health and safety case studies accidents

OSHA's most interesting cases

What happened – and lessons learned.

Every OSHA investigation offers an opportunity for using what comes to light to help prevent similar incidents.

At the 2022 NSC Safety Congress & Expo in September, OSHA staffers highlighted three investigations – and the lessons learned – during the agency’s “Most Interesting Cases” Technical Session.

• Brian Elmore , an OSHA inspector based in Omaha, NE
• Marie Lord , assistant area director of the OSHA office in Marlton, NJ
• Peter Vo , safety engineer in OSHA’s Houston South area office

Here are the cases they presented.

• Shelving collapse in a cold storage warehouse
• Lockout/tagout-related amputation
• Crane collapse  

Related Articles

More of osha’s ‘most interesting cases’, post a comment to this article.

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Injuries and Illness

Case studies in safety: a great training tool.

Updated: Nov 6, 2011

Case studies are a great safety training tool. It’s like CSI. Employees can really get involved examining the evidence and seeing why an accident occurred.

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.

Try OSHA Accident Case Studies and give a boost to your safety training program with real-life case studies of actual industrial accidents from OSHA files. We have a great one on lifting. Get the details.

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?
• 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.

Even your most skeptical workers will see what can go wrong and become safety-minded employees with OSHA Accident Case Studies . They’ll learn valuable safety training lessons from real mistakes—but in classroom training meetings instead of on your shop floor. Get more info.

• 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.

More Articles on Injuries and Illness

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The costs and effects of workplace accidents - Twenty case studies from Ireland

This report presents details and analysis of twenty case studies of accidents at work. The aim of the research is to highlight for employees and employers, the financial, physical and psychological effects an accident at work can have.

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How Did They Do That? Case Studies on EHS Excellence

While it might be an overused phrase — “no need to reinvent the wheel” — there is a lot to be learned from others who have tackled and found solutions to safety issues that many companies face. 

In this vein, the winners of the Campbell Award offer materials including business case studies, teaching notes and case study presentations. 

Frist a word about the award, which is a National Safety Council award. Its mission is to “identify and provide evidence-based findings that enable current and future business leaders to effectively advance business vitality through embracing the value of environmental, health and safety management.” The award is supported by a network of Global Partners across five continents. 

The Campbell Award recognizes organizations for commendable leadership and excellence in integrating EHS management with business operations systems. The award aims to:

• Establish a validated process by which organizations can measure the performance of their EHS operations system against well tested and internationally accepted key performance indicators.
• Capture and evaluate the successes and lessons learned through a rigorous systematic review process.
• Foster the sharing of leading-edge EHS management systems and best practices for educational purposes worldwide.
• Recognize organizations that have EHS well integrated as a key business value and in which measurable achievements in EHS performance are productive and profitable.

Here are some samples (and excerpts) of these case studies:

Johnson & Johnson -- Social Responsibility & Sustainable Competitive Advantages 

This business case study starts with the assumption that EHS is a core value — because, for them, it is. Johnson & Johnson’s leaders, however, are aware that this belief is not shared by everyone — including some of its shareholders, who may be more focused on profit margin. By examining the company's credo-based culture and a number of its key EHS initiatives, Johnson & Johnson wanted students to come to understand the myriad ways in which social responsibility offers the company a truly sustainable competitive advantage. 

Alcan- Leadership Challenges in Cross-Culture Ventures

This business case study takes a well-developed integrated EHS management system and puts it to the test in an extreme physical and cultural environment. In examining the astonishing results at the Ningxia facility, Alcan leadership wanted students to understand the difference an integrated, transferable system can make. Through this remarkable example, students come to see the value of integration and transfer as it extends not only to the business but the wider community — making the decision they’re faced with at the end of the study even more crucial.

Dow—Inseparability of Safety

“If you can’t do it better, why do it?” These famous words of Dow Chemical Company founder Herbert H. Dow begin the organization’s Campbell Award Case Study. It is this history of innovation, coupled with aspirational goal-setting and world-class expertise, which has enabled Dow to continue to reach and exceed its vision. In this study, readers gain insight into Dow’s transformational goal development process, including a look at incentives, empowerment, risk assessment, leading indicators, and more. Readers have the opportunity to put themselves in the shoes of Dow leadership and ask themselves, “What should we do next?”

