JournalofOccupational Accidents, 4 (1982)281-290 Elsevier Scientific Publishing Company, Amsterdam-Printed in The Netherlands

281

INVESTIGATION OF SERIOUS ACCIDENTS

Saara Vuorio

The Federation of Accident Insurance Institutions

Bulevardi 28, 00120 Helsinki 12, Finland

ABSTRACT

According to an agreement reached between the central labour market organizations and the Federation of Accident Insurance Institutions in 1971, investigations are carried out in the case of serious accidents at work. The investigation aims at determining the technical, human and medical reasons that caused the occupational accident.

The investigations are carried out under the quidance and super- vision of the Consultative Board of the Federation of Accident In- surance Institutions. The Consultative Board appoints The Board of Directors for the investigation.

The Board of Directors consists of four members, each member having a personal substitute. There are representatives of the employers' organizations and labour organizations, as well as the accident insurance institutions, on the Board.

In addition, a separate board, the Board of Investigators, is set up for each investigation. The members of the Board are chosen from experts in the branch concerned.

An occupational accident is investigated when it results in the death of two persons or more, or in the injury of several persons. Cases where several persons have been in danger are also investigated. Since 1971 44 occupational accidents have been investigated.

The results of the investigations are intended for distribution to such establishments and authorities that can make use of them, such as industrial enterprises and legislators as well as those who plan instruction books and train persons for tasks related to labour protection.

INTRODUCTION

According to an agreement reached between the central labour market

organizations and The Federation of Accident Insurance Institutions in

1971, investigations are carried out in the case of serious accidents

at work. The investigation aims at determining the technical, human and

medical reasons that caused the occupational accident.

The investigations are carried out under the guidance and super-

vision of the Consultative Board of the Federation of Accident

Insurance Institutions. The Consultative Board appoints the Board of

Directors for the investigation.

0376-6349/82/0000-0000/$02.75 0 1982 Elsevier Scientific Publishing Company

282

The Board of Directors consists of four members, each member having

a personal substitute. There are representatives of the employers'

organizations and labour organizations, as well as the accident in-

surance institutions, on the Board.

The task of the Board of Directors is

- to make a decision about whether to investigate the case

- to receive the reports of the investigation

- to decide on the distribution of the reports.

In addition, a separate board, the Board of Investigators, is set up

for each investigation. The members of the Board are chosen from ex-

perts in the branch concerned. The Chairman of the Board is a professor

in the relevant field at a university or an institute of technology,

the Technical Research Centre of Finland, Institute of Occupational

Health or some other competent authority. The other members are

competent representatives of the labour market organizations and the

accident insurance institutions. On the Board there are six ordinary

members, and if needed, expert members. The task of the Board is to

determine, as soon as possible, the reasons for the accident and to

submit proposals and recommendations for the prevention of similar

accidents in the future (Table 1).

Commencement of investigation

The investigation starts on the basis of a report, submitted from

the place of work through its labour protection organization, to the

contact person of the labour market organization concerned. The contact

person informs the Federation of Accident Insurance Institutions about

the accident. The Federation assembles the Board of Directors for the

investigation which then decides whether to carry out an investigation

or a preliminary investigation. In urgent cases, a preliminary investi-

gation is carried out by the Federation of Accident Insurance

Institutions before the Board of Directors assembles.

An employment accident is investigated when it results in

- the death of two persons or more

- the injury of several persons

- one person's death and one person's injury, and in addition, several

persons have been in danger, e.g. from an explosion, a cave-in, a

fire or a gas leak

- a dangerous situation arising as a result of an explosion, a

cave-in, a fire or a gas leak, which could have caused death or

injury to several persons.

283

The same applies to occupational diseases or the risk of occu-

pational diseases.

Table 1. Investigation of serious accidents; agreement reached in 1971.

