Safety & Health Incident ReportingAnd Investigation Policy

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Section

1. Purpose

2. Applicability

3. Definitions

4. Responsibilities

5. Near Miss Incident

6. Accident with Injury Incident

7. Investigate The Accident

8. Incident Guidelines

Forms

Leaders’s Report of Accident

Team Member’s Report of Accident

Witness’ Report of Accident

Incident Corrective Action Form

Near Miss Incident Form

TABLE OF CONTENTS

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SECTION 1. PURPOSE

1.1 Viafield recognizes that timely reporting and thorough investigation is an effective way to prevent unplanned events which may harm employees from occurring or reoccurring.

SECTION 2. APPLICABILITY

2.1 This policy/procedure establishes methods for prompt reporting and investigation of safety and health incidents at Viafield facilities, determination of causes, and documentation of resolutions and corrective actions.

SECTION 3. DEFINITIONS

3.1 Accident with Injury - an incident in which one or more people are injured or made ill.

3.2 Corrective Action - the application of a control to a hazard to eliminate the hazard entirely or significantly reduce the chance of an incident.

3.3 Incident - an unplanned, undesired event that resulted in or could have resulted in an injury or damage to Viafield property.

3.4 Incident Investigation - a formal step-by-step review of the circumstances leading up to an incident for the purpose of establishing potential and root causes and determining appropriate corrective action to prevent the incident from recurring.

3.5 Near Miss - an incident that does not result in injury and/or illness.

3.6 Root Cause - the most elementary cause(s) of an incident such that application of corrective action to that cause will eliminate the possibility or significantly reduce the possibility of the incident from occurring again.

SECTION 4. RESPONSIBILITIES

4.1 Location/Facility Leadership will:

4.1.1 Make appropriate incident notifications and complete investigation reports in a timely manner and in accordance with company policies, procedures and work plans.

4.1.2 Conduct an incident investigation upon becoming aware of any incident involving an accident with injury, near miss or damage to Viafield property.

4.1.3 Establish and implement reasonable corrective action in a timely manner.

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4.1.4 Complete incident investigation documentation as may be requested by the Safety Team Leader and/or otherwise required by Viafield policy/procedures

4.2 The Safety Team Leader will develop, distribute, update and otherwise administer this policy/ procedure, with assistance of Human Resources and location leader as required.

4.2.1 Assist in incident/accident investigation at any Viafield location or situation involving a team member.

4.2.2 Work with Human Resources to report safety and loss prevention related incidents to appropriate Viafield leader and government agencies when necessary in accordance with applicable laws, regulation and company policy/procedures.

SECTION 5. NEAR MISS INCIDENT

5.1 Upon becoming aware of a near miss incident, location/facility leadership shall promptly initiate an incident investigation and this should happen within 24 hours of incident by contacting the Safety Team Leader and/or Human Resources.

5.1.1 For a near miss incident, completion of a written report is at the discretion of Safety Leader and/or Human Resources considering the nature and complexity of the incident. When formal documentation of the incident is appropriate and useful, a Near Miss Incident Report Form should be used.

5.2 Location/facility leadership shall make an initial determination as to the potential causes of the incident and establish a team if and as needed to assist in the investigation to determine root cause(s) and corrective action. Incident investigation teams shall contain at least one person knowledgeable in the process involved in the incident. When an incident involves an outside contractor, a contractor representative(s) shall be included in the incident investigation as appropriate and necessary.

5.3 Location/facility leadership shall implement action as needed to promptly address and resolve the incident findings and recommendations. The Safety & Health Incident Corrective Action Documentation Form should be used to document corrective action in response to an incident.

5.4 Incident investigation findings shall be reviewed with all affected team member whose job tasks are relevant to the incident findings including contractors where applicable. Location/facility leadership shall share incident details with team members.

5.5 Incident investigation reports shall be sent to the Safety Team Leader for further processing per the record retention schedule.

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SECTION 6. ACCIDENT WITH OR WITHOUT INJURY

6.1 Upon becoming aware of an accident with injury, location/facility leader will promptly initiate an incident investigation and this should happen within 24 hours of incident by contacting the Safety Team Leader and/or Human Resources.

6.2 The Safety Team Leader may request the location/facility leadership to complete and submit a Supervisor’s Report of Accident.

6.3 As another supplement to reporting, the injured/ill team member will be requested to make a written report of the incident. A Team Member Report of Accident should be used for this reporting.