More  examples can be found here .  

There is also a Campbell Institute that was launched from the Campbell Award winners as well as thought-leaders from the National Safety Council. The mission of the Institute is to help organizations achieve and sustain EHS excellence through participation, research and events.

Adrienne Selko | Senior Editor

Email [email protected]

Adrienne Selko is also the senior editor at  Material Handling and Logistics  and is a former editor of  IndustryWeek. 

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Case Studies in Workplace Safety: Real-Life Examples of Successful Safety Initiatives

Introduction

Workplace safety is not just about compliance; it’s about saving lives, preventing injuries, and creating a culture of well-being. To illustrate the power of successful safety initiatives, we’ll dive into real-life case studies where organizations have gone above and beyond to ensure the safety of their employees. These inspiring stories showcase how proactive safety measures can lead to reduced incidents, improved morale, and enhanced overall productivity.

1. Tesla’s “Safety First” Culture

Tesla, the electric vehicle pioneer, places a strong emphasis on workplace safety. The company has developed a comprehensive “Safety First” culture, which goes beyond just meeting regulatory requirements. Tesla’s initiative includes rigorous safety training, daily huddles to discuss safety concerns, and a proactive approach to addressing any issues.

Result: Tesla has seen a steady decrease in workplace incidents and an increase in employee engagement. Their safety culture not only protects workers but also reinforces the organization’s commitment to innovation and excellence.

2. Alcoa’s Transformation Through Safety

Alcoa, a global aluminum manufacturer, underwent a significant transformation in the 1980s under the leadership of Paul O’Neill. O’Neill made safety the company’s top priority. His philosophy was simple: “If you want to improve safety, you have to improve everything.”

Result: Alcoa’s safety initiative not only led to a remarkable reduction in workplace injuries but also significantly boosted productivity and profitability. By focusing on safety, the company transformed its entire organizational culture.

3. DuPont’s STOP Program

DuPont, a multinational chemical company, introduced the STOP (Safety Training Observation Program) initiative to empower employees at all levels to identify and report safety hazards. The program encourages workers to speak up, and it trains them to spot potential dangers in the workplace.

Result: DuPont’s STOP Program led to a dramatic decrease in accidents and injuries. It also fostered a culture of transparency and accountability, where every employee played a vital role in ensuring their safety.

4. The Massachusetts General Hospital’s “Safety Matters” Campaign

Healthcare organizations are not exempt from the importance of workplace safety. The Massachusetts General Hospital initiated the “Safety Matters” campaign to reduce medical errors and ensure the safety of patients and healthcare workers.

Result: By emphasizing the importance of safety protocols and encouraging communication among staff, the hospital saw a significant reduction in patient safety incidents and workplace injuries. The “Safety Matters” campaign not only saved lives but also improved the quality of patient care.

5. Singapore Airlines’ Safety Excellence

In the aviation industry, safety is paramount. Singapore Airlines is a shining example of a company that prioritizes safety. The airline invests heavily in safety training and has a robust reporting system that encourages employees to report safety concerns without fear of reprisals.

Result: Singapore Airlines’ relentless commitment to safety has led to an impeccable safety record and a strong reputation for being one of the world’s safest airlines. Passengers and employees alike can feel confident in their commitment to safety.

These real-life case studies demonstrate that a proactive approach to workplace safety not only saves lives but also has a positive impact on an organization’s bottom line. Successful safety initiatives are not merely a box-ticking exercise; they are a reflection of an organization’s values and a commitment to the well-being of its employees. By learning from these examples, we can inspire a culture of safety in our own workplaces and reap the benefits of reduced incidents, improved morale, and increased productivity.

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Dindas Australia - Onsite traffic management in action

Practical information about the changes Dindas made to their traffic management to make their depots safer in all locations.

