TABLE OF CONTENTS. Incident Investigation

Transcription

1 TABLE OF CONTENTS Incident Investigation 9. INCIDENT INVESTIGATION A. PURPOSE B. SCOPE C. DEFINITIONS D. INVESTIGATION E. INVESTIGATION PROCEDURE F. INCIDENT REPORTING G. DETERMINING INCIDENT CLASSIFICATION H. FORMS July 2, 2010 RDOS Health & Safety Manual 9-1

2 9. Incident Investigation A. Purpose The purpose of an incident investigation is to determine the cause and to implement suitable corrective measures. The immediate supervisor is responsible for conducting incident investigations. The purpose is to find fact, not fault. Supervisors are reminded to focus on how and why the event occurred, rather than who should be blamed. B. Scope The investigation is a systematic process of examination, observation and inquiry comprised of three parts including: Description of Incident The description identifies in detail how, when and where the incident occurred including all related factors (i.e. weights, heights, and distances, time of day, weather conditions) Cause of Incident (Why did it occur?) What acts, failures to act and conditions contributed to the accident or incident Recommendations (How can we prevent it from reoccurring?) After the cause of the incident has been determined, recommendations to prevent recurrence should now be prepared C. Definitions Incident: Includes an occurrence, which results in or had the potential for causing an injury or occupational disease. D. Investigation What Incidents should be investigated? All incidents must be investigated, although the primary focus should be on serious and major incidents. Minor incidents, however, must not be overlooked. They may signal a trend toward unsafe acts that will eventually cause a serious incident. The investigation of an incident should be proportionate to the loss potential. As the degree of loss potential July 2, 2010 RDOS Health & Safety Manual 9-2

3 increases, so will the degree of investigation. preventive action taken. Cause(s) must be determined and The unreported incident is a big problem. Many workers do not report minor incidents because they fear ridicule from their fellow workers, reprisal from a supervisor, loss of wages due to lost time or a bad reputation as an incident prone worker. Unreported incidents mean: Nothing is learned from the experience; Incident causes are not corrected; A failure to report attitude could spread. Who Should Investigate? Investigations are to be conducted by the supervisor in charge of the area and/or personnel involved. A member of the Joint Health & Safety Committee may assist in the investigation and the Department Manager will ensure that the appropriate corrective actions take place. As the investigation can be rather complex, investigators must receive accident/incident investigation training. Investigation Kit Responding to the requirements of an incident investigation where time is of the essence can be a challenging experience. To assist this endeavor, an investigation kit should be available at each Department. Ideally, this kit should contain the following items including: A carrying case Clipboard, paper and pencils Flashlights with extra batteries Large envelopes or plastic bags for preserving evidence A complete list of emergency phone numbers and investigation procedures Camera Measuring device Disposable coveralls Medical latex or vinyl gloves Work gloves High visibility vest July 2, 2010 RDOS Health & Safety Manual 9-3

4 E. Investigation Procedure The success of an investigation is generally the result of prompt and efficient response. The investigator must be prepared so that the investigation process can be adequately planned, initiated and completed successfully. The person or team (Supervisor, Member of the Joint Health & Safety Committee) conducting an investigation into an incident should proceed as follows: establish and take control of the scene ensure that any injured persons are cared for ensure that no further injury or damage occurs get the big picture of what happened examine equipment/materials involved preservation of evidence, collect and safeguard any physical evidence. Where practicable, the scene of any accident should be left untouched, except for activity necessitated by rescue work or to prevent further failures or injuries until the incident has been investigated take photographs of the scene interview people involved and obtain written statements where appropriate analyze all the available information to determine the causes look for causes where the system failed the worker, not only for those where the worker failed the system (refer to the chart Cause of Incident, located on page 7); determine what corrective action will prevent recurrence, complete the report, and follow-up to ensure corrective action is completed Note: Incident investigations are NOT conducted to fix blame. They are conducted to prevent recurrence. F. Incident Reporting All serious incidents or injuries must be reported and documented immediately. The incident reporting procedures described here are intended to assist workers with legitimate claims for compensation as quickly and fairly as possible. July 2, 2010 RDOS Health & Safety Manual 9-4

