accident reporting, investigation & siir august 2009

ACCIDENT REPORTING, INVESTIGATION & SIIRAugust 2009

2TMD-8303-SA-0019 Rev. 0, October 09

Accident / Incident

Any event that could have or did result in:

Injury

Property Damage

Environmental Release

Adverse Community Reaction

Must be reported to your supervisor immediately, and investigated & documented (SIIR form) within 24 hours; LTI notification to CEO within 1 hour.


Responding to an Injury

Report all injuries immediately, no matter how minor - many times immediate medical care will prevent more serious outcomes such as infection

Your report will help us to identify & correct hazards that will prevent injury to others

First priority: make sure others are safe and tend to anyone who is injured

Secure the scene to make sure no one else gets hurt

Don’t disturb anything that could help in the investigation


Investigation of Incidents

USM investigates every incident, even when no injury or property damage occurs (Near Miss / Close Call)

Investigations uncover contributing & root causes to determine:

What happened

Why it happened, and

Ways to make sure it doesn’t happen again

Goal: Implement all corrective actions to make sure it won’t happen again – continual improvement

Investigations are not looking to assign blame


10% Unsafe Conditions

90% Unsafe Acts

• Protective Equipment

• Reactions of People

• Procedures

• Positions of People

• Tools and Equipment

• Housekeeping and Orderliness

• Behaviors / Habits

Most injuries are caused by unsafe acts and behaviors, not by unsafe conditions and equipment

Must ensure that all employees are trained how to work safely – develop safe work behaviors

Unsafe Conditions

Unsafe Acts/Behaviors

Injury Causes


Hazard Pyramid

Associate hits head on edge of desk while falling and breaks neck

Associate fractures arm as he hits the floor. Two weeks out of work

While falling, employee grazes edge of metal drawer and lacerates arm

A 2nd Associate slips on spill, falls, and gets bruisedAssociate spills coffee on floor and walks away


Iceberg Analogy

Remember most incidents are caused

by something someone does or

fails to do

Fatalities Lost Time Injuries

Medical TreatmentFirst-Aid Cases

Unsafe ActsUnsafe Conditions

Near Misses

Focus below the waterline – NON Injury Incidents


Investigation Strategy

Gather information – interview & take pictures

Search for & establish facts

Isolate contributing factors

Find root causes – dig deep

Determine corrective actions

Implement corrective actions


The Interview

Put individual(s) at ease - people may be reluctant to discuss the incident, particularly if they think someone will get in trouble. Remember:

It Is Not - a witch hunt, interrogation, or fault finding effort It Is - a fact finding mission to prevent recurrence

When interviewing: Conduct interview in private setting - separately Note what they saw, heard and why they think it occurred Be a good listener & don’t interrupt Don’t lead the witness – ask open ended questions Don’t assume, pre-judge or close your mind Ask for facts (be aware of conjecture) Note opinions as such Describe your viewpoint & thoughts

and get their feedback


The Interview

Don’t ask leading questions• Bad: “Why was the forklift operator driving recklessly?”• Good: “How was the forklift operator driving?”

If the witness begins to offer reasons, excuses, or explanations, politely decline that knowledge and remind

them to stick with the facts

Summarize what you have been told & get agreement• Correct misunderstandings of the events between you and

the witness(es)

Ask the witness/victim for recommendations to prevent recurrence

• These individuals will often have the best solutions to the problem


Investigation - Fact Finding

Visit the accident scene to clarify/re-enact and take note of:• Equipment/tools used, placement, condition • People involved, not involved• Time, shift, hours worked, day of week• Weather conditions, temperature• PPE worn, not worn

Review appropriate SOP’s, rules, training records, etc Motivational issues Management system failure Identify Primary & Secondary Causes:

• Primary - If eliminated, incident could not occur (usually obvious)• Secondary - Usually more than one - commonly more pertinent

to the real issues


Contributing Factors

Where there:

Insufficient or inappropriate systems or procedures

Lack of training in procedures

Poor housekeeping PPE Equipment & Tools Building structure

Ask “WHY” 5 times – an easy way to get from “what” to “why”


Address the “WHY” over the “WHAT”

“What” “Why”

Employee operated a machine without the guard in place. Corrective action: Discipline employee for not following work rules.

The guard was broken - repair parts are hard to get and expensive; parts not stocked - unable to make the repairs and left the machine in service until the repair parts arrived.

Corrective action: Improve inventory system to be assured critical parts are available to repair broken guards.

Employee tripped over pallet sticking out into aisle.

Corrective action: Tell employee to pay more attention where they are walking.

The painted lines on the floor had worn off and forklift operators had no reference lines to follow - pallet in the wrong place.Corrective action: Repaint all lines on floor.

After fact-finding phase, you should know what happened – now you must find why it happened - to address the “root causes”


Use of the 5 WHY’S

Fact (What?) Why Question Answer

Employee fell when rung on ladder broke.

Why did the rung break? The rung was too weak for the load on the ladder.

Why was the rung too weak to support the weight?