Dedicated WHS manager and improvements in WHS systems - CB Group

CB Group is a civil construction company based on the Gold Coast that specialises in energy. It has a workforce of 123, comprising office and field workers. CB Group undertakes a wide variety of civil construction work and specialises in underground work associated with telecommunications, streetlights and traffic signals. The energy division is also involved in renewable energy such as solar.

Onsite gym and healthy lifestyle program - Port of Brisbane Pty Ltd

The Port of Brisbane Pty Ltd (PBPL), which manages the Port of Brisbane under a 99 year lease from the Queensland Government, has undergone substantial organisational change in recent years. As part of due diligence for the leasing of the port, the new owners identified that workplace health and safety improvements were a priority given the high incidence of 33 injuries recorded in 2010–11.

Rotation of manual task roles and smaller milk jugs - BP Retail Wild Bean Cafes

BP is engaged in the exploration for and production of oil, natural gas and liquefied natural gas, and the refining, transportation and marketing of petroleum products. BP is also responsible for a number of coffee making facilities as part of retail activities at its travel centres. Some of these travel centres experience high volumes of coffee production, with approximately 140 coffees produced per hour during peak periods. These high volume sites include Wild Bean Cafes based at travel centres across South-East Queensland.

Cater Care Group: Emphasising capacity, not limitation

Cater Care Group provides contract catering, accommodation and facility management services to industries in regional and remote locations across Queensland.

Modern Teaching Aids

MTA was invited to join the Injury Prevention and Management (IPaM) program in 2013 after experiencing a higher than average number of worker’s compensation claims.

In 2011, mining and minerals exploration company, ‘Drill Engineering and Pastoral Co ‘(DEPCO), were invited to participate in IPaM and the results are paying off.

Risk of injury for manual handling

Griffiths v State of Queensland, 1 April 2011. The injured worker was employed as a nursing assistant at the Nambour General Hospital, where she worked in the Central Sterilising Service Department (CSSD). The CSSD is a large industrial washing area, equipped with sterilising dishwashers and other equipment for medical sterilisation and cleaning.

All Access Crewing Pty Ltd: The show must go on..safely

All Access Crewing provide specialist workers for the entertainment industry including stage managers, riggers, scaffolders, lighting and sound technicians. All Access Crewing provide support for concerts, music festivals, theatre productions, sporting events and film and television production across Australia.

Gay Constructions Pty Ltd

With IPaM, Gay Constructions reviewed its safety and injury management systems and surveyed employees about safety in the workplace. The company then worked with an IPaM advisor to develop an action plan that included a number of safety and injury management initiatives.

Verbal warning not enough

Samways v WorkCover Queensland & Ors, 28 April 2010. This case study shows that a verbal warning is not sufficient action if there is a reasonable way to isolate a risk and the plaintiff can be liable for contributory negligence

Instructions: a direction or mere request?

Vella’s Plant Hire Pty Ltd v Mistranch Pty Ltd & Ors, 29 March 2012. This case highlights the question that needs to be asked in matters where directions are being received from the principal contractor. That is, whether an instruction from a Principal is a mere “request” or is conduct amounting to direction and control of how the work is to be carried out.

Supporting HSE improvement

News, insights and thought leadership, keep up to date with all hse news and thought leadership interviews, health and safety cases.

As part of our news coverage, HSE Network keeps you up to date with some of the latest information on health and safety court cases out of the HSE Executive. We cover various cases ranging from gas safety register breaches to a breach of the Health and Safety at Work Act 1974 legislation. The health and safety cases are covered by the HSE Network to spread awareness around the consequences that can materialise when proper health and safety protocol is not followed.

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Manufacturing company fined for exposing workers to asbestos, company fined after a worker was injured by a forklift truck, high school fined after a student was critically injured, private security firm sentenced after employee attacked at a youth offender training centre, british airways fined after employee sustained serious crush injuries in a vehicle collision.

How do I get a health and safety job?

