Case Studies in Safety: A Great Training Tool

Safety case studies are fun, challenging, interactive, and a highly effective training method.

Armed with the knowledge they gain from examining the facts of real workplace accidents, workers can learn how to avoid similar incidents and injuries.

Here’s an example of such a case from BLR’s OSHA Accident Case Studies. This case is about a confined space incident.

The Incident

Two employees arrived at concrete pit at demolition site where they’d been working to salvage the bottom part of a cardboard baler imbedded in the pit. When the employees uncovered the pit, they both felt a burning sensation in their eyes.

Employee #1 climbed down into the pit to determine what might be causing their eyes to burn. He immediately climbed back out of the pit because it was hot. He decided to put a water hose into the pit to help cool it down.

The employees climbed down into the pit with the water hose. Both employees experienced chest tightness, difficulty breathing, and burning eyes. They decided to exit the pit because of the intolerable conditions.

Employee #2 climbed out first. As Employee #1 was climbing the ladder to get out, he was overcome by the fumes and fell back into the pit. He landed on his back, unconscious.

Employee #2 climbed down into the pit in an attempt to rescue employee #1, but was unable to lift him. Employee #2 exited the pit in order to get help. Unfortunately, by the time help arrived, Employee #1 had died of asphyxiation.

The accident investigation determined that employee #1 had attempted to extinguish a small cutting torch fire the day before by covering it with sand and dirt. Apparently the fire was not extinguished and smoldered overnight, which resulted in a build up of carbon monoxide inside the pit.

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Discussion Questions

Once the case has been presented, some discussion questions can help kick off the analysis of the incident. For example:

• What are the potential hazards of confined spaces?
• What was the specific hazard in this case that cause a fatality?
• Were these workers properly trained and equipped to enter a confined space?
• What type of air monitoring should be done before entering a confined space?
• Was this a permit-required confined space? If so, were the workers familiar with the safety requirements of the permit?
• Was confined space rescue equipment readily accessible?

Analysis

• Training? There is no indication on the accident report that the employees were trained as authorized entrants of confined spaces. If they did receive any confined space entry training, they clearly didn’t apply what they learned. Authorized entrants are trained on the hazards of confined spaces, atmosphere testing procedures, symptoms of lack of oxygen or exposure to toxic chemicals, personal protective equipment (PPE), communication equipment, rescue retrieval equipment, etc.

• Hazard warning? These employees entered the space despite experiencing "red flags," such burning eyes and unusual heat. An important part of training for confined space workers includes learning about hazards such as the symptoms of a lack of oxygen or exposure to toxic chemicals. Workers should never enter a space, and should immediately leave a space, in which they experience signs of hazardous conditions.

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• Permit-required? Most confined spaces require a permit before workers can enter the space. Permit-required confined spaces have the potential for hazards such as hazardous atmospheres, engulfment, entrapment, falls, heat, combustibility, etc. By reviewing a permit, entrants know they have obtained all the necessary equipment and the atmosphere has been monitored so they know the space is safe to enter.

• Testing? This worker died of asphyxiation, or lack of oxygen. If the atmosphere in the pit had been tested prior to entry, this accident would not have occurred. Common monitoring practices require a check of the oxygen concentration, a check for flammable gases or vapors (especially important if welding is going to be done in the space), and finally, a check for any other toxic chemicals known to potentially be in the space. Monitoring is conducted before entering the space and periodically while workers are in the space.

• Rescue procedures and equipment? The worker who collapsed back into the pit while climbing out could not be rescued because he was not wearing required rescue equipment. He should have been wearing a full-body harness attached to a retrieval line that was connected to a winch-type system that could have been used to pull the unconscious worker out of the pit. Of course, the other employee would have had to have been trained in confined space rescue procedures.

Tomorrow, we’ll introduce you to another case from OSHA Accident Case Studies, this one about a materials handling accident that resulted in a serious back injury.

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