1.0 Standard. Title: Date of Issue: Feb Incident Investigation Policy & Procedure. Approved By: Review/ Revision Date. 1-Nov-10.

Transcription

1 Title: Incident Investigation Policy & Procedure Date of Issue: Feb 2001 Approved By: Mark Runciman Review/ Revision Date 1-Nov-10 Location: All Locations Ref. No: HS Standard 1.1 Purpose To ensure that incidents are thoroughly investigated in accordance with the Occupational Health & Safety Act and company policy, and that appropriate corrective actions are identified and implemented to prevent the incident from recurring. 1.2 Definitions Incident Any unplanned event that results in, or could result in, an injury or fatality, or damage /destruction of equipment, property or the environment. Critical Injury (as per the Ontario Occupational Health & Safety Act) An injury of a serious nature that; places life in jeopardy; produces unconsciousness; results in substantial loss of blood; involves the fracture of a leg or arm but not a finger or toe; involves the amputation of a leg, arm, hand or foot but not a finger or toe; consists of burns to a major portion of the body; or causes the loss of sight in an eye. Occupational Illness A condition that results from exposure in a workplace to a physical, chemical or biological agent to the extent that the normal physiological mechanisms are affected and the health of the worker is impaired thereby and includes an occupational disease for which a worker is entitled to benefits under the Workplace Safety and Insurance Act. Near Hit or Near Miss Terms used to describe an event that could have caused harm but did not. 1.3 Scope All workplace injuries must be reported immediately, no matter how slight. Incidents that will receive a formal investigation by a Certified Management and Certified Worker Representative include: Fatality loss of life Critical Injury an injury that meets the criteria for a critical injury as defined above. Emergency situations where the injury is not a critical injury, however the injury is severe enough to call 911 for emergency medical assistance.. Near miss incidents where the potential for serious injury exists

2 Fire or explosion any type of fire whether small or large or any type of explosion. Chemical spill any release of chemicals from their means or containment to the environment, regardless of the size of the spill. Incidents that will receive a formal investigation by the supervisor of the injured worker: Lost Time an injury/illness that causes a worker to be off work for more than the day of the injury. Medical Aid an injury/illness that causes a worker to seek medical attention by a medical doctor in an office, hospital or clinic. Occupational Illness an illness that relates to the work environment (see definition above). Property damage damage to buildings and equipment in excess of $100. Near Miss an incident where no injury, ill health, fatality or damage occurred but where the potential for such exists. All employees are expected to cooperate and provide assistance during the investigation as requested. Incidents involving visitors, clients, suppliers or contractors will be investigated as well if they meet the identified criteria. 1.4 Critical Injury or Fatality In the event of a critical injury or fatality, the scene is not to be disturbed other than to provide immediate medical attention for the injured worker and to prevent further damage (e.g. shut down running equipment). Once this is done, the scene is to be secured and immediate notifications made to Senior Management, the Ministry of Labour and the Joint Health & Safety Committee. Documentation of the incident, photos etc. may be taken, but any investigations that may disturb the scene will not be completed until the scene has been released by the Ministry of Labour. 1.5 Roles & Responsibilities Supervisor Duties Provide/obtain first aid or medical aid for the injured worker as necessary Complete an Accident/Incident Investigation form (HR-002-a) Obtain assistance from any other person deemed necessary and appropriate (JH&SC, maintenance) Complete the investigation using the procedure contained in this standard by the end of the next working day Implement/schedule any corrective actions that are determined to eliminate a recurrence Follow to ensure that corrective actions are implemented Record all actions on the Accident/Incident Investigation Form (HR-002-a) Forward completed copies of forms to the Human Resources Manager or designate. Communicate details of the incident and any corrective actions taken to all applicable workers Monitor the situation to ensure that corrective actions have achieved the required result. Page 2 of 6

3 1.5.2 Senior Manager Duties 1. Assist in the investigation if requested 2. Review all investigations for completion and thoroughness 3. Review all recommendations for corrective actions 4. Implement all appropriate recommendations, respond to any other recommendations with alternative or explanation 5. Ensure all required reports are submitted to the Ministry of Labour as per the applicable regulation. Ensure all corrective actions are completed JH&SC Worker Representative Duties Assist in the investigation if requested Complete investigation of any critical injury or fatality Worker Duties Report all incidents and near misses to your supervisor or any member of the JH&SC. 1.6 Investigation Procedure Investigators should follow the steps outlined below in order to complete an investigation of incidents. For incidents involving fatalities, critical injuries or emergency situations the Certified Worker Representative and the Certified Management Representative will conduct the investigation together Access the scene Take notes, photos or sketches if appropriate, record any physical evidence to be secured Interview the Witnesses Obtain the names of any witnesses to the incident. Conduct interviews with the involved worker and any witnesses. The interviews will take place as quickly as possible to ensure that information is fresh in the minds of the persons being interviewed. The interviews are to be conducted as follows: Separate potential witnesses pending the interview, to prevent discussion. Take the persons being interviewed to a quiet location where they will be comfortable Be polite, thank them for helping you. Reassure interviewees that you wish to determine facts, not lay blame. Find out what happened, not who was at fault. Ask open ended questions, nothing that can be answered simply yes or no. Avoid leading questions, ask what they actually saw or heard, do not provide information and ask them to confirm it. Ask if they know why the incident occurred, or could recommend ways to prevent it from happening again. Record the statements of the injured worker and any witnesses Thank them for their cooperation and ask if you could speak to them again if needed. In the case of serious injuries or fatalities, be alert for signs that witnesses may need help for traumatic stress reactions. Advise management if concerns are identified. Page 3 of 6