5 Immediate Reporting Certain accidents must be reported immediately, according to Section 172 of the Workers Compensation Act which states: (1) An employer must immediately notify the Board of the occurrence of any accident that (a) resulted in serious injury to or the death of a worker, (b) involved a major structural failure or collapse of a building, bridge, tower, crane, hoist, temporary construction support system or excavation, (c) involved the major release of a hazardous substance, or (d) was an incident required by regulation to be reported. (2) Except as otherwise directed by an officer of the Board or a peace officer, a person must not disturb the scene of an accident that is reportable under subsection (1) except so far as is necessary to (a) attend to persons injured or killed, (b) prevent further injuries or death, or (c) protect property that is endangered as a result of the accident. Injury Reporting First aid Injuries: All injuries, major and minor must be recorded to the First Aid Attendant and immediate Supervisor. Medical Aid and Lost-Time Injuries: All injured workers must be transported to further medical attention, if required. Any incident requiring medical aid or results in time loss from work (including workrelated injuries, disabling occupational disease, claim for occupational disease, or allegation of an occupational disease) must be reported in accordance with WCB s requirements. All appropriate WCB documentation must be completed and forwarded by the employee to their immediate Supervisor. Once the Supervisor has completed the appropriate forms, all documentation must be forwarded to the Human Resources (HR) department for final review and submission to WCB. If an employee witnesses an injury of a co-worker and knows the incident has not been reported, they are obligated to inform the Supervisor. Reporting Equipment Property Damage The Manager must be promptly notified of serious equipment or property damage. An Incident Investigation Report must be completed (with diagrams) for all downgrading incidents and forwarded to the Department Manager, Safety Officer and HR Dept. July 2, 2010 RDOS Health & Safety Manual 9-5

6 Incident/Injuries Reporting All incidents must be reported immediately. The workers will report these to their immediate supervisor who in turn must then report occurrences to the Manager. Incidents must be treated seriously and the Incident Investigation Report must be completed. Government Notification The WCB must be notified in the event of certain injuries or incidents. In the event of any of the following occurrences and immediately after emergency measures have been activated, the Manager must be contacted and they will inform the appropriate agencies. G. Determining Incident Classification Lost Time Incident (LTI) A lost time incident (LTI) is an incident where a physician directs the injured worker to remain away from work longer than the day of the incident. Medical Aid (MA) An injury requiring treatment by a physician beyond simple first aid care but does not result in time lost from work beyond the day of the injury is classified as a Medical Aid (MA) injury. First Aid (FA) A first aid is when a qualified person renders immediate treatment and the worker immediately returns to work. H. Forms First Aid Record (Form SHM 9.1a) Incident Investigation (Form SHM 9.1b) Incident Sketch Map (Form SHM 9.2, Page 1 and 2) Witness Statement (Form SHM 9.3) Sequence of Events Record (Form SHM 9.4) Major Incident Report (Form SHM 9.5) July 2, 2010 RDOS Health & Safety Manual 9-6

7 CAUSE OF INCIDENT To determine the most appropriate cause, consider details of the investigation including, where possible, the employee s statement, and whether the incident was due to an ACT of the employee, a CONDITION of the individual s working environment, or a PERSONAL FACTOR inherent in the employee at the time of the incident or onset of illness. UNSAFE ACT Where the cause was a specific action or lack of action by the Individual, which would be considered UNDER THE INDIVIDUAL S CONTROL. (Generally, violation of safety rules or disregard of hazard would be considered unsafe acts unless specific criteria indicate a personal factor to be the cause. IMPROPER ATTIRE Failure to attire safety did not use (or misused) safety equipment available or required for use, or was inappropriately attired for the job conditions. SAFETY EQUIPMENT DEVICES MISUSED Lockout Testing devices not used or misused Making devices ineffective IMPROPER PROCEDURE Improper use of equipment Unauthorized use of equipment Failure to report a condition Failure to heed a hazard Failure to follow instructions or established procedure (not involving misuse of safety equipment) UNSAFE ENVIRONMENT OF CONDITION Where the cause was a situation or event NOT CONTROLLABLE BY THE INDIVIDUAL (A condition causing an allergic reaction to some but not most employees should be considered a personal factor and not an unsafe condition.) Inadequate training or instruction should be considered a condition as opposed to a deficiency in skill or ability). Inadequate safety attire prescribed, provided or available for use Inadequate safety devices (improperly or inadequately guarded or protected equipment) Inadequate supervision Faulty construction, design, layout (including lighting, ventilation, arrangement of facilities, etc.) Inadequate housekeeping/maintenance/inspection Defective equipment Unsafe act by another person Upset condition such as fire, explosion, etc. or abnormal operation Inclement weather (wind, rain, snow, ice, etc.) Alleged condition where REPEATED exposure could lead to physical impairment (such as hearing loss from noise, pneumoconiosis from dust, vapors, etc.) PERSONAL FACTOR (Mental, Physical) Where there is evidence of a deficiency in ability, physical condition or mental attitude, an uncontrollable factor inherent in the individual at the time of the individual s injury or illness including allergy, fatigue, intoxication, temper, etc. Deficiency in skill or ability Physical handicap including allergic sensitivity, crippled, poor hearing or eyesight, obesity, inadequate strength or stamina for job requirements Abnormal mental or physical state (affected by medication, alcohol, narcotics, worry, fear, etc.) Other personal factor Inadequate job experience July 2, 2010 RDOS Health & Safety Manual 9-7

