EMPLOYEE ACCIDENT INVESTIGATION FOR SUPERVISORS

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EMPLOYEE ACCIDENT INVESTIGATIONFOR SUPERVISORS
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TRAINING OBJECTIVE

• To provide supervisors information and tools to
  investigate employee accidents thoroughly to
  prevent them from happening again.
  

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TOPICS TO BE COVERED

• Definition of an Accident
• Purpose of Investigation
• Five Step Investigation Process
• Case Studies

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WHAT IS AN ACCIDENT?

• An unplanned, unwanted, but controllable event
  which disrupts the work process and causes injury
  to people.
  
• Source Labor and Industries Accident
  Investigation Basics PPT 2006

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Once An Accident Happens
Ensure Safety of Others Preserve and Secure Scene
Get Emergency Services 911, If Needed
Assist Employee with Completion of Incident Report
Investigate As Soon As Possible
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PURPOSE OF INVESTIGATING

• Why do we investigate employee accidents?
• To establish the facts of the incident
  (exactly what happened).
  
• To help ensure that a similar type of accident
  doesn't happen again - people don't get hurt and
  property doesn't get damaged.
  
• It is a DOSH requirement for all serious
  injuries (WAC 296-800-320).
  
• How do we investigate employee accidents?

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FIVE STEPS TO BASIC ACCIDENT INVESTIGATION

• GATHER THE FACTS
• REVIEW THE FACTS TO FIND CAUSES
• DOCUMENT FINDINGS AND ACTIONS
• TAKE PREVENTATIVE ACTION
• FOLLOW UP

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FIVE STEPS TO BASIC ACCIDENT INVESTIGATION1.
GATHER THE FACTS

• Answers what happened
• Look at the accident scene
• Record information who, what, when, and
  where
  
• Preserve the accident scene and any evidence
• Interview witnesses independently
• Ask open ended questions

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THINGS TO CONSIDER WHEN FACT FINDING

• Environment/facility
• Equipment, clothing, personal protective
  equipment (PPE)
  
• Procedures/practices
• Training - in procedures and safety
• Employee readiness mental and physical

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FIVE STEPS TO BASIC ACCIDENT INVESTIGATION
2. REVIEW THE FACTS TO FIND CAUSES

• Answers why it happened
• Review all the information you gathered
• List all possible causes (direct, indirect,
  basic)
  
• Identify all the contributing factor(s)

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CAUSES

• Direct Cause the actual energy (movement or
  source) that caused injury to employee. If this
  energy wasnt present, the injury would not have
  occurred.
• Indirect Causes any unsafe acts or conditions
  that contribute to the injury occurring.
  
• Basic Causes policies, procedures, environment
  or personal factors that contribute to the injury
  occurring.

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FIVE STEPS TO BASIC ACCIDENT INVESTIGATION3.
DOCUMENT FINDINGS AND ACTIONS

• Complete the INCIDENT REPORT
• State only the facts in the incident
  report (no opinions)
  

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FIVE STEPS TO BASIC ACCIDENT INVESTIGATION4.
TAKE PREVENTATIVE ACTION(S)

• Corrective actions must address the cause(s) of
  the accident
  
• Look for both short-term and long-term solutions
• Include dates for completion of the corrective
  actions and identify those responsible
  
• Report corrective actions to the safety committee

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DOSHs SOLUTION TO HAZARDS

• Eliminate the hazard or use less hazardous
  processes or materials
  
• Use operational controls - SOPs
• Use administrative controls (policies, rules,
  training, signage)
  
• Use engineering controls (mechanical means
  substitution, ventilation, isolation)
  
• Use personal protective equipment and/or
  safety equipment

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FIVE STEPS TO BASIC ACCIDENT INVESTIGATION 5.
FOLLOW-UP

• Follow-up to ensure that corrective action has
  been taken and is effective at reducing
  accidents
  
• Monitor the progress of both short-term and
  long-term corrective actions.

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CASE STUDY - Ladder
Accident Description I was going to clean gutte
rs. I set up the ladder and when I stepped on
the fourth rung up, it broke. I fell to the
ground and felt extreme pain in my leg.
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QUESTIONS TO UNCOVER CAUSES

• What kind of ladder was used? Load rating?
• What was the condition of the ladder?
• Where did the ladder break?
• Was the ladder inspected for damage prior to
  use?
  
• What kind of training has the employee had to use
  and inspect ladders prior to use?
  
• What was the employee carrying? How much did it
  weigh?
  
• Did the load on the ladder exceed the load
  rating?
  
• How was the ladder stored? Where?
• Has the ladder ever been dropped or damaged? If
  so, how?
  
• How did the ladder rung break?
• What is the procedure for cleaning gutters?
• Is there a fall protection plan in place?
• What was the weather?
• What was going on around the work location at the
  time?

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Investigation Findings - Ladder

• Ladder is a Type II, metal, load capacity of 225
  pounds.
  
