Title: Incident Reporting Effective Date: 4/7/2015 Control Number: THG_0028 Revision Number: 2 Date: 4/05/2016 Annual Review Completed: 5/13/2015 Incident Reporting CONTENTS I. INTRODUCTION II. PURPOSE III. RESPONSIBILITIES IV. PROCEDURES V. TRAINING. Attachments A Injury Report B Near Miss Report C Supervisors Incident Report Page 1 of 19
I. INTRODUCTION a. The management of The Hillis Group, LLC is committed to providing a safe work environment for all employees. These Procedures contribute to a safe and healthy work environment by: i. Improving communication and training associated with the causes of Accidents, Incidents, and Near Misses; ii. Increasing awareness of potentially unsafe practices, acts and conditions; and; Ensuring investigations and fact-finding to minimize the potential for future accidents and incidents. b. The Safety & Health department will conduct accident, incident and near miss investigations with all the parties involved. i. Investigations will focus on fact-finding and root cause analysis. II. III. PURPOSE a. The purpose of this program is to have effective procedures for reporting and evaluating/investigating incidents and non-conformances in order to prevent further occurrences. RESPONSIBILITIES a. Responsibilities for incident investigation will be assigned prior to occurrence of an incident. Individual responsibilities for reporting and investigation must be pre- determined and assigned prior to incidents. i. Safety Manager 1. Ensures investigations are conducted and assists in identifying corrective actions. ii. Site Manager and Supervisors 1. Investigates (or assists in) incident investigations 2. Corrects non-conformances 3. Ensures injured employees are transported to the medical provider for initial treatment. 4. The supervisor completes a Supervisors Incident Report. iii. Employees 1. Immediately report any injury, job related illness, spill or damage to any property to their immediate supervisor. If their immediate supervisor is not available the employee is then to immediately notify the project manager. 2. Employees who could be first responders will be trained and qualified in first aid techniques to control the degree of loss during the immediate post-incident phase. IV. PROCEDURES a. An incident must be reported after immediate rescue or response actions to prevent further loss if the scene is safe. b. For example: i. maintenance personnel should be summoned to assess integrity of buildings and equipment, ii. engineering personnel to evaluate the need for bracing of structures, and Page 2 of 19
iii. special equipment/response requirements such as safe rendering of hazardous materials or explosives employed. c. Investigations of Incidents & Non-conformances i. Investigation is an important part of an effective safety program in that it determines the root cause and corrective actions necessary to prevent similar incidents or nonconformances. ii. The following must be reported to the employee's supervisor immediately. If that person is not available then The Hillis Group, LLC Safety Manager shall be immediately notified for: 1. Near miss incidents with the potential to harm people, the environment or assets (Near Miss Report form) 2. Work related injuries or illnesses (Injury Report form); 3. Property damage including vehicle incidents (Incident Report form) 4. The supervisor completes a Supervisors Incident Report. Hazardous chemical spillage, loss of containment and contamination Nonconformance to safety or environmental rules, policies or standards (Incident Report form) iii. The supervisor shall make the necessary notifications and begin the incident investigation process. iv. In the case of a major injury or incident the scene of the event should be closed off and kept "as is" at the time of the incident. This is vital for effective incident investigation. v. Incident investigation occurs as soon as possible, while the facts are still fresh within the minds of those involved (i.e. witnesses). Take the opportunity to talk to all of those involved before they become unavailable or memory fades. 1. An incident investigation must be thorough and concerned only with cause and prevention and must be separate from administrative disciplinary action. d. Equipment i. Proper equipment will be available to assist in conducting an investigation. ii. Equipment may include some or all of the following items; 1. writing equipment such as pens/paper, 2. measurement equipment such as tape measures and rulers, 3. cameras, 4. small tools, 5. audio recorder, 6. PPE, 7. flags, 8. Equipment manuals, etc. iii. The Safety Manager shall have an incident investigation kit prepared in advance. e. Incident Reporting Matrix i. The Incident Reporting Matrix identifies, based on type of incident, who within corporate management shall be verbally notified and when. ii. It also specifies which type of report from the field shall be completed based on the type of incident. Page 3 of 19
