INCIDENT INVESTIGATION REPORT
Factory 1 Chemical Spill Report
Date of Incident: November 15th 2016
Date of Report: December 17th 2016
Approved for release by B Quinn Investigation team leader
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Contents
Scope ............................................................................................. 3
Organisational Background ........................................................... 3
Premise.......................................................................................... 3
Personnel....................................................................................... 3
Working Conditions ....................................................................... 4
Incident details Sequence of Events leading up to the Incident .... 4
The Incident ................................................................................... 4
Post Incident .................................................................................. 5
Evidence Site Inspections .............................................................. 5
Witnesses Accounts and Interviews .............................................. 6
Samples ......................................................................................... 6
Photographs .................................................................................. 7
Sketches ........................................................................................ 8
Documentation.............................................................................. 8
Causative factors ........................................................................... 9
Timeline of events ......................................................................... 9
Contributing factors .................................................................... 10
Direct causes of the incident ....................................................... 10
Root cause of the incident ........................................................... 10
Proposals for Corrective Actions ................................................. 10
People ......................................................................................... 10
Supervision .................................................................................. 10
Workplace Environment .............................................................. 10
Individual Performance ............................................................... 10
Communications.......................................................................... 11
Training........................................................................................ 11
Control Plan ................................................................................. 11
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Introduction
Investigation Team
B Quinn – Health and Safety Manager
Gina – Assistant Manager and First Aid Officer
Adam – Health and Safety Representative, Member of Health and safety
Committee
Scope
The investigation surrounds the findings in building 1 work environment
especially around stainless steel finishing area. All involved parties to be
interviewed. Recommendations and corrective actions to be supplied at end of
report.
Organisational Background
Premise
ABC Steel is a metal fabrication and engineering organisation and is located in
the outer eastern suburbs of the city in the suburb of Edgetown.
ABC Steel is open five days a week.
It is open and operating from 7am until 4.30pm Monday to Friday. Overtime is
sometimes carried out and at times employees are asked to work off site or over
the weekends.
The first staff member (stores person) arrives at the establishment 6.30 am and
the last to leave (cleaner) is after closing approximately 7.30pm.
Personnel
There are 89 staff members employed at ABC Steel.
Employees relative to the incident include:
 1 x General Manager (Alan Steel)
 1 x Assistant manager (Gina - First Aider)
 1 x Supervisor (Jeremy)
 1 x Welder (Kelvin)
 1 x Machinist (Lisa)
 1 x Fabricator (John)
 1 x Forklift driver (Jin – Interpreter )
 2 x Labourers (Kim – Injured Person, Steve – Eye Witness)
 1 x Stores Person (Bruce)
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Working Conditions
Employees work 8 hour shifts. Majority of workers in the factory start at 8.00am
and finish at 4.30pm. Sometimes staff will work an “extra” when a job is urgent or
behind schedule and can come in early at 7.00am and work until to 7pm.
At times this can occur up to 4 times a week and it is not uncommon for staff to
work 50 plus hours a week. The business is very busy and all workers are under
pressure to finish jobs on time. Environment is hot, noisy and not well illuminated.
Incident details
Sequence of Events leading up to the Incident
Kim Lee (48), the injured worker, started work on Thursday 15th November at
8.00am as per shift requirements in his duties as general labourer at factory
number 1. (It is worth noting that Kim Lee is one of the new Korean immigrant
workers and speaks hardly any English).
As the company was quite busy and already behind in their duties Kim started
work straight away on general housekeeping duties for the day which include
moving metal products for welders, cutters and machinists, loading/unloading
materials from trucks, collecting and returning materials from storage areas for
trades people, cleaning up off cuts into recycling bins as well as assisting in
assembly of plant and equipment.
Kim did not take obligatory morning break at 10am although he did stop at 1pm
for 15 minutes of his half hour lunch break to eat lunch.
It had been noticed earlier that there was a lot of off cuts and housekeeping
items that needed attention in factory 1 but Kim was busy helping a welder with
his welding duties. Kim was “noticeably tired and irritated” (Kelvin - welder)
according to reports trying to keep up with the heavy demand in his area. After
finishing working with the welder (2.15pm) the supervisor (Jeremy) has shouted
to Kim to hurry up and put the chemical for finishing stainless steel products
being used in one area back into storage. Jeremy had noticed it sitting there at
9.30am Jeremy noticed that Kim ran over to chemical in a hurry to put it away.
The Incident
At 2.20pm, Thursday afternoon 15th November, Kim, the general labourer had a
serious incident where he spilt Stainless Steel finishing chemical (basehydrofluoric and nitric acid) onto his arms and hands while rushing to put product
into storage area in factory building 1.
As he was approaching the product he was told to “Walk, not run and to put on
safety gloves” by the supervisor Jeremy. Kim gave him the thumbs up but
continued to run towards the area where the chemical was sitting. The chemical
was in an open 20 Lt container. Kim grabbed the container and rushed towards
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storage area when he slipped and then the chemical spilt and splashed on to his
arms and hands. As he felt the effects of the chemical burn he then dropped the
container which spilt onto the floor and at the same time Kim dropped to his
knees in obvious physical pain.
