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I respectfully disagree that an injury or incident investigation can result in no solution. With proper analytical tools used, like Root Cause Analysis, Fish Bone Diagrams, Failure Mode and Effect Analysis, 5 Whys etc. , a proper cause for the injury can be rooted out and a solution can be provided accordingly.
Sometimes, the injury is caused due to lack of awareness of the worker, or casual attitude of worker towards safety, that's why he gives no heed to using proper PPEs, tools and taking precautions while doing a job. Such issues are considered as human factors, which can be solved by proper training, exercises, and rewards and reprimand programs.
Sometimes there is lack of administrative controls. Like Work Permit was not properly filled or the work permit protocol was not present at all. Sometimes the lack of engineering controls result in a tragedy.
To sum it up, there is no way an incident can occur without a cause, and for every cause, there is a solution. Ask yourself and the group involved in the incident more and more questions. You'll surely reach to a conclusion
first of all i will take a detailed pictur of the situation and suggest rmmedial measures by consulting with the team of the institution
While using Lathe machine in machining department the Jaw from machine chuck came out and hit the forehead of worker standing nearby. It resulted in serious injury. During investigation i came to know that worker did not clamp the jaws with required force. Initially i could not advise any solution but after some time i got it. I engraved a small line marking on lathe machine Chuck upto which the jaws must be tightened before operation. After that i made a Clear Work Instruction and pasted right infront of that machine. Thats how we resolved that issue.
