NAME DUE DATE SUBMISSION REMARKS
DATE
DR ALIAS MOHD SAMAN 26 DECEMBER 26 DECEMBER -on time/- late

GROUP NO EMD7M6A

No Name Student ID
1 NUR SYAZREEN BINTI MAHDZIR 2016218556

GENERAL LEVEL POOR MARGIN ACCEPTAB GOOD EXCELLEN

GUIDELINES AL LE T
: Scale 1-2 3-4 5,6 7,8 9,10

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

Introduction 10
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
TOTAL 100%

REMARKS:

RUBRIC ASSESSMENT-REPORT

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GENERAL LEVEL POOR MARGIN ACCEPTAB GOOD EXCELLENT

GUIDELINES: AL LE
Scale 1-2 3-4 5,6 7,8 9,10

Scale 1-2 3,4 5,6 7,8 9-10

Criteria Poor Mar Acceptable Go Excellent Fact
gin od or
al
Topic is poorly Topic is fairly
introduced. Lack of introduced. Moderately
Introductio Topic is well
understanding on understand on the topic.
n introduced. Clearly
the topic.
explain on the
topics.
Fairly general Well and thorough
research on the research in the
Research Topic is poorly
Contents concept and its concept and its
Result discussed. Lack/
Part A-C applications. Some applications.
absent of supporting
supporting evidence Effective supporting
evidence.
is provided. evidence is provided.

all relevant and

available resources
effectively
resources resources
ideas, critics,
new ideas and new ideas and partially suggestions and able to
unable to utilize able to act autonomously act accordingly
Utilization them
of
curiosity in acquiring and curiosity in
resources
and curiosity new knowledge and acquiring new
References
in acquiring expanding it through knowledge and
and citation
new new resources utilization expanding it to new
knowledge horizon through
resource utilization.
references
resources explored
explored
citation of resources
are well cited with
complete
explanation of tables
and figures
Conclusion Unclear conclusion Topic is fairly Topic is well
of the topic. concluded. concluded.

Writing Writing is found to be Writing is well

is in accordance with organized and covered
disorganized, course requirements and relevant to the course
unfocused to have some focus on requirements and
the main discernible theme and topics for discussions.
Organiz Format
theme and supporting details. Each sub-topic is
ati on
disconnected. clear and well
Not following structured.
the required format
of presentation.
Writing lacks Excellent writing
clear sentences and skills in the use of
Writing skills are words and prefect
paragraphs.
Deficiencies somehow clear and grammar.
paragraphs are well Sources of
Languag Writing in good structured. Less reference are well
e grammatically grammar mistakes cited with complete
skill witting. explanation of tables
and figures

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TABLE OF CONTENTS

LIST OF FIGURES....................................................................................................................5

INTRODUCTION......................................................................................................................6

PART A: ACCIDENT INVESTIGATION...............................................................................8

1.1 Dealing with immediate risk............................................................................................8

1.2 Select level of investigation.............................................................................................8

1.3 Investigation event...........................................................................................................8

1.4 Record and analysis result..............................................................................................14

1.5 Result from the investigation.........................................................................................15

PART B: PREVENTATIVE ACTION....................................................................................16

2.1 Identify Control Actions................................................................................................16

2.2 Select Controls...............................................................................................................17

2.3 Develop and Update a Hazard Control Plan..............................................................18

2.4 Select controls to protect workers during nonroutine operations and emergencies.......18

2.5 Implement selected controls in the workplace..........................................................18

2.6 Follow Up to Confirm That Controls are Effective.......................................................18

PART C: ETHICAL PRINCIPLES AND PROFESSIONAL ETHICS IDENTIFICATION. 19

3.1 No proper Standard Operation Procedure (SOP)...........................................................19

3.2 Ignorance of preparing PPE...........................................................................................19

3.3 Failed to implement Hazard Identification, Risk Assessment and Risk Control
(HIRARC)............................................................................................................................19

CONCLUSION........................................................................................................................20

REFERENCES.........................................................................................................................21

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LIST OF FIGURES

Figure 1: Kubota tractor drove by the worker............................................................................6

