Introduction
A safety accident report is a formal, detailed account of an accident or incident within an organization. The primary purpose of a safety accident report is to document the context of the event, the causes, and the contributing factors to the said incidence, thereby preventing the recurrence of such an event. As such, a safety accident report is an essential document for creating and maintaining a safe working environment. This paper provides a safety accident report for an electric shock accident that happened at TechCom Solutions. By analyzing the incident, the root causes and the contributing factors will be identified, opportunities for improvements highlighted, and recommendations made. This report will outline the sequence of events, an analysis of the events, the actions taken by responders, any injuries sustained, and recommendations for mitigating risks and strengthening safety measures.
TechCom Solution is a client-focused information systems and technology consulting firm that conducts business at CityScape Towers, Durbanville, Singapore. It was founded in 2005 with a mission to help companies maximize their business potential by designing, developing, and installing customized systems or internet solutions so they can effectively utilize information technology. Currently, the firm has 150 employees.
Accident Sequence
On a Tuesday morning at TechCom Solutions, an unfortunate accident occurred involving Emily Johnson. Emily was performing routine maintenance on a server rack located in the company's server room on the 5th floor of Cityscape Towers. When inspecting the electrical connections, she noticed wiring that seemed off. While inspecting the wiring connections, she was electrocuted. Emily fell to the ground and was rendered unconscious. Quickly, her coworkers called for medical assistance. An ambulance arrived at the scene and took Emily to the hospital, where she received treatment for her injuries. She was released from the hospital the following day.
Evidence
Paper Evidence
In this case, the paper evidence is in the following forms. First, the maintenance logs. This helped determine the extent to which the scheduled maintenance was followed, specifically if there were specific days where scheduled maintenance was skipped. This also helped in determining whether there were issues identified in the previous maintenance days but were not addressed. The review of the maintenance records showed that they were not being kept. Second, the schematic diagrams of the server room electrical connections were critical in determining whether the incident was a result of poor connections or professional malpractice. Further, an aerial view of the server room relative to the eye-witness's positions. The aerial view of the server room relative to the eyewitness's positions ascertains whether, indeed, it is probable they witnessed what they testified, as shown in Figure 1 below. Third, the training records were reviewed. The training records are critical in determining whether the employees have received all the necessary training sessions. Electrical safety training sessions are important in determining the firm’s compliance with legal requirements for accountability purposes since one can determine the topics covered by the employees and how far back to determine whether the employee had forgotten safety procedures, increasing risk.
As such, after an interview with Emily’s supervisor, Sarah, the training records were requested. A review of the training records showed that while the records were kept, files on certain employees, including Emily, were missing. Upon further inquiry, Sarah claimed that Emily’s training records were lost as a result of a computer malfunction.
Figure 1 Server Room Photograph and a Schematic for the Witness Locations.
Physical Evidence
In this case, the physical evidence involved an inspection of the server rack and the maintenance tool that Emily was using. An analysis of the conditions of the equipment is critical in documenting the incidence because its condition determines the extent to which Emily was exposed to electrocution. A review indicated that the firm uses old equipment that was installed in the building in 2005 upon its completion.
Photograph/Video Evidence
In this case, the photographic evidence is derived from the photograph of the server room. The photograph of the rack documents the status of the equipment. The image of the rack shows that the equipment is old, and the electrical connections seem to be loose. However, none of them seems exposed. The issue, in this case, is what is missing. For example, finger-safe panelboards and overhead busways with prefabricated junction boxes seem to be missing. Closely related is a fire extinguisher, which is not captured in the frame.
People/Witnesses
The most crucial source of evidence in this case is one coming from the witnesses and parties close to the incident. In particular, an interview with Sarah Miller was the most informative. The interview revealed the discrepancy in the documentation for the safety procedures training, where some files for certain employees, including Emily, were missing. Sarah claimed the files were lost due to a computer malfunction. The interview also revealed that before every shift, there is no meeting to debrief the supervisor on various safety concerns. Furthermore, the discussion about the status of the server room revealed that all the equipment was the original equipment installed during the building completion in 2005, and maintenance records was not being kept.