The Consultative Board

of the Federation of

Accident Insurance

Boards of Investigators

- directs and supervises

- appoints the Board of Directors for the investigation

- makes a decision on whether to investigate the case

- appoints Boards of Investigators

- decides on the distribution of reports

- carry out investigations

- give recommendations for the prevention of accidents

- settle other tasks the Board of Directors has assigned to the Board of Investigators

Cases investigated

Since 1971, 44 employment accidents have been investigated. The

investigations are divided according to branches as follows:

1. Metal industry 23 cases

- Mines 6 "

- Production of iron and steel 5 "

- Steel construction 4 "

- Ship building 3 "

- Other metal industries 5 "

284

2. Construction industry

- House building

- Earth and hydraulic work

- Building material industry

3. Chemical industry

4. Woodworking industry

5. Transport and warehousing

6. Timber industry

7. Forestry

8. Investigated occupational diseases

11 cases

6 "

4 "

1 "

3 "

2 "

2 "

1 "

1 "

1 "

44 cases

The investigations were carried out as a result of:

1. Collapse of building or cave-in of earth mass

2. Explosion or fire

3. Breaking or malfunction of machine or appliance

4. Poisonous gas or lack of oxygen

5. Accident risk factors (several accidents of the same kind)

6. Occupational diseases

7. Others

11 cases

10 "

7 "

7 "

3 "

1 "

5 "

44 cases

Reasons for accidents

Malfunction or work done in the wrong order are usually the main

reasons for the collapse of constructions. Examples: the overloading of

a mobile crane overturned the crane, which in turn resulted in the

supporting structures of a prefabricated building which was being built

giving way. This resulted in the collapse of a part of the building.

TWO persons died and four were seriously injured. The reason for the

accident was the crane driver's lack of experience and consequent

inability to judge the situation. The collapse of a high-tension pylon

took place when defective diagonals were changed. The reason for the

collapse of the pylon was the detachment of too many diagonals at the

same time. Two fitters, who were working at the top of the pylon, lost

their lives.

An example of constructions giving way is the falling of a hoisting

cage intended for lifting people and goods. According to investigations

the fall was due to faults in construction which led to metal fatigue

in the steel and the breaking of the fixing taps of the guide rollers.

Accidents caused by cave-ins of earth masses have occurred in mines.

These accidents have been caused by unexpected occurrence of phreatic

water, torn layers of earth and too high charging.

Of explosion accidents the most unexpected was that caused by the

leaking of methane gas from an incinerator through rain water pipes

into the basement of a nearby building under construction. A violent

explosion took place in the basement during erection work there. The

probable reason was a spark caused by a movable lamp.

Lack of oxygen has caused many fatal accidents. Oxygen can be

depleted for example when zinc concentrate is stored in an enclosed

place, such as a ship's hold, etc.

The investigation into one occupational disease concerned allergies

caused by feed yeast at a feed yeast plant and its surroundings.

Recommendations for the prevention of similar accidents

In many cases a lack of training has contributed to accidents.

Boards of investigators have recommended more effective training. As a

result, e.g. it is recommended that drivers of mobile cranes should

attend specialist driving school.

Suggestions have been made concerning the publishing of instruction

books for increasing knowledge. On the basis of these recommendations

several instruction books have been published. For the prevention of

danger caused by a lack of oxygen, for instance, a book containing

information about working in containers and enclosed places is now

being prepared.

When working on legislation the results of investigations have been

taken into consideration. As to legislation relating to mines a para-

graph concerning closer investigation of phreatic waters and other

environmental factors has been included.

The results of investigations have also contributed, at the local

level, to the improvement of working methods as well as to increased

safety and supervisory measures at work. An example of the improvement

of working methods is the case where the loading order of cellulose

bales was changed after two stevedores had died when a pile of bales

fell over.

286

In many cases an accident has been caused by a human factor, es-

pecially when separate working groups are working simultaneously

without paying due attention to the working order of other groups. This

was the case when one working group in a cableship tested the sealing

of tanks which were on the quay side of the ship by fil.ling them with

water. At the same time another group was testing the ship's cranes by

lifting heavy trial weights from the quay. The result was that the ship

capsized. There were about 200 workers on board engaged in tasks of

various kinds. The workers managed to leave the ship, but 16 of them

were injured.

In another case, which also occurred when building a ship, one group

was painting in the ship's tank room whereas another group was welding

in a neighbouring tank. The tanks were connected by a 15" pipe hole.