The rung was only designed for a load of 300lbs.

Why was there more than a 300lb load on the ladder?

The combined weight of the employee and shingle bundles being carried were more than 300 lbs.

Why was the employee carrying the shingles up the ladder?

There was no delivery truck available to shuttle the shingle bundles onto the roof.

Why was there no delivery truck available?

The company has grown significantly in the last year, they need a second delivery truck to keep up with the jobs, but there is still only one delivery truck.


Find Root Causes

When you have determined the contributing factors, dig deeper!

If employee error, what caused that behavior?

If defective machine, why wasn’t it fixed?

If poor lighting, why not corrected?

If no training, why not?


Unsafe Acts / Conditions

Identify unsafe behavior(s)• Be specific• Avoid labeling terms (lazy, stupid, not thinking, careless, etc.) • Determine frequency of this behavior • Determine if others have similar habits

Identify motivation for unsafe behavior • Describe existing motivation• Describe required safe actions • Describe what new or different motivation will be required for safe

behavior

Identify unsafe conditions• Determine what needs to be corrected, changed or repaired• Write work order• Assign level of urgency (H – M – L)• Assign responsibility• Estimate expected completion date


Corrective Action / Follow-up

Supervisor Incident Investigation Reports (SIIR) must be: Complete & accurate Identify key factors Suggest adequate and practical recommendations Include timing and responsibility State key learning's & follow-up

Determine if action items will prevent future occurrence Does it (they) apply to other employees? Does it (they) apply to other shifts? Will the change(s) positively affect future behavior? Determine how the change(s) will be communicated Determine who needs to be informed - by when? Review open and recently closed items Revisit expected completion dates Look for new hazards Interview employees for changes in habits


Supervisor Responsibilities

Supervisors are expected to be fully engaged in activities related to the management of work-related injuries: Coordinate care of injured employee - if injury requires emergency assistance, call 911 If the employee wishes to seek medical treatment, the supervisor will ensure

that the employee sees a health care professional on the day of injury or the same day the injury is reported

Supervisors will provide an injured employee with:• a WORK CAPABILITIES CERTIFICATE and an AUTHORITY TO

RELEASE MEDICAL INFORMATION form immediately, if the employee wishes to seek medical treatment

• completed, forms should be faxed to (484) 322 4473 or e-mailed to the HSE Office - [email protected]

Supervisors will notify their managers via voicemail or email – up the chain of command to at least the VP level

Supervisors will investigate all accidents/incidents and document findings on the SIIR report form within 24 hours. Report forms will be emailed or faxed up the chain of command and copied to Monika Buchanan & Bruce Thornton [email protected]. LTI notification to CEO within 1 hour.

mailto:[email protected]

mailto:[email protected]


Supervisor Responsibilities

A fatality or multiple hospitalization event requires immediate notification to Bruce Thornton, VP-HSE (CELL: 610-937-6996)

Restricted Duty & Lost Time Injuries: Absences due to work-related injury must be documented with a

doctor’s note – we must strive to follow doctors notes as much as possible (i.e., restrictions, return to work, full-duty, etc) Ensure employees are attending all medical appointments and

providing work status documentation (dr. notes) after each visit Maintain contact with injured employees on a weekly basis (minimum) Supply the HSE/WC Manager with all documentation pertaining to

the injury and post-injury treatment Work with injured employee, HSE/WC Manager, and HR to bring the

employee back to work as soon as medically possible Continue these efforts until employee is released to full duty


Employee Responsibilities

Employees are required to immediately report all work-related accidents and incidents to their supervisor, and fully participate in the accident or incident investigation

Attend doctor appointments, and supply doctor notes after each visit to their supervisor

Failure to comply with the policy may result in the denial of a claim If the injury requires medical attention, the employee will contact their

supervisor and seek medical attention. The employee is expected to seek medical attention on the day of injury and make every effort to schedule follow up doctor visits outside their work hours.

It is the employee's responsibility to complete and provide his/her supervisor with the following forms:

• WORK CAPABILITIES CERTIFICATE – to be completed by treating physician

• AUTHORITY TO RELEASE MEDICAL INFORMATION – to be completed by employee


Employee Responsibilities

Employees must return to work immediately unless authorized by a doctor’s note to be absent from work. An employee who is unable to return to work must contact his/her supervisor immediately for further instructions.

Light duty / work restrictions: Employees are expected to follow work restrictions and cooperate with light duty and alternative work arrangements while in the recovery stages of a work-related injury.

Work Absence and Medical Authorization Employees must attend all appointments and obtain notes from the

medical provider after each visit. Doctor’s notes, at a minimum, must contain the following information:

explanation for the absence, the period the absence is to cover, and if possible, a projected date for return to work – written doctor’s notes only (no verbal instructions).

Notes must be given to the supervisor immediately after each visit. If an injured employee is put out of work (or on restricted duty), that

employee must provide the supervisor with a doctor’s note before resuming work or returning to full duty.


Summary

Reporting an accident / incident could prevent a catastrophic event – report all accidents / incidents

It’s important to investigate all incidents, even if no one was hurt.