4 1.6.3 Identify Contributing Factors It is almost always the case that incidents are caused by a number of factors and not by one single factor. To better examine the causes of the incident perform the following: Talk to anyone who may have special expertise that could be relevant e.g. equipment technicians, designers, suppliers, etc. Do not settle for easy answers look for root causes, not just immediate causes. Keep asking why this happened not just what happened Look for substandard or inappropriate actions and conditions Look for any contributing factors as well, such as weather, lighting, lack of sleep, or anything else that may have in some way contributed to the incident occurring, or to the severity of it. Each situation will be different. When deciding how much time and effort each investigation warrants, don t just look at what happened, look also at what could have happened. Could the results have been more serious if things had gone even slightly differently? Reporting Complete the provided investigation form with as much detail as possible and attach additional pages as needed Recommendations Make any recommendations that you, the workers, supervisors, etc. feel may help to prevent the incident from recurring. Submit to Senior Management Notifications Critical injuries or fatalities Senior management is to be notified in person or by telephone immediately of these occurrences. Management will notify the Ministry of Labour and the Joint Health and Safety Committee immediately by phone or in person. Management will submit the written report as per appropriate regulation to the Ministry of Labour within 48 hours. WSIB will be notified by the submission of the appropriate Form 7 within 72 hours Emergency Situations Human Resources will notify a certified Worker Representative of the JH&SC immediately of any injury where 911 is called. Human Resources will notify WSIB of any disabling injury by the submission of a Form 7 within 72 hours Occupational Illnesses Human Resources will notify Senior Management of reported occupational illnesses immediately. Human Resources will notify WSIB by the submission of a Form 7 within 72 hours. Human Resources will notify the Joint Health and Safety Committee of reported occupational illnesses within 4 days. Management will notify the Ministry of Labour of reported occupational illnesses within 4 days. Page 4 of 6

5 Chemical Spills Human Resources will notify a certified Worker Representative of the JH&SC immediately in the case of a chemical spill. Senior Management will notify the Ministry of the Environment of any spill that meets reporting criteria immediately and submit written report as mandated. See Chemical Spill procedure for specifics Medical Aid Injuries requiring medical attention, but not disabling, will be reported to WSIB by Human Resources through the submission of an appropriate Form 7 within 72 hours. 2.0 Communication All new or revised standards will be posted on the bulletin board for a minimum of 14 days. Relevant key points from the standard will be communicated to workers at staff meetings or safety talks. 3.0 Training All persons required to complete investigations must have received training on the theory of incident causation and the investigation process either through the certification process or through separate Incident Investigation training. All workers not performing investigations will receive an overview of the process during orientation. All persons receiving investigation reports will be briefed on the process for documenting corrective actions. All training will be documented by sign in sheets at minimum and records will be maintained by Human Resources. 4.0 Evaluation This policy/procedure will be formally evaluated against the Workwell Audit standard. Any gaps identified will have actions identified to close the gaps. Progress towards closing the gaps will be tracked using an RBG Action Plan form (HS-001-a). The Joint Health and Safety Committee will evaluate the effectiveness of this standard annually by reviewing a representative selection of investigations for thoroughness, identification of basic or underlying causes, corrective actions identified, and timely completion of corrective actions. They will summarize their findings in their minutes and make any recommendations for improvement they feel necessary. 5.0 Acknowledging Success/Make Improvements Acknowledgement of successes and plans for improvement will be communicated through Joint Health and Safety Committee minutes and summarized at an all staff meeting. 6.0 Appendices Referenced legislation: Critical Injury definition from: Occupational Health & Safety Act Regulation 834 Page 5 of 6

6 Occupational Illness definition from: Occupational Health & Safety Act R.S.O co.1 S.1 Definitions Reporting requirements Occupational Health & Safety Act, S.51 Prescribed Criteria, Contents and Report Retention Regulation 851, Industrial Establishments, S. 5-6 Regulation 231/90, Construction Projects, S 8 12 Forms: RBG Accident/Incident Investigation Form HS-002-a RBG Action Plan Form HS-001-a Page 6 of 6