Two care provider companies fined and a manager cautioned after employee stabbed, news categories, popular videos, connecting safety, health and wellbeing | jane le count and dr maggie samuel, do health and safety management systems make a difference | kate field: bsi group, andrew barratclough | the true cost of overlooking driver safety | edriving, how to transform your company’s health and safety performance | matt taylor, british steel, the importance of good safety and medical testing in the oil and gas industry | dr eva reichardt, brands who we work with.

Chemical safety and biosafety

The chemical industry is one of the largest industrial sectors in the world and is expected to quadruple between 2020 and 2060. Governments and industry share the responsibility for ensuring safe chemical production and use. The OECD helps countries develop and implement policies for safeguarding human health and the environment, and in making their systems for managing chemicals as efficient as possible.

• OECD work on Chemical Safety and Biosafety 2021-24
• Progress report: Catch up on OECD's latest work on chemicals

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Key messages, countries go mad for saving time, money and animal lives.

The time-tested OECD Mutual Acceptance of Data (MAD) system provides a common basis for co-operation among national authorities and avoids creating non-tariff barriers to trade. Under MAD, tests conducted on chemicals in one country are accepted by all 38 OECD members as well as the seven non-member countries that adhere to MAD, saving the chemical industry costs of duplicative testing for products marketed in more than one country.  The MAD system not only saves around EUR 309 million annually but also contributes to reducing animal testing.

Shaping a sustainable future through coordinated global action

The OECD collaborates closely with several international organisations through the Inter-organization Programme for the Sound Management of Chemicals (IOMC) , supporting the implementation of the Global Framework on Chemicals – For a Planet Free of Harm from Chemicals and Waste (GFC) .  The GFC unites governments from over 150 countries along with a range of stakeholders. As part of these efforts, the IOMC created the IOMC Toolbox , a web-based solving tool designed to help countries find the best tools for addressing specific national issues related to chemicals management. 

Setting common standards to ensure consistent rules across countries

The Organisation's governing body, the Council, has the power to adopt legal instruments, usually referred to as "the OECD Acts".  Many of the OECD Council acts in force are related to chemicals management: 7 legally-binding OECD Council decisions, 11 Council Recommendations and 2 Declarations. There are also more than 150 testing guidelines in operation. 

How is your country addressing the risks associated with industrial and consumer chemicals?

The Chemical Legislation indicator allows you to explore the legal frameworks set up by each country to support the safety of human health and the environment. This map measures country progress on the adoption of management systems specifically dedicated to managing the risks of industrial and consumer chemicals, i.e. chemicals which are not covered by specific legislations such as pesticides or pharmaceuticals. It identifies legislation allowing countries to prioritise chemicals for risk management, perform a risk assessment on priority chemicals and implement risk reduction measures based on the outcome of the risk assessment.

The OECD saves countries more than EUR 309 million every year

The OECD’s Guidelines on Chemicals Testing and other tools save countries more than EUR 309 million per year.  By getting together to address the same chemicals, countries reduce duplicating testing and remove non-tariff trade barriers. This ensures safer chemicals for people and the environment, and that those chemicals are developed in a more efficient and sustainable manner. 

The OECD programme also facilitates the exchange of information between countries on chemical accidents to identify prevention methods and improved preparation, as well as harmonised tools to identify the risk of endocrine disrupters, that can affect people’s health.

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Programme of work

• The OECD Programme on Chemical Safety and Biosafety The OECD work on chemical safety and biosafety deals with the safe use of chemicals, nanomaterials, pesticides, biocides, and products of modern biotechnology. It also addresses related areas of concern and interest, such as chemical accidents, Pollutant Release and Transfer Registers (PRTRs) and Best Available Techniques (BAT). Learn more

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• Testing of chemicals
• Assessment of chemicals
• Risk management, risk reduction and sustainable chemistry
• Nanomaterials and advanced materials
• Pesticides and biocides
• Chemical accident prevention, preparedness and response
• Monitoring and preventing industrial pollution
• Biosafety, novel food and feed safety

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Case studies

Successful leadership.

There are many benefits to be gained from successful leadership in health and safety, as these case studies show.