Figure 2: Fatal accident case from DOSH.................................................................................7
Figure 3: Hierarchy of controls................................................................................................17

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INTRODUCTION

Unintended and unexpected accidents interfere with the operational cycle, resulting in
injury and damage to property especially in sectors where there may be a lot of risk.
Nonetheless, accidents are inevitable and preventable when there is proper and safe
management of human activities and process flow. This is where the Department of
Occupational Safety and Health steps in to implement rules and regulations for employees
and employers in any workplace. This minimizes and avoids security issues that may occur in
any field of employment, be it factory, shopping complex, hotels or workshops. The safety
officer is therefore essential to monitoring and safeguarding the working environment in any
field.

Investigations must be carried out when an accident occurred. The investigations will
focus on finding the root cause of the incident and preventing any similar incidents in the
future. There will be arguments in identifying and evaluating the causes, but these claims
should be focused on evidence and proof that may lead to remedial action.

The chosen study case for the assignment is “Died Crushed by a Kubota Tractor” that
occur at Palm Oil Mill Kelantan. The Kubota tractor drove is as shown in Figure 1.

Figure 1: Kubota tractor drove by the worker

The victim of a Kubota tractor driver died after being hit by a tractor crush into steep
depth over 30 feet. The focus of investigation stated by DOSH as shown in Figure 2 are as
follows: i) High slope surface exceeds 10 degrees, and ii) SOP for tractor driving after
rain/slippery road is not explained.

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Figure 2: Fatal accident case from DOSH

CASE INFORMATION

Title case : Died crushed by Kubota tractor

Location : Palm Oil Mill, Kelantan
Date : 02-01-2019
Summary case: The victim of a Kubota tractor driver died
after being hit by a tractor crush into sleep
depth over 30 feet
Classification Case Death

Contributing Factor: 1) High surface exceeds 10 degrees

2) Not following SOP for tractor driving after
rain
3) Slippery road is not explained
Observation tragedy site: Weakness in the surface angle which is more
than 10 degrees and not following the safety
measures during rain
In the fatal accident at Palm Oil Mill Kelantan, a 38-years-old Che Husain was killed
crushed by Kubota tractor. The incident has been put in as a serious accident that requires
proper investigation.

Victim profile
NAME Che Hussin Md Samad
AGE 38
CITIZEN Malaysian
STATUS Married
COMPANY Seri Sawit Jaya SDN BHD
POSITION Service Technician

PART A: ACCIDENT INVESTIGATION

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Main steps of accident investigation

1. Dealing with immediate risk

2. Select level of investigation
3. Investigate event
4. Record and analysis result
5. Review process

In this case of accident planning whom to meet up with, from the company management and
seek for permission to operate an investigation.

1.1 Dealing with immediate risk.

The aim of this stage is to make disaster situation safe and prevent more accidents from
occurring at the place where Che Hussin was crushed to death during working at the palm oil
mill. In fact, to determine whether the victim needs help, care or need to be rescued. Well,
Che Hussin already died on the spot in this case when he was crushed. This is to ensure that
Che Hussin had no other exposure to the same threat.

1.2 Select level of investigation

Choosing which one victim should be treated and these severe injuries, ill health or death
should to put the effort on first. In this case the death of Che Hussin after a week of dying is
chosen and looked at more closely. To find the underlying causes of the significant event due
to the event could occur again and harm others.

1.3 Investigation event

This phase was designed to prevent future incidents, mitigate and recognize the risk in the
work environment that is exposed to them. It is stated that there should be 3 phases for an
effective inquiry; investigation, review and reporting. The purpose of this process of
investigation is listed below:

1. Develop a plan
2. Investigate all incidents and accidents immediately
3. Collect the facts
4. Interview witnesses
5. Write a report
 Develop a plan

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The object of preparation is to deal with situations in a timely manner, minimizing the
possibility of losing evidence and ignoring witnesses. It is important to list all procedures,
forms, alerts, etc. as step-by-step procedures. A flow chart is developed to show the major
components of the program quickly, and the head of management of the company can be
informed and request an investigation.