8 FIRST AID RECORD Full name of injured worker: PHN: Follow-up visit: Yes No N/A Job Title: Department/Division: Supervisor s Name: Date of incident: Incident Location: Time of incident: am pm Date incident reported: Reported to: Time: am pm Type of incident: Near Property First Medical Lost Injury/ Miss Damage Aid Aid Time Illness Name of Witness: 1. Name of Witness: 2. What was worker doing at the time of the incident? (eg. Using a weed eater, lifting refuse onto truck, stepping down from ladder, etc) Describe what happened to cause the incident. (eg. Twisted back picking up garbage, squashed finger in vice, etc.) Describe the injury. (eg. Painful lower back, bruised swollen left ankle, grazed knuckle right hand, cut big toe left foot, etc. Make sure to indicate left/right/front/back/side, etc.) Describe first aid treatment and advice given. (eg. Applied Band-Aid, iced, removed sliver, ice at home, see me tomorrow, etc.) Was violence a contributing factor in this incident? Yes No Is the worker returning to his/her shift without lost time? Yes No Is the worker going to medical aid without completing his/her shift? Yes No If so, the relevant Supervisor must be notified by the worker before leaving the workplace. Has the worker been referred by the First Aid attendant to a hospital, doctor or clinic? If yes, Doctor s name and phone no.: Yes No If first aid treatment was rendered before worker went to doctor/hospital, Form 7A must be completed by the First Aid attendant. If the worker goes to the doctor and/or is off work beyond the date of injury, Human Resources to report incident to Worker s Compensation Board. First Aid Attendant s signature: Date: Injured Worker s signature: Date: Foreman s signature: Date Distribution: Department Supervisor (Form 9.1a) July 2, 2010 RDOS Health & Safety Manual 9-8

9 INCIDENT INVESTIGATION Location/Address Incident Occurred: Description of incident: Any damage to City property: Yes No Details of damage: Any damage to private property: Yes No Estimate of damage: Immediate action taken: Is action taken: Permanent Temporary Was protective equipment being used? If yes, what type? Are written safe work procedures or instructions in place for doing this task? Yes No Have they been reviewed with the worker? Yes No If incident is a motor vehicle accident, please complete the following: Driver s Name: DOB: (dd/mm/yy) Driver s Lic. No.: Was our vehicle involved: Yes No If yes, Unit Number: Year: Make: Model: Serial No.: License Plate Number: Province: Insurance Company Name: Insurance Co. City: Insurance Agent: Agent Address: Policy No: Expiry Date: Corrective measures taken: Yes No Corrective action referred to: Committee Member s Signature Foreman or Supervisor s Signature: Date to be completed by: Date: Date: Please return completed form to the Safety Coordinator For Office use only Is an MSI investigation required for this incident? Is a Violence Incident Report and Investigation required for this incident? W.C.B. Claim #: Yes Yes No No (Form 9.1b) July 2, 2010 RDOS Health & Safety Manual 9-9

10 INCIDENT SKETCH MAP Claim Number On Street or Road Building At Intersection In Location Hour Month Day 20 Reported by Show North by Arrow Scale Indicate on this diagram what happened: Please see reverse side (Form 9.2, Page 1) July 2, 2010 RDOS Health & Safety Manual 9-10

11 SKETCHING CHECKLIST By eliminating irrelevant details and adding measurements, you can often sketch a scene more clearly than you can photograph it. The following points will make sketching for Incident maps easy without sacrificing accuracy: 1. Use squared paper. Let each square represent a fixed distance such as a foot and write the scale at the top of the sketch. 2. Use a strip of squared paper to measure diagonals on the sketch. 3. Locate each important object with a rough outline. 4. Label large objects inside their outline. Label small objects outside their outline with an arrow to the object; the arrow should just touch the object. 5. For maps with a lot of detail, use a sketch log. Use double letters to identify reference points and single letters to identify items of evidence. 6. Indicate distances of movable objects from at least two fixed points. Logs for detailed maps have columns for measurement data. 7. Include a north arrow in each sketch. 8. Mark camera positions by a letter inside a circle. Later the appropriate letter should be used on each print. 9. Identify the sketches with a label, data box or on the back just as you would a photograph. (Form 9.2, Page 2) July 2, 2010 RDOS Health & Safety Manual 9-11