Most importantly, Sarah testified that at the start of Tuesday morning, Emily was on time for work. Sarah informed Emily that the server room on the 5th floor needed a routine maintenance inspection. According to Sarah, Emily grabbed her work belt but not her hard hat, which was left on her desk. At the time, Sarah did not think much about it, assuming Emily had another one. I followed up on this with other witnesses, Michael Rodriguez and Lisa Thompson. Michael corroborated Sarah’s statement by informing me that Emily did not have a hard hat on when she went for the maintenance inspection. This position is further collaborated by Lisa Thomson, who claims that while she was not paying attention at the moment, she did see Emily go into the server room but cannot recall seeing any hard hat.
Analytical Method
The appropriate method for analyzing this accident was the events and causal factors analysis method. This method involves identifying the events that led to the incident, the causal factors that caused the event, and the preventive or corrective actions that could have been taken. The accidents occurred as a result of several events which occurred in chronological order. According to Stephans (2004), event and causal factors charts are graphical representations of the accident in such a way that they produce the events in the sequence in which they occurred. In these charts, the events leading up to the accident are represented with rectangles, while ovals represent the conditions that created the said events. A circle represents the accident itself, while arrows join together all the elements of the chart.
The purpose of the event and causal factors chart is to create a systematic way of analyzing the accident (Stephans, 2004, p.253). The event and causal factor chart produce more vital knowledge regarding the accident (Stephans, 2022). As shown in Figure 2 below, the events that occurred on the eventful day are as follows. Sarah requested Emily to conduct a routine maintenance inspection, which was due. However, Emily went without the appropriate personnel protection equipment (PPE). In the server room during the inspection, she noticed some wire connections, which, to her, seemed off. She decided to investigate further right about when she was electrocuted.
Figure 2 The Event and Causal Factors Analysis Chart
Causal Factors
Based on the event and causal factors analysis, there are two causal factors and four contributing factors, which are analyzed as follows.
Lack of Appropriate Safety Gear
Emily was working with equipment where there was a risk of an arc flash incident. Two pieces of evidence support the assertion that she was not wearing appropriate PPEs. First, the electrocution was sufficient to cause trauma that rendered her unconscious, and with a significant head injury, she was held overnight by the hospital for monitoring. If she were wearing the appropriate gear, including cotton protective clothing with long sleeves, a helmet or hard hat, goggles for eye protection, gloves made of leather or rubber, hearing protectors, and safety footwear, electrocution would not have been possible, and in case of an arc flash, she would have been shaken but not physically harmed as she was (Electrical Technology, 2021). The second piece of evidence is the testimonies of Sarah, her supervisor, Michael Rodriguez, and Lisa Thompson, who all ascertain that she did not wear her hard hat during the process. It is a logical assumption that if she failed to wear a hard hat, it is highly unlikely she wore other PPEs.
Contributing Factors
Two factors contributed to the lack of appropriate clothing during maintenance. First, evidence indicates that there is a probability that Emily missed an electrical safety training. A review of the paper evidence, specifically the training records, reveals no evidence that Emily was trained. This poses a challenge in the organization of future topics because there is no documentation of what Emily was trained for and what she lacks. This leaves the employees exposed to delayed or lack of electrical safety training. While Sarah attributes the loss of records to computer malfunctions, it does not explain why selective data in one database was lost. Second, on the eventful day, there was no safety meeting. Safety meetings are critical for reviewing the safety protocols, which include emphasizing the need for PPEs. Also, such a meeting is important for briefing the employee on the risk involved and the emergency procedure, not to mention an opportunity for updates on the training.
Faulty Connections
Even with the appropriate gear, Emily could not have been electrocuted without being exposed to a live wire. There are several evidence indicating the presence of faulty connections. First, the photograph of the server room shows electrical wires that are not arranged in a particular order and ones that are not held together. This is further supported by the fact that Emily noticed there was something off with the electrical connections. In addition, the image evidences the absence of finger-safe panelboards and overhead busways with prefabricated junction boxes, which is advanced technology protecting personnel from the risk of electrical shock when operating in an area such as the server room.
This is supported by the second piece of evidence, the maintenance records, which are non-existent, highlighting the probability that maintenance might be inconsistent, which explains the exposure to a live wire. The third piece of evidence is Sarah’s testimony that there has not been an upgrade of the equipment since 2005, which means the possibility of splicing or exposed wire is high due to wear and tear.