6.4 Location/facility leadership shall make an initial determination as to the potential cause(s) of the incident and establish a team if and as needed to assist in the investigation to determine root cause(s) and corrective action. Incident investigation teams shall contain at least one person knowledgeable in the process involved in the incident. When an incident involves an outside contractor, a contractor representative(s) shall be included in the incident investigation as appropriate and necessary.

6.5 Location/facility leadership shall implement actions as needed to promptly address and resolve the incident investigation findings and recommendations. The Safety & Health Incident Corrective Action Form should be used to document corrective action in response to an incident.

6.6 Incident investigation findings shall be reviewed with all affected team members whose job tasks are relevant to the incident findings including contractors where applicable. Location/facility leadership shall share incident details with Safety Team Leader.

6.7 Incident investigation reports shall be retained by Human Resources with Safety Team Leader access.

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SECTION 7. INVESTIGATE THE ACCIDENT

For every accident there are usually several contributing factors, most of which can be controlled. Best way to prevent the reoccurrence of an accident is to investigate the facts surrounding the incident. By investigating the root cause(s) of an incident, steps can be taken to eliminate the hazard and improve the work system.

An incident investigation is FACT FINDING, NOT FAULT FINDING. To plan for the prevention of similar accidents, an accident report form should be completed after every accident, preferably as soon after the incident as possible, so that details are not forgotten. Accident investigation requires careful, accurate reporting. Develop good investigative practices.

• Secure the incident scene. Keep it unchanged to accurately collect the facts. Use photographs, videos, drawings or measurements.

• Document everything in writing. Put down just the facts, a detailed description of exactly what happened, not an interpretation of the facts.

• Interviews should be conducted separately and confidentially. Let interviewees know why they’re being interviewed.

• Ask all interviewees the same questions. Ask open-ended questions like: “Describe in your own words...,” or “How was the machine operating?” Ask their understanding of the safety procedures. Conclude by asking if they want to add anything.

• Try to reenact the events leading up to the incident.• Try to determine the causes of the accident to prevent it from happening again.• Communicate recommendations and commit to corrective action.

Sometimes there are multiple causes for an accident involving: equipment (unguarded machinery), environment (poor lighting or noise level), people (procedures not understood or not followed) or management (allowed shortcuts). Don’t rush to judge. Examine the facts and find what’s missing. Look for immediate mechanical failure or it could be an unsafe action by a team member. The underlying cause could be poor machine maintenance, a missing guard, a crowded work area or a lack of training.

All accidents should be reported to the leader so that accident/injury report forms can be completed and provided to Human resources and the Safety Team Leader. Once an investigation is completed, solutions should be sought to prevent the accident from occurring again. Solutions may involve engineering controls, administrative controls, additional training or increased communication between management and team members. Team members should inspect the work area daily for unsafe conditions or unsafe actions and, if found, report them to the supervisor. Hazard awareness is key to preventing accidents before they happen. Take steps to eliminate hazards as soon as they are discovered. Encourage team members to tell the supervisor about every accident, no matter how minor it may seem at the time. You never know when an incident may be repeated and result in an injury or even death.

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SECTION 8. INCIDENT GUIDELINES

These guidelines help organize the investigation of accidents and incidents involving team members, plants, tools, equipment or materials. All accidents and incidents should be investigated no matter how minor. The same conditions that cause a minor incident could lead to a major accident. The unsafe acts of workers and the unsafe conditions that causes accidents can be identified and corrected. It is your responsibility to find them, name them, and correct them.

Unsafe Acts - Personal Factors Unsafe Conditions Fundamental Causes

Making safety devices inoperable Inadequate guards or protection Inadequate hiring standards

Failure to use guards provided Defective tools or equipment Inadequate job placement standards

Using defective equipment Unsafe conditions or machine Lack of proper or unsafe procedures

Servicing equipment in motion Congested work area Inadequate job instructions

Failure to use proper tools or equipment Poor housekeeping Inadequate enforcement or work

standardsOperating machinery or equipment at unsafe speed

Unsafe floors, ramps, stairways, platforms, etc.