One labourer who witnessed the incident, Steve, called for the assistant manager,
Gina, (who is also the first aid officer), who rushed to administered first aid.
Gina checked Kim and found he was obviously hurt around the hands and arms
and he was holding these close to his chest. He was shouting in Korean and
Gina did not know what he was saying. On closer inspection Gina noticed that
Kim’s arms and hands were very red and starting to blister.
An ambulance was called (2.26pm) Kim’s breathing was erratic and he was
starting to go into shock. A fellow Korean worker (Jin) attended the scene and
helped interpret (2.28pm). Kim was saying he needed a doctor and it was relayed
to him through Jin that one had been called and was on the way.
Kim was taken to the wash area (2.33pm) and his arms and hands were rinsed
with cold water.
The ambulance arrived (2.45 pm). The ambulance crew confirmed he had
suffered corrosive burns to his hands and arms and was also in shock. Kim was
taken to hospital for further treatment and observation. (2.55 pm).
The HS Manager was contacted at 2.30pm and arrived on the scene at 2.45pm
just as the ambulance was arriving and proceeded with cleaning and securing
the incident scene.
Post Incident
The HSR informed the designated work group (2.46pm) that an investigation was
to be undertaken and the incident site was secured with the use of barrier tape
and signs prohibiting disruption of the area. The Authority was notified (3.00pm)
as per the requirements of the Health and Safety Act. Management were then
notified by the HS Manager at (3.00pm) that an incident had occurred and that
the company was establishing an investigation team to implement the
investigation as per the requirements of the Incident Investigation Procedure.
The return to work coordinator who liaised with the injured persons medical
practitioner then informed management (5.00pm) that Kim (injured worker) would
be away from work for a period of four weeks (20 days) rehabilitating from the
effects of a chemical burn and would only be allowed to return to work when he
had a full capacity for normal duties.
Evidence
Site Inspections
The initial inspection of the incident site occurred at 2.45pm when the HS
Manager arrived. Additional site inspection was carried out by the regulator at
5.00 pm the same day.
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Witnesses’ Accounts and Interviews
Statements and interviews were given by all concerned with the incident.
These include;
 Kim - Injured Person
 Steve - Labourer
 Gina - Assistant manager (first aider)
 Peter - Factory manager (liaised with ambulance officers)
 Kelvin - Welder
 Jeremy - Supervisor for the shift
 Alan Steel - ABC General manager
 Lisa - Machinist
 Jin - Forklift driver (interpreter at scene)
 Bruce - Stores Person
(Copies of the interview transcripts would be included in this section)
Interview transcript with Lisa the machinist – Recorded at 16.30pm 15th November 2016
When the incident occurred, can you please describe what you saw?
I was on the cutting machine at the back of the factory. I looked up and saw Kim running
through the factory. As he grabbed the container he covered his arms with the chemical
as the container didn’t have a lid. He was then on the ground. He looked in bad shape.
Who else was at the incident scene?
Gina and Steve were there pretty quick then Peter came over from across the other side
of the factory. We all stopped work at this point.
In your own words, what communication took place between worker and others prior to
the incident?
Well, we don’t really talk to the Korean workers because we can’t understand each
other. We point and show them what to do and they nod that they agree. Jin sometimes
relays what is going on for us like an interpreter. They are good at their jobs but
generally keep to themselves and don’t turn up to pre start meetings.
What previous near misses or similar incidents have occurred?
I don’t usually have anything to do with the chemicals but I have heard some of the guys
moaning about lack of storage, PPE, training etc. We had a spill last week but no one
was hurt.
Samples
No chemicals were required for sampling
(Descriptions of any chemical/biological samples taken surrounding the incident
would be included here as well as details of the agency where they have been
analyzed. This may include random drug and alcohol testing pursuant to
Regulations and or organisational protocol.)
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Photographs
Photographs were taken of the incident scene.
Picture 1: Spilt container of chemical
Picture 2: Chemical spill clean-up team securing site
Picture 3: Current storage of chemicals
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Sketches
Sketches were drawn to establish workers positions at the time of the incident.
50 m
N
1
IPs starting
position
B
A
IPs Finishing position
1
30m
Forklift moving
in easterly
direction
2 C
8
7
9
5
3
D
4
E
6
F
Factory Building 1 – Legend
1 Kim Lee – Injured Person
2 Jin - Forklift Driver
3 Lisa - Machine Operator
4 Kelvin – Welder
5 Steve - Labourer
6 Gina – First Aider
7 Jeremy – Supervisor
8 Bruce – Stores Person
9 John - Fabricator
A Chemical Container
B Chemical Storage Area
C Forklift
D Cutting Machine
E Welding Bay
F Site Office
NOTE: Distance between 1 and 7 is 30.5m
Documentation
Documents that were used as evidence included:
 MSDS
 Induction records
 Production schedules
 Training manuals
 Safe Work Method Statement
 Timetables and work schedules
 Incident report forms
 First aid register/Injury Register
 Incident notification form
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Causative factors
Timeline of events
TIME
EVENT
Month Prior
Korean workers employed.