• The ladder is kept on a rack on the truck and the
  truck is parked outside.
  
• The ladder was placed up against a wall at a 14
  ratio.
  
• Employee was wearing tool belt which weighed
  approximately 30 pounds. The total load was above
  maximum load capacity.
  
• Three days ago the ladder fell off the truck
  while transporting because it was not secured
  properly.
  
• The employee says he inspected the ladder after
  and did not note any deficiencies. It had not
  been inspected since.
  
• Employee received training on ladder safety when
  first employed seven years ago.
  
• Procedures are in place for ladder inspections
  but not followed or enforced.
  
• No procedures in place for cleaning gutters.

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Accident Causes Ladder

• Direct causes
• Rung Failed
• Indirect causes
• Ladder overloaded
• Improper storage caused ladder damage (not tied
  down)
  
• Not inspected prior to each use
• Improper selection of equipment
• Using defective equipment
• Basic causes
• Supervisor not enforcing procedures
• Inadequate training

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CAUSATION SUMMARY
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GROUP WORK
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DIRECTIONS

• Divide into small work groups (not more than 6).
• Each group will be given a case study to work
  on.
  
• From the accident description, come up with
  questions to ask to uncover the causes.
  
• Once questions are complete we will give each
  group the findings of the case study they are
  working on.
  
• From the findings determine all causes (direct,
  indirect and basic) and corrective actions to be
  taken for each cause.
  
• List causes and corrective actions on causation
  summary sheet.
  

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CASE STUDY- Meat Slicer

• Accident Description
• I was slicing roast beef with a meat slicer. My
  hand slipped into the rotating blade cutting my
  thumb and forefinger.

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QUESTIONS TO UNCOVER CAUSES

• How was the employee cutting the meat?
• What was she doing before she cut meat?
• How long had she been using the meat cutter?
• Who taught her how to use it?
• Are there procedures for using it correctly?
• Does the blade have a protective guard? Was it
  functional?
  
• Have there been other injuries on this cutter?
• Is there any protective equipment available?
• Who was around before, after?

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Investigation Findings Meat Slicer

• Meat being sliced is slippery.
• There is a guard on the meat cutter. The
  configuration of the meat cutter would have
  prevented a cut if the guard were used.
  Procedures required the use of the guard.
• The employee was not trained in the safe use of
  the meat cutter, although she was an experienced
  kitchen worker.
  
• The employee says guard was used, but the person
  who cleaned the cutter after the accident said
  the guard was NOT engaged.
  
• There have been no other accidents on this
  equipment. However, there have been several
  employee injuries in this kitchen.
  
• Employee was talking to another employee and
  looked away just before the accident.
  
• There were cut-resistant gloves available but not
  used. No procedures mandated their use.
  

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Accident Causes Meat Slicer

• Direct causes
• Unguarded rotating blade
• Indirect causes
• Employees hand slipped
• Employee was distracted
• Meat cutter could be operated without guards in
  place
  
• Cut-resistant gloves were available but not used
• Basic causes
• Supervisor not enforcing procedures for
  equipment
  
• Procedures not in place for use of gloves (PPE)
• Employee was not aware that guard use was
  mandatory

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CAUSATION SUMMARY
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CASE STUDY - Bus

• Accident Description
• I was checking the steering fluid in bus engine.
  I had to climb up on the front tire and when I
  was getting down, I felt my left knee pop.

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QUESTIONS TO UNCOVER CAUSES

• Why did employee have to stand on the tire?
• Are there other ways of checking fluids?
• What is the process for getting down?
• What type of training did you receive for
  checking fluids? By
  
• who?
• What is the distance between tire and first step
  to get down?
  
• Each additional step?
• Tell me what you did from the time you arrived
  at work?
  
• What was going on/happening around you at the
  time you were
  
• getting down?
• What type of shoes were you wearing?
• Have there been similar incidents? Explain.
• What was the weather?

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Investigation Findings Bus

• Driver was not trained how to check fluids on
  this type of bus.
  
• There are two step ladders available, but none
  close by.
  
• No process or procedures in place for checking
  fluids.
  
• Ladder use is covered in Accident Prevention
  Program but there was no training specific to
  ladder use provided to drivers.
  
• Distance from tire to the peg step is 34 inches,
  step to ground is 20 inches.
  
• Driver had washed bus prior to checking fluids
  and area
  
• around the bus was still wet.
• Shoes being worn did not have good tread on
  soles to
  
• prevent slipping. (3 slip-ons)
• Another driver came up and started talking as
  driver was
  
• getting down.

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Accident Causes Bus

• Direct causes
• Improper body movement
• Indirect causes
• Failure to use proper equipment - step ladder
• Wearing inappropriate footwear
• Lack of step ladders available and not close by
• Employee was distracted
• Basic causes
• Inadequate training in pre-trip procedures for
  all types of buses
  
• No designated bus wash area

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CAUSATION SUMMARY
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CASE STUDY - Student

• Accident Description
• A severely Autistic high school student struck
  me in the back while I was walking him to the
  time out room.