 Investigate all incidents and accidents immediately

Gathering evidence and interviewing witnesses as soon as possible is important because

evidence will dispose, and people will forget about it. To begin a security officer, the system
kept in the investigation must know who is involved and be aware of them. The first move is
to alert all workers involved such as:

1. All witness.
2. The service technician
3. Supervisor on duty during the accident

Approach and observe the scene:

Second, make sure you don't become victims with others! Also search for dangerous
situations that are still there. Then it's necessary to help the injured. Secure the scene and
trigger physical evidence custody chains. Identify visual evidence and witnesses. Separate
witnesses from each other If physical evidence is collected, interviews should continue the
investigation as soon as possible.

 Check for danger

 Secure and isolate the scene
 Identify and separate witnesses
 Gather the facts

One of the crucial steps is to distinguish the scene by increasing the cross-line sign around the
accident site. It is very necessary because to keep the obvious secure and to encourage the
investigation process. Other than that, to avoid the disruption of the investigation by
unauthorized people.

Site scene inspection and check for any dangerous work environment. In this situation, it is
found that the tractor was park on a surface with 10 degrees angle.

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 Collecting the facts

Provide the best sources of information related to injuries by taking photos, videos, and
writing notes about the body and location of the condition of the victim. Investigate the
tractor movements before, during and after the crash. Once proof of the accident is obtained,
the answer is:

 Check the PPE

 Check data of equipment records
 Note general working environment
 Note floor or working surface condition
 Take many pictures
 Draw the scene

 Interview witnesses

Investigation with the witness present can be more effective at the site of the incident.
Witness will be able to provide more information and tell about what happened in an
accident. Compile a list of witnesses. Record and separate names on the register, including
primary witness and secondary witness, in three categories.

List of guidelines for the interview session:

 Interview promptly after the incident

 Choose a private place to talk
 Keep conversations informal
 Talk to witnesses as equals
 Ask open ended questions

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Safety Officer:

NAME NUR SYAZREEN BINTI MAHDZIR

AGE 33 YEARS OLD

CITIZEN MALAYSIAN

POSITION SAFETY OFFICER

HOMETOWN SELANGOR, MALAYSIA

COMPANY SERI SAWIT JAYA SDN BHD

CONTACT NO. 01110832781

EMPLOYMENT DURATION 5 YEARS

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Witness 1:

INTERVIEW FORM
NAME NIK AIMAN
AGE 43 YEARS OLD
CITIZEN MALAYSIAN
STATUS MARRIED
COMPANY SERI SAWIT JAYA SDN BHD
POSITION SUPERVISOR
Can you tell me a little bit about the accident? What are you doing during the
accident? What time you notice the accident happen?

I was on my way to the mill to check the progress of my workers. Then suddenly I
heard sound of someone screaming “It Hurts!”. I ran towards the victim and I saw that
1. the victim was lying flat on the ground underneath the tractor.

What time do you see the accident?

2.
Around 11.30 am
What is your connection with the victim?
2.
Supervisor.
What did you do when the accident happens?
I immediately run towards him, but I noticed that he was unconscious. So, I tried to
3. wake him up, but he didn’t wake up. So, I called an ambulance and Police.

When you arrived at him, what did you see?

4.
I saw him not moving anymore and his body is full of blood.
What is the cause of the accident?
From what I see, the victim did not wear proper PPE like safety helmet and harness
5. during doing his job and the supervisor does not follow the SOP when working.

Interview by: Date:

Nur Syazreen Binti Mahdzir 09/01/19
Safety Officer

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Witness 2:

INTERVIEW FORM
NAME MD NOOR
AGE 33 YEARS OLD
CITIZEN MALAYSIA
STATUS MARRIED
COMPANY SERI SAWIT JAYA SDN BHD
POSITION Service Technician

Can you tell me a little bit about the accident? What are you doing during the
accident? What time you notice the accident happen?
Before the accident happened, victim and I were talking on his way to the mill. When I
1. was going to the area and then I saw him lying on the ground.

What time do you see the accident?