Inadequate preventative maintenance program

Failure to use personal protective equipment/clothing Inadequate warning system Inadequate job training methods

including PPE

Operating without authority Improper material storage Inadequate supervision

Lack of skill of knowledge Fire or explosion hazard Improper layout or design

Improper lifting, lowering or carrying

Hazardous atmosphere gases, dust, fumes or vapors

Inadequate maintenance standards

Unsafe loading or placing Hazardous substances Unsafe design or construction

Taking unsafe position Inadequate ventilation Poor work practice

Unnecessary haste Radiation exposures Inadequate environmental control program

Influence of alcohol or drugs Excessive noise Inadequate staff complement

Physical limitation or mental attitude Inadequate illumination Inadequate SOP/Standing Orders

Team Member inattentiveness Lack of assistance

Unaware of hazards Poor work design

Unsafe act of another staff Inadequate security system

Lack of communication between staff Inadequate purchasing standards

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Leader’s Report of Accident

Team Member Name Job Title/Occupation

Date of Accident Time of Accident

Location of Accident Department of IncidentEmployer Site

Yes No

All safety rules being observed? PPE being utilized properly?Yes No Yes No

Description of accident (include tools/equipment used, involved)

What property/equipment damaged

Description of the injury/illness (Include body part injured)

Witness Name: Title: Phone Number:

Witness(s) account of accident:

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Description of work area (Include any unsafe conditions)

Task being performed

Describe all Contributing factors

What were the basic causes of the accident (usually multiple causes)?

Corrective actions taken: (What should be done, what has been done thus far?)

How will this help prevent future accidents?

Investigator’s Name: Date of investigation:

Estimated lost wage and medical expenses:

Estimated damage cost to property and equipment:

Team Member Signature Witness Signature Investigator Signature

OFFICE USE ONLY

* Please submit form to Human Resources *

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Team Member’s Report of Accident

Full Legal Name:

Date of birth:Home Address:

City: State: ZIP Code:

Last First Middle

Home Phone #: Cell Phone #:

Present Classification: Length of Employment:

Location of accident:Address Area (loading dock, bathroom, etc.)

Date of accident: Time of accident:

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CLAIM NUMBER:

Social Security #: E-mail Address:

Marital Status: Single Married Divorced

Number of children under 21: Total number of household dependents:

Are you currently receiving Medicare or Social Security Benefits: Yes No

If Yes to the above question, please describe:

Name of Location Leader:

Do you receive Room, board, or any other allowances? (If yes, please describe:

Your Job Title:

Location Address:

Describe fully how the accident occurred (including events that occurred immediately before the accident:

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Name(s) of witness(es): Phone #:

When did you report the accident to your location leader?Attach witness(es) report(s))

To whom did you report the injury?

Do you require medical attention? Yes No Maybe

Name of treating physician? Phone #:

Team Member Signature Date:

Describe bodily injury sustained (be specific about body part(s) affected:

Date of first medical treatment: Date of last medical treatment:

Are you still under doctors care? Yes No Are you working? Yes No

Hospital name and address (if applicable):

Did you miss any time from work? Yes No Dates of lost time?

Recommendation on how to prevent this accident from recurring:

Any prior work injuries (If yes, please describe injury and date:

This injury is currently resolved and requires no further treatment? Yes No

* Please submit form to Human Resources *

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Viafield Witness Report of Accident

Injured Team Member’s Name:

Phone #:Name of witness:

Job title of witness: How long employed here:

Last First Middle

Home address of witness:

City: State:

Location of accident:Address Area (loading dock, bathroom, etc.)

Date of accident: Time of accident:

Describe fully how the accident occurred (including events that occurred immediately before the accident:

Describe bodily injury sustained (be specific about body part(s) affected:

Recommendation on how to prevent this accident from recurring:

Name of witness’ Leader: Phone #:

Signature of Witness: Date:

Zip Code:

Last First

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* Please submit form to Human Resources *

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Incident Corrective Action Form

Type of incident Accident with property damage Accident with injury Near miss Other

Date of incident:

Location of incident:

Department name:

CORRECTIVE ACTION

Planned

Target date of completion:

Implemented

Actual date of completion:

Describe planned or implemented corrective action. Attach additional sheets as needed:

Prepared by: Date:

Reviewed by: Date:

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* Please submit form to Human Resources *

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Near Miss Incident Form

Date:Reported by:

Location:

Incident type (check all that apply): Damage

Environmental

Safety/Team Member

Date of incident: Time of incident:

Narrative description and analysis: Describe the events which resulted in the near miss. Tell what happened and how it happened. Name any objects or substances involved and tell how they were involved. Give full details on all factors which led or contributed to the incident. Be specific, if team member was using tools or equipment or han-dling materials, name them and tell what the team member was doing with them, name the object or substance directly involved in the incident. Attach additional sheets as needed.

Describe recommended or implemented corrective action if determined.

Prepared by:

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* Please submit form to Human Resources *

Copyright © 2012 Viafield, a cooperative. All rights reserved. Reproduction in whole or in part without the express written permission of Viafield is prohibited

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533 Bradford StreetMarble Rock, IA 50653

Phone: 1-800-992-2516Fax: 1-641-315-2519

www.viafield.com