The solvent vapour from the paint seeped into the nearby tank where a

welding spark ignited the gas. The fire spread explosively throughout

both tanks. Five persons were injured in this accident.

Accordingly, Boards of Investigators have recommended more effective

co-operation and planning of work between groups working in the same

place of work.

The results of investigations are intended for distribution to such

establishments and authorities that can make use of them, such as

industrial enterprises and legislators as well as those who plan in-

struction books and train persons for tasks relating to labour protec-

tion.

Utilization of the results and the observance of recommendations has

been followed by questionnaire investigations during the last few years.

SERIOUS EMPLOYMENT ACCIDENTS REPORTS OF BOARDS OF INVESTIGATOR5 DURING 1971-1980

1. Metal industry

1.1. Mines

- Rautaruukki Oy, mine at LeveBselkZ Cave-in Report of group that carried out preliminary investigation (no injuries to persons)

- Outokumpu Oy, mine at Pyh;isalmi Cave-in (one person died)

- Myllykoski Oy, mine at Luikonlahti Lift accident at work Report of the Board of Investigators (one person died)

Dated

7. and 9.1.1974

5.8.1974

8.11.1976

287

- Outokumpu Oy, mine at PyhBsalmi Pyrite dust explosion Report of the Board of Investigators (one person died, injuries of various kinds to nine persons)

20.1.1977

- Gobbet accidents at Kotalahti and Keretti Motor vehicle accident at Keretti Report of group that carried out preliminary investigation (four miners lost their lives in these accidents)

29.5.1978 14.1.1979

17.1.1979

- Report of Board that investigated mine drillers (The Board was set up to investigate the shielding of the drill rod as a result of two similar fatal accidents)

2.1.1978 and 14.3.1972

1.2. Production of iron and steel

- Ovako Oy, Koverhar works Gas poisoning accident (death to one person, serious carbon- monoxide poisoning to four persons)

- Ovako Oy, iron works in Turku Employment accident at the sintering mill Report of the Board of Investigators (one person died: in 1974 one person had died in a very similar accident)

- Oy Koverhar Ab, blast furnace accident Report of the Board of Investigators (one person died after having fallen into a slag ladle)

1.7.1974

19.6.1976

17.-18.8.1977

- Rautaruukki Oy, Raahe ironworks Collapse of discharge trestle bridge Report of the Board of Investigators 4.9.1979 (one person died, four persons were injured)

- Rautaruukki Oy, Raahe ironworks Report of group that carried out preliminary investigations on account of an accident where two persons received burns caused by molten cast iron 20.1.1980

1.3. Steel construction

- Mast accident at Joensuu Report of the Board of Investigators (one person died after having fallen along with an auxiliary mast)

- Accident caused by falling at Tahkoluoto (two persons died after having fallen from steel constructions) Report of the Board of Investigators

- Collapse of column at Loviisa Report of the Board of Investigators (two persons died)

- Oy W%rtsil$ Ab, shipbuilding yard in Helsinki

Collapse of steel constructions of basin hall which was being built (no injuries) Report of the Board of Investigators

12.6.1974

24.1.197s

18.3.1976

21.6.1976

1.4. Shipbuilding

- Hollming Oy, paint fumes fire Report of the Board of Investigators (five persons were injured due to fire in connection with anti-rust treatment of tank)

21.6.1973

- Capsizing of cable ship "Katunj" Report (18 workers engaged in outfitting work were injured when the ship capsized)

- Rauma-Repola

14.8.1973

Accident in connection with cutting by burning Report of the Board of Investigators (oxygen fire in the ship's tank caused death to one person)

24.3.1976

1.5. Others

- Accident at Salmisaari due to boiler explosion Report of the Board of Investigators 3.11.1975 (master mechanic died after having jumped from the window of the boiler room into the yard)

- Explosion at the Lapua cartridge factory Report of the Board of Investigators 13.4.1976 (40 persons died, several persons were injured)

- Raahe Oy, screw conveyor accident Report of the Board of Investigators 17.8.1977 (one person died when the screw conveyor was test run)