A Near Miss report is good thing - it identifies a hazard – it provides a chance to learn & improve

Corrective actions can only be implemented if all accidents are reported & investigated

The purpose of an investigation is to determine the facts, identify root causes, and implement corrective actions so that it will not happen again

An accident is a symptom of a problem for which you need to find the cause


Accident Investigation - QUIZ

1. If you’re not involved in the incident, then you are not part of the investigation or the solution.

2. Most decisions about what will happen in the future are made before the investigation team has wrapped up its

work.

3. The most important result of any incident investigation is to determine who’s at fault

T

FT

F

6. The primary purpose of the accident investigation process is to:

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4. If no one was injured, an incident doesn’t need to be investigated.

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5. Most accidents (90%) are due to unsafe acts/behaviors FT

Learn from incident to prevent recurrence

COMPLETING SIIR FORM

August 2009


Completing the SIIR Form

If investigations and follow-ups are not done timely, they lose their purpose, and send the wrong message to employees.

Most of the information you need to get directly from the injured employee, but that is not the only source of information (i.e., witnesses, files, etc.). If the employee is available, be sure to involve them, but do not allow employee to fill out their own accident investigation report.

Investigate the accident, don’t just document it. Accident Description - Whenever possible, have the injured

employee show you what happened, as long as this will not put them at risk for a repeat accident. When you write the accident description, everyone should be able to visualize exactly what happened, and exactly where it happened.

This is a discoverable document – it must be complete and it must be accurate


Completing SIIR Form

Injury/Illness - Do not make a diagnosis as to what the injury is, or is not. Use “possible strain” rather than strain or sprain. It is better to identify the complaint - back pain, sore wrist, etc. When listing body part affected, be sure to note exactly - right or left, high or low, (i.e, right index finger), etc.

Causes Contributing to Accident - There are usually several causes leading to an accident. Be sure to identify each & every one, including possible causes. Look for unsafe acts, as well as unsafe conditions. Primarily answers the why & how of the accident - very important.

Corrective Actions - Each contributing cause must have a corresponding corrective action. Be sure to fill out the responsibility, target and completion dates and initials. Once a corrective action is identified, it must be followed-up on. This section, combined with contributing causes, is the most important part of the entire process. Remember that the ultimate goal is to learn from this incident, and take the necessary steps to insure that this doesn’t happen again.


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Supervisor Incident Investigation (SIIR) Form No: TMF-8303-SA-0070

Used to report and investigate ALL work related incidents

Single form called the SIIR Incorporates all required

elements of Transfield Services and OSHA recordkeeping

Focuses on Root Cause identification & Corrective Action Implementation

Better Info In = Better Analysis Out = Fewer Incidents

Benefits

•Can be inputted by computer

•Assures Claims Manager has needed contact info on employee, other party and supervisor

•Includes Supervisor Signature so to assure ownership

WHO – WHERE – WHEN???


28

Supervisor Incident Investigation (SIIR) Form No: TMF-8303-SA-0070

Used to report and investigate ALL work related incidents

Incorporates all required elements of Transfield Services and OSHA recordkeeping

Focuses on Root Cause identification & Corrective Action Implementation

Better Info In = Better Analysis Out = Fewer Incidents

X X

Ima Sohurt

Landscape Technician

2

Low back pain lifting /twisting 50 lbs piece of concrete

Dr. Doolittle

406-334-9087

X

Employee was lifting 50 lbs piece of concrete from ground, twisted and then lowered it into bed of pickup at waist level. This is a common practice and size of object he lifts approx. 25 times per day.

XXX

Bruce Thornton

No

Supervisor Drove to Occupational ClinicX

Employee has low back strain. No damage to equipment or piece of concrete identified.

WHAT HAPPENED???


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WHY DID IT HAPPENED?

Supervisor Incident InvestigationRoot Causes

Employee performing repetitive manual lifting of excessive weight without assistance. Employee generally works alone with no one that can be immediately available to help raise and lower objects into pickup bed weighing up to a maximum of 70 lbs which violates 45 lbs limitation. No mechanical lift or crane available to assist in area. Employee trained in proper lifting techniques and limitations in 9/08, with documentation on file.

Purchase a 500 lbs capacity jib crane and install over bench to assist in raising and lowering parts and train employee in using jib crane.

Joe Supervisor 11/30/2008

Employee counseled and received verbal warning on weight limitations related to manual lifting.

Joe Supervisor 10/30/2008


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Supervisor Incident InvestigationIdentifying Corrective Action(s)

Purchased 500 lbs capacity jib crane and installed on pickup to assist in raising and lowering objects and trained employee in using jib crane. Reviewed all other pickups and employee assignments to determine need and found no other exposure situations.

John P. Manager 11/30/2008

John P. Manager

Senior Manager

Ima Sohurt 10/30/2008

X


QUESTIONS ??

Please feel free to ask any questions about the material we’ve covered…

accident reporting, investigation & siir august 2009

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