Case study - North Staffordshire Combined Healthcare NHS Trust

The board found itself facing service improvement targets. Using new corporate and clinical guidance, it set about taking a 'whole systems' approach to managing corporate risk, giving one of its directors responsibility for the leadership of health and safety for the first time. Health and safety was also made a key item on the board agenda.

This has resulted in a much better integrated health and safety management system that increases the opportunity to identify and manage all corporate risks, and a much more open culture, improving reporting and monitoring. The board actively promotes a culture that gives staff the confidence to report incidents. This has resulted in:

• incidence rates reduced by 16% over two years;
• insurance premiums reduced by 10%.

Case study - British Sugar

British Sugar had an excellent safety record and was devastated in 2003 when it suffered three fatalities. Although health and safety had always been a business priority, the company recognised that a change in focus was needed to achieve behavioural change. This included:

• the CEO assigning health and safety responsibilities to all directors, and monthly reports go to the board;
• creating effective working partnerships with employees, trade unions and others;
• overseeing a behavioural change programme and audits;
• publishing annual health and safety targets, and devising initiatives to meet them.

Results include:

A two thirds reduction in both lost time and minor injury frequency rates over a 10 year period.

much greater understanding by directors of health and safety risks.

Case study – Mid and West Wales Fire and Rescue Service

To give health and safety a high priority, Mid and West Wales Fire and Rescue Service recognised that it was critical for its leadership to demonstrate to its staff that accountability for health and safety was a fundamental element in the success of its overall service delivery. The director of service policy and planning was nominated as the health and safety director for the service in order to clearly define the importance this subject held within the organisation. The director implemented a revised health and safety framework, which included a programme of fire station visits to engage the workforce, and placed a renewed emphasis on improving incident reporting, investigation and monitoring procedures. The service has reported:

• £100,000 reduction in insurance liability premiums in one year through improved corporate strategic risk management;
• 50% reduction in sickness absence through work related injury over a two year period;
• 50% reduction in injury incidence rate over a three year period.

Case study – Sainsbury's

An external health and safety audit identified a need to develop a unified approach, and also recommended more direction from the board, to develop an effective strategy.

The result was a radical revision of the company's approach, including:

• the group human resources director creating a health and safety vision, supported by a plan with targets over three years;
• training on health and safety responsibilities was introduced for all board directors.

This has resulted in:

• the board providing a role model for health and safety behaviour;
• 17% reduction in sickness absence;
• 28% reduction in reportable incidents;
• improved morale and pride in working for the company;
• raising the profile of health and safety so it is becoming embedded in the culture of the organisation.

When leadership falls short

Many high-profile safety cases over the years have been rooted in failures of leadership. When board members do not lead effectively on health and safety management, the consequences can be severe. These examples mark issues for all boards to consider.

Competent advice, training and supervision

Following the fatal injury of an employee maintaining machinery at a recycling firm employing approximately 30 people, a company director received a 12-month custodial sentence for manslaughter. The machinery was not properly isolated and started up unexpectedly.

An HSE and police investigation revealed there was no safe system of work for maintenance; instruction, training and supervision were inadequate. HSE's investigating principal inspector said: 'Evidence showed that the director chose not to follow the advice of his health and safety adviser and instead adopted a complacent attitude, allowing the standards in his business to fall.'

The managing director of a manufacturing company with around 100 workers was sentenced to 12 months' imprisonment for manslaughter following the death of an employee who became caught in unguarded machinery. The investigation revealed that, had the company adequately maintained guarding around a conveyor, the death would have been avoided.

The judge made clear that whether the managing director was aware of the situation was not the issue: he should have known as this was a long-standing problem. An area manager also received a custodial sentence. The company received a substantial fine and had to pay the prosecution's costs.

Risk assessment

A company and its officers were fined a total of £245,000 and ordered to pay costs of £75,500 at Crown Court in relation to the removal of asbestos. The company employed ten, mostly young, temporary workers; they were not trained or equipped to safely remove the asbestos, nor warned of its risk. The directors were also disqualified from holding any company directorship for two years and one year respectively.

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