Contributing Factors
The contributing factors were as follows. First, there is a lack of proper maintenance practices, which is evidenced by faulty connections. Second, outdated equipment that is possibly worn out and lacks advanced capabilities to protect the personnel. This is evidenced by the photographs and Sarah’s testimony that the equipment has not been updated since 2005.
Corrective Actions
Safety Gear and Contributing Factors
To address the issue with PPEs, there is a need for an organizational policy mandating compliance with electrical safety practices, specifically wearing PPEs, including cotton protective clothing with long sleeves, a helmet or hard hat, goggles for eye protection, gloves made of leather or rubber, hearing protectors, and safety footwear. The first contributing factor to this aspect is the lack of proper employee safety training records. To address this, the firm should back up the firm data to the cloud, ensuring that in case of any damage to the terminal or the server, all documents can be retrieved from the cloud (Rao & Nayak, 2014). This ensures that the training level for each employee is easily tracked. Second, the firm needs to ensure there are daily safety debriefing meetings to ensure the employees are appraised of the danger and areas where more knowledge is needed are identified. These meetings offer a platform for employees like Emily to voice their safety concerns. It is also an opportunity for inspecting the PPEs and tools to ascertain they comply with set standards.
Faulty Connections and Contributing Factors
To address the faulty connections, the organization must dedicate time to the replacement of worn-out equipment, shielding the rack, and implementing new technology, including finger-safe panelboards and overhead busways with prefabricated junction boxes. A fire extinguisher should also be installed. The first contributing factor in this case was improper maintenance, as evidenced by poor record keeping. In this case, the records should be digitized and backed up to the cloud. Moreover, the supervisor must be more involved in determining the quality of maintenance practice. For example, failure to replace a shrouding exposes worker to an arc flash. Second, there is a need to document the recommendations made after every scheduled maintenance to ensure that equipment is updated as required.
Preventing Future Accidents
By following the above corrective actions, the firm will prevent future accidents for the following reasons. First, the policies will ensure that employees wear PPEs, and the safety meeting will provide the supervisor with an opportunity to inspect this. Second, by documenting the safety training, the employees' preparedness will be ascertained before exposure. Third, replacing worn-out wire and equipment and installing new preventive technology reduces the opportunity for the recurrence of such an incidence. In this report, changes were recommended for policy, operation, and equipment. I affected change by creating a safety framework that minimizes the probability of an accident occurring (by improving equipment) and reducing harm even if an accident happens (by PPEs). The changes will be communicated face-to-face in a safety briefing, and then a memo will be sent to the employees and the appropriate managers. This experience was a lesson for all parties, including Emily, Sarah, and other employees, because they witnessed the risks associated with professional negligence. To make sure everyone learns something, I will hold a safety meeting where I will present the analysis of the accident and how it can be prevented.
Conclusion
In conclusion, this report highlights a safety accident report for an electrocution incident that happened at TechCom Solutions. The evidence gathered included maintenance records, safety training records, photographs of the server room, a physical inspection, and testimonies from the witnesses. The event and causal factors analysis was used, which revealed that the accident occurred because of two reasons. First, there was a faulty connection due to worn-out wires and improper maintenance. Second, Emily failed to use PPEs, exposing her to live wires. This is possible because of a lack of lessons and a lack of emphasis from the organization. Policies to emphasize the use of PPEs, daily safety meetings, management of records, and replacement of worn-out equipment were recommended.
References
Electrical Technology. (2021). Personal protective equipment (PPE) for electrical works. Electrical Technology. https://www.electricaltechnology.org/2018/07/personal-protective-equipment-ppe.html
Rao, U. H., & Nayak, U. (2014). Data backups and cloud computing. In Apress eBooks (pp. 263–288). https://doi.org/10.1007/978-1-4302-6383-8_13
Stephans, R. A. (2004). System safety for the 21st Century: The updated and revised edition of System Safety 2000. https://ci.nii.ac.jp/ncid/BA70117447
Stephans, R. A. (2022). System safety for the 21st century. John Wiley & Sons.