iii. Reporting of the incident must occur in a specified manner based on site specific requirements and the reporting sequence shall be posted. EXTERNAL INCIDENT NOTIFICATION MATRIX Type of Incident Notify Verbally When Incident Report Form Required Minor First Aid Owner / Client 24 hours Yes Injury above Minor First Aid As Required Injury Reporting 911 / Site Medical Response Owner/Client ASAP OSHA Owner/Client Within 8 hours Yes Fire / Explosion Owner/Client ASAP Yes Reportable Spill Owner/Client Within 24 hours Yes Property or Vehicle Damage Owner/Client Within 24 hours Yes INTERNAL INCIDENT NOTIFICATION MATRIX Type of Incident Notify Verbally When Incident Report Form Required Minor First Aid Safety Manager ASAP Yes Injury above Minor First Safety Manager ASAP Yes As Required Injury Reporting Preside nt ASAP Yes Fire / Explosion Safety Manager ASAP Yes Reportable Spill Safety Manager ASAP Yes Property or Vehicle Damag Safety Manager ASAP Yes f. Time Elements for OSHA and Client Notification i. Required incidents must be verbally reported to OSHA within 8 hours of their discovery. ii. Incidents must also be reported to the owner client as soon as possible or in a timely manner (within 24 hours of incident). g. Incident Review Team and Incident Investigation Report i. All incidents will be investigated to the appropriate level with regards to incident severity. While all incidents should be investigated, the extent of such investigation shall Yes Page 4 of 19
reflect the seriousness of the incident utilizing a root cause analysis process or other similar method determined by The Hillis Group, LLC. Safety Manager. ii. He/She will form an Incident Review Team that participates in the determination of the final root cause investigative incident report. The team consists of representatives of management or other designees as assigned by The Hillis Group, LLC Safety Manager. h. Initial Identification/Assessment of Evidence i. Initial identification of evidence immediately following the incident could include: 1. a listing of people, equipment, and materials involved and 2. a recording of environmental factors such as weather, illumination, temperature, noise, ventilation, etc. i. Collection/Preservation and Security of Evidence i. Evidence such as people, positions of equipment, parts, and papers must be preserved, secured and collected through notes, photographs, witness statements, flagging, and impoundment of documents and equipment. ii. All shall be dated. j. Witness Interviews and Statements i. Witness interviews and statements must be collected. ii. Locating witnesses, ensuring unbiased testimony, obtaining appropriate interview locations, and use of trained interviewers should be detailed. iii. The need for follow-up interviews should also be addressed. iv. All items shall be dated. k. The final incident investigation report consists of findings with critical factors, evidence, corrective actions, responsible parties, and timelines for corrective action completion. i. Results of incident investigations are communicated to employees via Stand Downs, Safety Meetings, Toolbox Talks, or through a written report. l. Preparation of the Written Incident Report i. Written incident reports will be prepared and include The Hillis Group, LLC Incident/Accident Report Form or The Hillis Group, LLC Near Miss Report Form including a detailed narrative statement concerning the events. ii. The format of the narrative report may include an introduction, methodology, summary of the incident, Incident Review Team member names, narrative of the event, findings and recommendations. iii. Photographs, witness statements, drawings, etc. should be included. m. The supervisor completes The Hillis Group, LLC Incident Report and takes the below steps when beginning an incident investigation. i. Provide emergency assistance, as needed and qualified for. ii. Secure the area as quickly as possible to retain area in the same condition at the time of the incident iii. Notify management by phone according to the Incident Notification Matrix iv. Identify potential witnesses v. Use investigation tools, as needed (camera, drawings, video, etc.) Tag out for evidence any equipment that was involved vi. Interview witnesses (including the effected employee) and obtain written, signed statements. Page 5 of 19
vii. Prepare the required HILLIS GROUP, LLC Reports, sign the form, deliver it to the HILLIS GROUP, LLC Safety Manager viii. Implement any immediate corrective actions needed n. Incident Notice Form i. THE HILLIS GROUP, LLC shall provide documentation and communication of lessons learned and review of similar operations to prevent reoccurrence. ii. Lessons learned are reviewed and communicated. iii. Changes to processes must be placed into effect to prevent recurrence or similar events. iv. In order to communicate incident information and lessons learned from incidents THE HILLIS GROUP, LLC Safety Manager shall send the Information to all work sites. This shall be communicated to all employees and shall be discussed in weekly safety meetings until all employees have been informed of the incident. o. Corrective Actions Resulting from Incident Investigations i. Incident investigations should result in corrective actions, individuals should be b. assigned responsibilities relative to the corrective actions, and these actions should be tracked to closure. ii. Site Managers are held accountable for closing corrective actions. Corrective actions for safety improvement input are posted at each site and tracked by THE HILLIS GROUP, LLC Safety Manager to ensure timely follow up and completion. iii. Corrective actions are also used as needed for revisions to site specific safety plans and THE HILLIS GROUP, LLC Safety and Health Management System. p. Injury Classifications i. Injuries shall be classified per the following: 1. First Aid a. Dressing on a minor cut, removal of a splinter, typically treatment for household type injuries. 