accident investigation-immediate cause

[julietrvn]

Hi

i am undertaking an accident investigation which resulted in an employee having emergancy surgery to re-connect a tendon in his finger.

He was advised by a fellow employee to wear anti-cut gloves but refused. (He received NO safety briefing from the manager)

In immediate cause i have stated:
'Immediate:
Employee error, failure to comply with company PPE policy. Due to the fact the instruction to wear the protective gloves came from a fellow employee and not the relevant Senior Process Manager, it may be deemed as a skill based error.'

am i right in labelling it a skill based error? in my opinion if the instruction was not delivered by the manager, its not classed as a violation?

i would like to add that i have continued with both underlying and root causation and the appropiate factors listed (such as unskilled employee being moved into a role with no training, and no supervsion)

Thank you in advance.

[julietrvn]

I have just changed the wording from:
'Employee error, failure to comply with company PPE policy' to 'Skill based error on behalf of employee'

[Andyblue]

I’d take a step back and see what we have besides the “other employees “ account that he refused to wear the no-cut gloves. Was he trained and knew to wear them, were there gloves available etc.
RCA too early may lead to incorrect results

[julietrvn]

Hi Andy
i have got witness statements from other members of the team in which the accident happened and they all collaberate that they heard the other employee advise the IP to wear gloves and he refused.
i have also documents and statements that show the IP has never undertaken this role before, received no formal training or discussion on the PPE requirements from management, other than being told 'the lads will show you what to do'
The anti cut gloves (along with other required PPE) are stored in the vacinity of the department to ensure they are always available for use.

[Blackstone]

I would suggest maybe the root cause is a management of staff issue as he was allowed to operate the machine without the relevant experience, knowledge or training.

The maybe some contributory negligence from the IP but he was allowed to carry out this task.

My thoughts are to look higher at how he was allowed to use the machine without proper knowledge or training from management.

Has he been asked why he used the machine, why he was not wearing PPE, etc?

Just my though based on the comments above.

Glen

[PaulDonaldson]

Is the immediate cause not the fact that the IP came into contact with a sharp object causing the injury? The fact that they were not wearing the correct PPE would come later surely

[Smudger207]

Spot on there Paul!

Also what type of cut resistance gloves were available? There are different levels of cut resistance gloves out there, these should be based upon the hazards with the task.

[Juan Carlos]

Agree. immediate cause is contact with sharp object / moving machinery. Also let's not jump straight into PPE. Was there a need to guard this dangerous part of the equipment in the first place?

[andybz]

I agree with the last three posts. You are way off the mark identifying failure to use PPE as the immediate cause. If you continue with this line of inquiry you are likely to antagonise the employee (feel they are being blamed) and will miss opportunities to fundamentally make the job safer. First things to ask are why was the sharp edge required and why was the employee required to be anywhere near it?

Also, I am not clear why you want to classify this as a skill based error. Is this imposed on you by your investigation reporting system or something you want to do?