- Wgrtsila, Kotka works Spray painting accident Report of the Board of Investigators (one person died when the spray pistol was being cleaned and vaporized solvent caught fire and exploded)

13.3.1978

- Report of the Board of Investigators that carried out investigations concerning accident risks at work in containers (The Board was set up due to several similar fatal accidents at work. The report concerns labour safety at work in containers)

2. Construction industry

2.1. House building

- Prefabricated concrete element constructions Report of the Board of Investigators (the roofing elements of a factory building collapsed when being erected: three persons were injured. The Board also investigated the overall risk factors associated with prefabricated element building)

- Lift accident at Merihaka (the falling of a lift resulted in the death of four persons)

29.8.1972

16.1.1974

289

17.1.1974

4.4.1974

- Explosion accident at Kylasaari (explosive of methane on the building site of an addition to an incinerator building resulted in the death of four persons and injuries to four persons)

- Oy Schaumann Ab, accident due to a crane overturning of a crane (a mobile crane overturning on the building site of a plywood factory resulted in the death of two persons and injuries to four persons)

- Tower crane accident at atomic power plant site at Loviisa 11.10.1974 (two persons lost their lives and one person was injured when the hoisting cage fell)

- Collapse of a vault at the atomic power plant at Olkiluoto Report of the Board of Investigators 19.6.1976 (the collapse of a concrete vault resulted in the death of two persons and injury to one person)

2.2. Earth and hydraulic work

31.3.1971 - Dam accident at Vanttauskoski (on the power plant site steel rope splices gave way when set flitched beam was being erected. This resulted in the death of three persons)

- On bridge-building site at Isokyrc the sheltering roof collapsed 12.2.1974 (one person died and five persons were injured)

- Suffocation accident at Kariniemi 5.4.1975 Report of the Board of Investigators (on the building site of water purifying plant one person lost his life due to lack of oxygen in a enclosed box provided with an access hole)

- Collapse of a bridge at JyvBskylB Report of group that carried out preliminary investigation (no injuries to persons)

14.4.1978

2.3. Building material industry

- Saseka, autoclave accident (an autoclave, dimensions @ 2.5 x 25 m, flew as a result of an explosion through various departments of the factory (about 70 m); no injuries to persons)

3. Chemical industry

4.9.1973

- Isora Ky, extended plastics factory Explosion accident (due to an explosion in connection with fire one fireman died and three workers were injured)

19.6.1974

290

- Kemira Oy, Kokkola works Sulphur dioxide accident (one worker died due to a high concentration of sulphur dioxide caused by an electricity cut

- Kemira Oy, Siilinjgrvi works Nitric acid leakage Report of the Board of Investigators (cloud of nitrogen dioxide caused danger of poisoning; no injuries to persons)

4. Woodworking industry

- Enso-Gutzeit Oy, Kaukopda works Chlorine accident (damaged chlorine gasifier caused chlorine leakage; no injuries to persons)

- Enso-Gutzeit Oy, Uimaharju works Report of the Board of Investigators that investigated chlorine leakage (malfunction in storage tank of chlorine caused chlorine leakage; no injuries to persons)

5. Transport and warehousing

- Outokumpu Oy, zinc concentrate accident Report of the Board of Investigators (zinc concentrate stored in the cargo hold of a ship had become oxidized and thus caused a lack of oxygen; two persons died in the cargo hold)

- Stowage accident at Hamina Report of the Board of Investigators (cellulose bales that fell when the ship was taking on a cargo resulted in the death of two persons)

6. Timber industry

- Oy Faner Ab, dust explosion (three persons were injured due to fire in a dust bin which exploded)

7. Forestry

- Accidents during clearance of forests damaged by storm Report of the Board of Investigators (due to four fatal accidents the Board was set up to investigate labour protection relative to clearance of forests damaged by storm)

8. Investigated occupational diseases

- Report of feed yeast working group (The working group furnished a report on feed yeast allergies at lisnekoski feed yeast plant of Metssliiton Teollisuus Oy.

According to the report, 48 cases could be proved)

5.8.1975

13.5.1976

18.1.1972

19.10.1977

5.7.1972

9.1.1973

3.9.1971

16.1.1978

December 1974