2. Lost Work Day Case (LWDC) a. An injury that results in an employee being unfit to perform any work on any day after the occurrence of an occupational injury. 3. Number of Lost or Restricted Work Days a. The number of days, other than the day of occupational injury and the day of return, missed from scheduled work due to being unfit for work or medically restricted to the point that the essential functions of a position cannot be worked. 4. Occupational Injury a. An injury which results from a work related activity. 5. Occupational Illness a. Any abnormal condition or disorder caused by exposure to environmental factors while performing work that resulted in medical treatment by a physician for a skin disorder, respiratory condition, poisoning, hearing loss or other disease (frostbite, heatstroke, sunstroke, welding flash, diseases caused by parasites, etc.). Do not include minor treatments (first aid) for illnesses. 6. Recordable Medical Case (RMC) a. An occupational injury more severe than first aid that requires advanced treatment (such as fractures, more than one stitch, Page 6 of 19
prescription medication of more than one dose, unconsciousness, removal of foreign body embedded in eye (not flushing), admission to a hospital for more than observation purposes) and yet results in no lost work time beyond the day of injury. 7. Restricted Work Day Case (RWDC) a. An occupational injury which results in a person being unfit for essential functions of the regular job on any day after the injury but where there is no time lost beyond the day of injury. An example would include an injured associate is kept at work but not performing within the essential functions of their regular job. 8. Work or Work Related Activity a. All incidents that occur in work related activities during work hours, field visits, etc. are reportable and are to be included if the occupational injury or illness is more serious than requiring simple first aid. Incidents occurring during off hours and incidents while in transit to or from locations that are not considered an employee s primary work are not reportable. b. The following are examples of incidents that will not be considered as recordable: i. The injury or illness involves signs or symptoms that surface at work but result solely from a non-work-related event or exposure that occurs outside the work environment. ii. The injury or illness results solely from voluntary participation in a wellness program or in flu shot, exercise class, racquetball, or baseball. iii. The injury or illness is solely the result of an employee eating, drinking, or preparing food or drink for personal consumption (whether bought on the employer's premises or brought in). iv. The injury or illness is solely the result of an employee doing personal tasks (unrelated to their employment) at the establishment outside of the employee's assigned working hours. v. The illness is the common cold or flu (Note: contagious diseases such as tuberculosis, brucellosis, hepatitis A, or plague are considered work-related if the employee is infected at work). V. TRAINING a. THE HILLIS GROUP, LLC shall train personnel in their responsibilities and incident investigation techniques. b. Personnel must be trained in their roles and responsibilities for incident response and incident investigation techniques. c. Training requirements relative to incident investigation and reporting are described below: i. Training frequency will be based on the specific area of responsibility but shall not exceed once every two years. ii. Training requirements relative to incident investigation and reporting shall include: 1. First Responder Responsibilities Page 7 of 19
2. The Initial Investigation at the Accident Scene Managing the Accident Investigation Collecting Data 3. Analyzing Data 4. Developing Conclusions and Judgments of Need 5. Reporting the Results Controlled Document Review and Approval Procedure Number THG_0028 Revision 2 Effective Date: 4/7/2015 Page 8 of 19
Originator: S.C. Brockman Signature Date Safety Committee Review Date: Chairman: History Revision Number Effective Date Pages Revised Reason for Revision 1 10/21/15 All Revised Procedure Format 2 4/05/2016 11-19 Added - Near Miss Report; Injury Report; Supervisors Incident Report Page 9 of 19