Week Prior
Day Prior
8.00 am
Kim Lee assigned to factory 1
Kim Lee assigned to Kelvin as assistant
Majority of workers (including Kim) start shift as per
requirements
Collection of metals, materials for days work
Jeremy notices chemical is not stored away
Kim did not take morning break
Kelvin notices Kim yawning and “nodding off”
Lunch taken (only 15mins)
Kim returns to work
Finishes work with welder (Kelvin)
Kim told to put chemical away (By Jeremy)
Kim runs to chemical position
Kim slips and spills chemicals over hands and arms
Steve witness incident calls for Gino (first aid officer)
Gino arrives to calm Kim. Ambulance called
Jin (fellow Korean/interpreter) attends scene
OHS manager Brad Quinn contacted
Kim taken to wash area for first aid
Ambulance arrives. Medics apply medical treatment
OHS officer Brad Quinn arrives. Declares site
closed until further notice. Staffs retire to lunch room
to await further instruction.
Kim taken to hospital for further treatment
Incident site /initial investigation/photos taken
Spillage is cleared and disposed
OHS manager informs staff of interviews that will be
needed to undertaken
Site reopened workers return to work.
HS manager starts interview process
Inspector from authority arrives to discuss incident
Site closed for the day
Inspector leaves.
8.15 am
9.30 am
10.00 am
12.30 pm
1.00 pm
1.15 pm
2.15 pm
2.19 pm
2.20 pm
2.21 pm
2.22 pm
2.26 pm
2.28 pm
2.30pm
2.33 pm
2.45 pm
2.45pm
2.55 pm
3.00pm
3.05 pm
3.20 pm
3.25 pm
3.45 pm
5.00 pm
5.30 pm
5.45 pm
INTERVENTION
POINTS
SAFETY
INDUCTION
SITE INDUCTION
PRE START
TAKE FIVE, PPE
SUPERVISION
TAKE BREAKS
SUPERVISION
PPE
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Contributing factors
Environmental and Working Conditions – Heat, noise, light
Workplace Design and Layout – Storage facilities, PPE
Procedures and Systems – Safety Operational Procedures, Lack of
supervision, rules and responsibilities
Human Factor/Behavioural – inexperience, stress, fatigue, language
Direct causes of the incident
The immediate cause of this incident was a spillage to arms and hands of
hazardous substance. Not wearing PPE.
Root cause of the incident
The root cause of this incident is directly linked to the lack of initial induction
training in a language that is appropriate to the employee and direct
observation from senior management. There were numerous stages for this
incident to be averted if supervisors had carried out procedures and supplied
correct training.
Proposals for Corrective Actions
People
It is recommended that additional training in appropriate languages is given to
staff members (especially immigrant workers) as this was perceived as one of
the contributing factors behind the incident. Engaging a safety representative
from the Korean workforce is highly recommended.
Supervision
Supervision was recognised as one of the primary root cause of this incident.
This could be corrected by implementation of a checklist, Take Five or pre-start
meeting that can reiterate the day’s duties and hazards associated with them as
well as control measures needed. These will also need to be given in languages
other than English where appropriate.
Workplace Environment
Breaks from work should be adhered to as this reduces fatigue and stress which
was also a contributing factor to this incident. Correct PPE should always be
worn. Correct lighting needs to be investigated further.
Individual Performance
The individual employees must stop work immediately if they see a potential
health or safety hazard. The hazard must then be reported immediately following
the steps outlined in the Hazard Reporting Procedure.
10
Communications
There could to be daily pre-start meetings attended by all staff members to reveal
any other unsafe work place situations that may be going on unreported.
All staff members may need to have safety issues explained to them fully (in an
appropriate language). It is recommended that they are added to induction
processes.
Training
Additional safety training could be issued to all staff. In this environment safety
issues can be explained and compliance requirements clarified.
Control Plan
ITEM
TASK
Induction session Carry out
induction session
with all workers
Implement prestart meetings
Issue PPE
Lighting
Assessment
Noise
Assessment
Develop SWMS
Store Chemicals
Training session
for chemical
handling
Meet with
workers prior to
work - daily
Distribute
appropriate PPE
Test Lux of
factory 1
Test dB levels in
factory 1
Create a safe
work procedure
for chemical
handling
Establish correct
storage for
chemicals
Train workers in
safe handling,
storage of
chemicals
RESOURCES
Induction books
(in appropriate
language)
Attendance
sheet
Meeting Sheet
Take Fives
BY WHOM
Health Safety
Supervisor
BY WHEN
2st Jan 2017
Designated HSRs
8th Jan 2017
Masks, Goggle,
Gloves,
PPE Register
Light meters
Lighting Plan
Noise meters
Work schedule
SWMS template
MSDS
Factory Manager
2st Jan 2017
Occupational
Hygienist
Occupational
Hygienist
HS Manager
14th Jan 2017
AS 1940 Cabinets
Storage manifest
HS Supervisor
20th Dec 2016
Training plan
Training
materials
MSDS register
HS Manager
20th Dec 2016
14th Jan 2017
19th Dec 2016
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