2.
Around 11.30 am
What is your connection with the victim?
2.
Colleague
3. What did you do when the accident happens?
I immediately run towards him, but I noticed that he was unconscious. So, I get the
supervisor to inform about the accident.
When you arrived at him, what did you see?
4. I saw him not moving anymore and his body is full of blood.
What is the cause of the accident?
From what I see, the victim did not wear proper PPE like safety helmet and harness
5. during doing his job and the supervisor does not follow the SOP when working.

Interview by: Date:

Nur Syazreen Binti Mahdzir 09/01/19
Safety Officer

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1.4 Record and analysis result

8.10 AM: Victim had been

7.45 AM: Victim arrived at given the task to go to check
the office and the morning the machine at site. Then he
briefing was conducted went to the store to collect
before start the work. and prepare the equipment
before leaving.

9.35 AM: He arrived at the

11.30 AM: Second witness
site and Supervisor has given
saw the victim on the ground
his task to be done

11.35 PM: The supervisor call 12.05 PM : The ambulance

the and police arrived at the
accident site but the victim
ambulance from the nearest was died due to serious injury
Hospital on his body and unconscious.

12.25 PM : The Police has

confirm the death of the
Victim and the body has been
bring to the hospital.

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1.5 Result from the investigation

1. The victim did not wear a safety helmet and safety harness as a PPE during working
at the workplace.
2. The tractor is parked on the surface with an angle more than 10 degrees
3. Safe procedures had not been established relative to performing work on the mill.
4. No personal protective equipment was prepared by the Employer

To conclude, on both sides, the cause of the accident was related to the fault of the person
who parked the tractor on a dangerous surface. The victim who does not wear PPE. The
supervisor and the service technician did not practice the working procedure. The service
technician is not alert, and nobody is tracking the accident-causing work area.

In addition, it is an unsafe act for the company not to provide any safety helmet and safety
shoes to all employees who carry out the activities on the mill. That led to the accident as the
worker could injure to falling objects or other things that could hit them.

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PART B: PREVENTATIVE ACTION

Good preventative action protects workers from occupational hazards; help prevent
accidents, diseases, and incidents; reduce or eliminate threats to safety and health; and help
employers provide safe and healthy working conditions for workers. Employers should track
and avoid hazards effectively by:

i. Identify control actions

ii. Select controls
iii. Develop and update a hazard control plan
iv. Select controls to protect workers during nonroutine operations and emergencies
v. Implement selected controls in the workplace
vi. Follow up to confirm that controls are effective

2.1 Identify Control Actions

Employers will have to compile, coordinate and review workers ' information to
determine which types of hazards can occur and which employees may be exposed or
potentially exposed to in the palm oil factory. The employer could get proper guidance by:

i. Reviewing sources such as OSHA standards and guidance, palm oil mill industry
consensus standards, National Institute for Occupational Safety and Health (NIOSH)
publications, and engineering reports to identify potential control measures
ii. Investigating control measures used in other palm oil mills and determine whether the
measures are applicable to the employer’s palm oil mill
iii. Getting input from his workers who may be able to suggest and evaluate solutions based
on their knowledge of the facility, equipment, and work processes
iv. Consulting with safety and health experts for complex hazard

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2.2 Select Controls

Figure 3: Hierarchy of controls

If feasible, employer should choose inherently safer equipment, machinery and
materials based on the principles of "Prevention by Design" (PtD). The employer should
apply PtD when making decisions about his plantation, equipment or product design.

In this case, the employer could not physically eliminate the hazard as Kubota trucks are
needed during the working process and the jobs have to be done at the palm oil mill, but
however he could replace the hazard by at least making sure there is no surface that exceeds
10 degrees of angle. The employer could also apply administrative controls by making sure
his employees at the palm oil mills have adequate training on:

i. How to operate the machine

ii. How to do the tasks required
iii. Use of personal protective equipment (PPE)
iv. How to keep the machine in good working order

Employer must also assess the risks for the works at the palm oil mill by:

i. Choosing which machine and trucks to use

ii. Deciding who should use the machine and trucks
iii. Deciding how to supervise the work and take account of changing conditions
iv. To work safely on steep ground, you need to think about the entire harvesting
operation - not just the forwarder or harvester. Everyone involved in the work needs
to be in regular contact with each other.
v. Recording how to plan to do this in risk assessment and site safety rules