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THE HILLIS GROUP, LLC. Injury-Incident Report Job#: First Aid Recordable Medical Only Restricted Duty (# of days ) Lost Time (# of days ) Time and Place of Accident Location of Incident: Date of injury: Time of injury: a.m. p.m. Crew: Foreman: Date injury reported: Person to whom reported: Name of other witness and phone number: Further Investigation Needed: Yes No Employee Name of employee (Last, First, Middle): Phone Number: Date of Hire: Days on Job: Address: Date of Birth: Marital Status: Age: Single Divorced Employee ID Number: Married Widowed Craft: Nature and Cause of Accident Describe Accident: Insurance Claim Probable? Yes No Number of dependent children: Contributing Factors: Resulting Injuries: Comments Regarding Prevention/Reoccurrence: PPE that was used: Root Cause Analysis Completed? Yes No Corrective Action: RCA Findings: Additional Comments: Medical Treatment Information Physician (name, address, and phone number): Hospital (name, address, and phone number): Positive X-Ray: Yes No N/A Prescription Drugs: Yes No Probable Time Off: Date Should Return To Work: Yes No Reporter s Information Report Prepared By: Surgery Expected: Yes No Drug Test: Yes No Date: Needs Return Visit: Yes No Drug Test Results: Positive Negative N/A Page 11 of 19
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2100 Wood Avenue Easton, PA 18042 (610) 438-3921 Office (610) 438-3830 FAX Instructions: Employees shall use this form to report all work related near miss events (which could have caused an injury, illness, or property damage) no matter how minor. This helps us to identify and correct hazards before they cause serious injuries. This form shall be completed by employees as soon as possible and submitted to the Safety & Health Department. I am reporting a Near Miss: Injury Property Damage Your Name: Job title: Supervisor: Have you told your supervisor about this near miss? Yes No Date of near miss: Time of near miss: Names of witnesses (if any): Where, exactly, did it happen? What were you doing at the time? Describe step by step what led up to the near miss. (continue on the back if necessary): What could have been done to prevent this near miss? How could you have been hurt? Your signature: Date: Page 13 of 19
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2100 Wood Avenue Easton, PA 18042-3104 (610) 438-3921 Phone (610) 438-3830 FAX 1. Employee Details Name: Job Title: 2. Incident Details Date Of Birth Employee Status Salary Wage Contract Medical Aid Lost Time Fatality Personal Property Damage Reported by: Date: / / Time: am pm Description of Incident/Injury/Illness: Reported to: Is this a Workman s Compensation Incident: Yes No Unknown Body Part Injured This Section is not to be completed for Personal Property Damage Unknown Buttocks/tailbone Eye(s) Groin Other Neck Face Undetermined medical Chest/ribs Hand(s) Knee(s) Arm(s) Ears(s) Finger(s) Leg(s) Toe(s) Back Foot/feet Hip(s) Lungs Page 15 of 19
Nature of Injury/Illness This Section is not to be completed for Personal Property Damage Multiple injuries Heat stress Burn Whiplash Hearing loss Puncture Sprain Tooth damage Welding Skin condition Respiratory Poison flash Undetermined Electric shock Hypothermia Bruise medical Fracture Allergic reaction Disease Emotional/psychological Frostbite Amputation Strain Foreign body-eye Incision/cut Concussion Hernia Other Source of injury This Section is not to be completed for Personal Property Damage Animal/insect Chemical(s) Machinery type: Body mechanics Climate Computer Material/object: Lifting use Human (client) Vehicle type: Over exertion Human (non-client Tool(s) type: Facility Ground/floor/terrain Vegetation Activity at time of incident Other: Recreation Fire operations Hand tools Demolition Office work Power tools Travel (non-driving) Driving Maintenance/repair: Heavy equipment operation: Material handling Inspection Construction Instruction/training: Other: Page 16 of 19
3. Direct causes check all that apply Hazardous Acts Not following procedure(s) Failure to warn Failure to secure Improper lifting Operate at improper speed Safety devices not installed/removed Defective equipment Violence Other: Hazardous Conditions Chemicals/biohazards Defective tools / materials Improper guards / barriers Improper procedure Noise Inadequate housekeeping Poor visibility Other: Contributing Factors - check all that apply Physical stress Physical capabilities Engineering Behavior(s) Mental stress Knowledge/skill Maintenance Immediate Corrective Action Supervision Other 1) By Whom: Date: 2) By Whom: Date: Page 17 of 19
Long Term Corrective Action 1) By Whom: Due Date: 2) By Whom: Due Date: Have Immediate Notifications Been Completed Yes No Immediate Supervisor s Name: Signature: Date: / / 4. Injured/Involved party s Statements (attach additional pages if necessary) Signature: Witnesses: Name Name Date: Contact Contact Contact Has this condition developed over time? Yes No Is this a recurrence? Yes No Previous Date(s): If this a recurrence of a previous injury, indicate the dates of previous injuries. / / / / / / Page 18 of 19
List all equipment involved in incident Rental Equipment ID (Serial Number, etc.) 1. Yes No 2. 3. Yes Yes No No 4. Yes No 5. To be completed by the reviewing manager/officer. If additional actions are necessary, identify them here for completion. 1) By whom: Due Date: 2) By whom: Due Date: 3) By Whom: Due Date: Manager s Signature Date: Page 19 of 19