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QUESTIONS TO UNCOVER CAUSES

• What training has employee had in dealing with
  autistic students? And this student?
  
• Has the child ever acted out in this way before?
  When and under what circumstances
  
• Is there a behavior plan in place for this
  student? Was employee following it?
  
• How did employee take student to time out room?
• What was going on prior to the misbehavior?
• Is there any personal protective equipment?

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Investigation Findings Student

• Teacher was a substitute. Has a Special Ed
  endorsement but has only taught in a Special Ed
  classroom twice before.
  
• Student is not familiar with substitute teacher.
• Substitute teacher was informed of the students
  behavior.
  
• Substitute teacher was not informed of how to
  handle the situation.
  
• Teacher was holding students hand and leading
  him to the room, she was in front of him.
  
• Teacher put her arm around student.

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Accident Causes Student

• Direct causes
• Student hit teacher
• Indirect causes
• Teacher was walking in front of student (unsafe
  act) and touched student (behavioral plan
  identifies the child is uncomfortable with being
  touched)
• Teacher was not able to de-escalate the student
• Basic causes
• Inadequate practices regarding staff selection
• Inadequate training
• Inadequate experience/skills

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CAUSATION SUMMARY
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CASE STUDY - Chair

• Accident Description
• I was standing on student desk to hang art work
  from the ceiling. When I stepped back on to the
  chair to get down, it collapsed.

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QUESTIONS TO UNCOVER CAUSE

• Why was employee standing on desk?
• Is there a step ladder available? Where are they
  located?
  
• What is the age, style and condition of desk
  chair?
  
• What type of shoes were they wearing?
• Have there been similar incidents?
• What was employee doing prior to getting on the
  desk?
  
• What was going on at the time employee got off
  the desk?
  
• What other ways do employees have for hanging
  items?
  
• What training have employees received for
  hanging items?
  
• What are the procedures for hanging items from
  the ceiling?
  

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Investigation Findings Chair

• Desks are for kindergarten students.
• Desks and chairs are new this year.
• Current practice is to use desks for hanging
  items.
  
• Teacher changes items hanging from ceiling once a
  month.
  
• Stepladders are available in every wing.
• There are no procedures in place for using
  stepladders. Ladder use is covered in Accident
  Prevention Program.
  
• There has been no training on stepladder use.

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Accident Causes Chair

• Direct causes
• Chair broke
• Indirect causes
• Improper use of equipment
• Failure to use proper equipment
• Basic causes
• Safety procedures not in place
• Inadequate training

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CAUSATION SUMMARY
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CASE STUDY - Groundsperson
I was unloading 50 pound bags of fertilizer from
truck, twisted wrong and hurt my back.
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QUESTIONS TO UNCOVER CAUSE

• What are the procedures for unloading fertilizer
  from a truck?
  
• What type of truck were the bags on?
• Where were the bags on the truck?
• How were the bags stacked?
• Where was the employee unloading bags from?
• Where was the employee moving the bags to?
• Where were you located?
• How often do you perform this type of lifting?
• What were you doing before the incident?
• Have you been trained in lifting?
• Did you have help? Did you ask for help?
• What were the conditions at the time?
• How was the employee dressed?

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Investigation Findings - Groundsperson

• Employee had been trained in lifting properly.
• This unloading requires two people in its current
  configuration.
  
• Employee did not seek a lifting partner.
• The bags were being removed from inside the bed
  of the truck and swung to landing them on the
  ground beside him.
  
• Employee was performing an unsafe act by twisting
  his body while lifting.
  
• This employee has had previous on the job
  injuries due to lifting.
  
• Location for unloading puts employees in awkward
  positions for lifting.
  

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Accident Causes Groundsperson

• Direct causes
• Twisted back bodily motion
• Indirect causes
• Failure to seek assistance
• Lifting improperly swinging, too heavy, no
  help
  
• Loading, placing supplies improperly
• Basic causes
• Injury repeater
• Insufficient supervision/enforcement policies
• Unsafe layout for loading/unloading

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CAUSATION SUMMARY
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SUMMARY

• Purpose of Investigation
• ? Establish the facts
• ? Ensure similar incidents do not occur
• ? Reduce the number and severity of losses
• Five Step Investigation Process
• ? Gather the facts
• ? Review the facts to find causes
• ? Document findings and actions
• ? Take preventative action
• ? Follow up

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Questions?

• Contact Info
• Suzanne Reister
• Program Manager
• Workers Compensation/Unemployment Cooperative
• North Central ESD
• 509-667-7100
• suzanner_at_ncesd.org
• Paula Vanderpool
• Program Assistant
• Workers Compensation/Unemployment Cooperative
• North Central ESD
• 509-667-7110
• paulav_at_ncesd.org