12 WITNESS STATEMENT Witness Name: Company Name: Department: Location: Date: Time: Address: City: Postal Code: Phone: ( ) Witness Signature: If more space is required, please use reverse side and/or obtain another form from the investigator. (Form 9.3) July 2, 2010 RDOS Health & Safety Manual 9-12

13 SEQUENCE OF EVENTS RECORD Date Time Description of Action Taken and Persons Involved Initials (Form 9.4) July 2, 2010 RDOS Health & Safety Manual 9-13

14 MAJOR INCIDENT REPORT Department: Division: Date of Report: Exact Location of Incident: Date of Occurrence: Time of Occurrence: AM PM Report Prepared by: Title: Phone Number: Injured (name): Nature of Injury: Employment Status: Full-Time Part-Time Relief Hours worked: Day Week Body Part: Source of Injury: Job Classification: Activity at Time of Incident: Name of Doctor: Doctor s Address and/or Phone Number: Property Damage/Identification: Other Incident/Damage (Identification): Model/Serial Number: Damage Results: Name of Person With the Most Control of Incident: Title: Phone Number: Type of Incident: Caught In Caught Between Struck By Fall same level Exposure to Caught on Struck Against Strain/stress Fall to lower Contact with Describe How Incident Occurred: Activity, Authority, Job Procedure, Post-Contact Actions. Head Protection: Eye Protection: Respiratory Protection: Ear Protection: Body Restraint: Foot Protection: Gloves: Fire/Heat Protection: Other: Other: Remarks: Sketch Attached: Yes No PROTECTIVE EQUIPMENT USE: Function Required Available Used Needed (Form 9.5, Page 1) July 2, 2010 RDOS Health & Safety Manual 9-14

15 INFLUENCING FACTORS: CODE: C Contributed N Not a Factor P Present but not significant Supervisory:1 C N P Psychological: C N P Inadequate Training Human Design Factors Inadequate Instructions Perceptual Distortion Inadequate Planning Perceptual Illusion Task Overloading Habit Interference Used Unqualified People Misinterpretation Allowed Insufficient Time Preoccupation Inadequate Requested Equipment Distraction Written Instruction Not Used Attention Fixation Proper Tools Not Provided Inattention Correct Material Not Provided Boredom Lack of Order Apprehension Inadequate Coaching and Tipping Overconfidence Inadequate Job Analysis Excessive Motivation to Produce Inadequate Job Observation Panic Protective Equipment Not Provided Physiological: C N P Communications: C N P Fatigue, Chronic No Instructions/Feedback Fatigue, Acute (Temporary) Misinterpretation Toxic Poisoning Disrupted Hyperventilation Noise Interference Drug or Medication Language Barrier Used Only One Mode Environmental: C N P Dizziness Heat Nausea Cold Other Illness: Noise Vibration Pressure Loss/Change Smoke/Fumes Alcohol Hangover Hypoglycemia (Low Blood Sugar) Dust Wind, Draft, Air Blast Acceleration, Deceleration Weather: Immediate Causes: What substandard acts and conditions contributed directly to this incident? What Personal Factors Were Basic Causes of This Incident? Explain. Lack of Knowledge/Skill Improper Motivation Physical or Mental Problems Inadequate Planning Willful Deviation What Job Factors Were Basic Causes of This Incident? Explain. Inadequate Work Inadequate Inadequate Inadequate Purchasing Abuse or Inadequate Standards Design Maintenance Standard Misuse inspection What are the Reasons for the Activity Being Out of Control? Explain. Inadequate Program Inadequate Program Standards Inadequate Compliance with Standards (Form 9.5, Page 2) July 2, 2010 RDOS Health & Safety Manual 9-15

16 ACTION PLAN Loss Severity Potential: Major Serious Minor What Has or Should be Done to Prevent Similar Loss: Probability of Recurrence: Frequent Occasional Seldom Signature of Investigator: Committee Member s Name: Committee Member s Signature: Date: Reviewed by: Title: Date: cc: Manager (Form 9.5, Page 3) July 2, 2010 RDOS Health & Safety Manual 9-16