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vi. Every operation will be different and employer will need to assess the specific site
and the weather conditions and surroundings
vii. Everyone operating machinery on steep ground must receive the appropriate training
and be competent to do this type of work
viii. Setting up the right and safe place to park any vehicles and trucks at the palm oil mill
area during work and during off-work

2.3 Develop and Update a Hazard Control Plan

Employer should:

i. List the hazards that needs controls in order of priority

ii. Assign responsibility for installing or implementing the controls to a specific person
or persons with the power or ability to implement the controls
iii. Establish a target completion date
iv. Plan how to track progress toward completion
v. Plan how to verify the effectiveness of controls after they are installed or
implemented

2.4 Select controls to protect workers during nonroutine operations and emergencies
The action should include provisions for the safety of staff during non-routine activities and
predictable emergencies.

2.5 Implement selected controls in the workplace

Once risk prevention and control measures have been established, they should be enforced in
compliance with the risk control plan by implementing risk control measures in keeping with
the priorities set out in the risk control strategy

2.6 Follow Up to Confirm That Controls are Effective

i. Tracking and verifying the progress of implementation
ii. Conducting regular inspections to make sure that the taken engineering controls are being
operated as designed
iii. Evaluating whether the control measures are effective or need to be modified by involving
the employees in the evaluation of controls
iv. Confirming that work practices, administrative controls and personal protective equipment
use policies are being followed

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v. Conducting routine preventive maintenance of equipment, facilities, and controls to avoid

equipment failure

PART C: ETHICAL PRINCIPLES AND PROFESSIONAL ETHICS

IDENTIFICATION

3.1 No proper Standard Operation Procedure (SOP)

The company did not have enough written SOP to instruct workers on how to best do
their work. In this line of work, this is very important because it concerns the lives and safety
of the workers and the local people. Such as wearing and behaving at a height while
employed. Even if height work is only to grab a tool without the measure of safety, it is a
high risk.

3.2 Ignorance of preparing PPE

It is highly dangerous to use proper Personal Protective Equipment (PPE) for the
work environment, and the ignorance of preparing the PPE for the worker is also highly
unethical. It is under the act of osha that the employer should prepare a PPE for each
employee at the height of the work.

3.3 Failed to implement Hazard Identification, Risk Assessment and Risk Control
(HIRARC)
In line with PREVENTIVE MEASURES ' departmental strategy to enforce the
Occupational Safety and Health (OSH) rule, HIRARC seems to have become extremely
important. With HIRARC, one can identify hazard, analyse and evaluate its associated risk
and then apply the appropriate control measures. The business does not follow HIRARC's
protocol in this situation and this allows the possibility of the staff getting a rise in the
accident. Consequently, this company's working environment does not meet the security
criteria.

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CONCLUSION

As a safety officer at the in this project. I ensured the safety, health and welfare of the
individual at the workplace against harm because of the work activities. Occupational Safety
and Health (OSHA) is, in addition, one of the organizations that will protect people from
safety or health risks arising from occupational practices at a workplace other than those at
work. We have also become more positive and are actively striving to improve health and
safety in the workplace by making safe and healthy work practices part of Malaysian culture.

In summary, the aim of the project was successfully achieved as a security officer,
identifying ethical principles and subscribing to professional ethics, investigating the reported
fatal accident and discovering the causes of the employees' fault due to the lack of safety of
the company.

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REFERENCES
.

1. Department of Occupational Safety and Health of Malaysia (n.a.) Guidelines For

Hazard Identification Risk Assessment and Risk Control HIRARC. Retrieved on 24th
December 2019 from
http://www.dosh.gov.my/index.php/legislation/guidelines/hirarc-2/1846-01-guidelines
for-hazard-identification-risk-assessment-and-risk-control-hirarc-2008/file
2. Health and Safety Executive UK (n.a.) Steep Groud Working, Retrieved on 24th
December 2019 from https://www.hse.gov.uk/treework/safety-topics/steep-
ground.htm

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