ACCIDENT REPORTING, INVESTIGATION

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ACCIDENT REPORTING, INVESTIGATION SIIR

• August 2009

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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.

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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
• Dont disturb anything that could
  
  
  help in the investigation

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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 doesnt happen again
• Goal Implement all corrective actions to make
  sure it wont happen again continual
  improvement
• Investigations are not looking to assign blame

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Injury Causes
Unsafe Conditions
10 Unsafe Conditions
Unsafe Acts/Behaviors

• 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

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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
bruised
Associate spills coffee on floor and walks away
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Iceberg Analogy
Fatalities Lost Time Injuries Medical
Treatment First-Aid Cases
Unsafe Acts Unsafe Conditions Near Misses
Remember most incidents are caused by something
someone does or fails to do
Focus below the waterline NON Injury Incidents
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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

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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 dont interrupt
• Dont lead the witness ask open ended questions
• Dont 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

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The Interview

• Dont 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

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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 SOPs, 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

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Contributing Factors
Ask WHY 5 times an easy way to get from
what to why

• Where there
• Insufficient or inappropriate systems or
  procedures
• Lack of training in procedures
• Poor housekeeping
• PPE
• Equipment Tools
• Building structure

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Address the WHY over the WHAT
After fact-finding phase, you should know what
happened now you must find why it happened - to
address the root causes
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.  


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Use of the 5 WHYS
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.
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Find Root Causes

• When you have determined the contributing
  factors, dig deeper!
• If employee error, what caused that behavior?
• If defective machine, why wasnt it fixed?
• If poor lighting, why not corrected?
• If no training, why not?

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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

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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

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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 -
  buchananm_at_usmservices.com
• 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 thorntonb_at_usmservices.com. LTI
  notification to CEO within 1 hour.

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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 doctors 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

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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

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Employee Responsibilities

• Employees must return to work immediately unless
  authorized by a doctors 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.
  
• Doctors 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 doctors 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 doctors note before resuming
  work or returning to full duty.  

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Summary

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

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Accident Investigation - QUIZ
1. If youre not involved in the incident, then
you are not part of the investigation or the
solution.
F
T
2. Most decisions about what will happen in the
future are made before the investigation team
has wrapped up its work.
T
F
3. The most important result of any incident
investigation is to determine whos at fault
T
F
4. If no one was injured, an incident doesnt
need to be investigated.
F
T
5. Most accidents (90) are due to unsafe
acts/behaviors
F
T
6. The primary purpose of the accident
investigation process is to
Learn from incident to prevent recurrence
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COMPLETING SIIR FORM

• August 2009

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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, dont 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

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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 doesnt happen again.

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

• 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

• 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

WHO WHERE WHEN???
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Supervisor Incident Investigation (SIIR) Form
No TMF-8303-SA-0070
X
X

• 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

WHAT HAPPENED???
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.
X
Bruce Thornton
X
No
X
Supervisor Drove to Occupational Clinic
X
Employee has low back strain. No damage to
equipment or piece of concrete identified.
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Supervisor Incident Investigation Root 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.
WHY DID IT HAPPENED?
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
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Supervisor Incident Investigation Identifying
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
X
Ima Sohurt
10/30/2008
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QUESTIONS ??
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