With Evergreen Safety Council. July

Transcription

1 With Evergreen Safety Council July

2 Objectives Explain the Benefits of a Complete Accident/Near Miss Investigation Prevention of Future Accidents Modification of JSA s Modification of Job Processes Basic Investigation resources July

3 Elements of an Accident/Incident Management/ Supervision People Environment Equipment July

4 Accident/Near Miss Elements People Participants / Victim Witnesses Other employees Trainers / Training Suppliers/Distributors Equipment Vehicles/Equipment Maintenance How was it being used? As designed? Tools screw chisels Environment Surface Conditions Weather Lighting Temp, noise, vibration Management/Supervision Training support Maintenance & Housekeeping Policies/Procedures Lead by Example July

5 Why Investigate Accidents/Near Misses Establish cause(s) and learn from them, to prevent future accidents/near misses and determine preventability Improve/review safety of procedures and processes, for gaps or effectiveness Protect workers and the company by elimination of future accident/near misses July

6 Why Not Rely on the Police to Investigate Work Related Accidents? Law enforcement investigation strictly focused on culpability Your focus is on preventability Minor accidents not investigated by police Even minor accidents are expensive CULPABILITY VS. PREVENTABILITY July

7 What is an Accident/Incident Unplanned, undesired event adversely affecting work or results in injury to anyone, or damage to equipment or property. July

8 WAC Employer Must: Report the death, probable death of any employee, or the in patient hospitalization of any employee within 8 hours Insure any equipment involved is not moved Assign people to assist the department of Labor & Industries Conduct a preliminary investigation for all serious injuries Document the preliminary investigation findings. July

9 Who should serve on the Accident Investigation Team? Employer representative Immediate supervisor of employees involved Internal & External Experts Employee representative Required to investigate Good idea or not? Authoritative expertise on procedures; can provide unbiased evaluation May be required in a bargained for environment July

10 What is the task of the Accident Investigation Team? Collect data to document an accurate, unbiased narrative of the event Segregation of duties? Should the same team that collected the data analyze the data to determine preventability and potential disciplinary action? July

11 Steps of Accident Investigation Immediate action Determine facts Establish causes Recommend corrective actions July

12 1. Immediate Actions Immediate Actions depend on location, scale and nature of the event July

13 Contact 911 and Supervisor Immediate Actions In house phone system extra digit needed for an outside line? Get to the scene ASAP! Calling tree Public Information Officer (PIO), who else? Scene Safety Is the situation deteriorating? Can the problem spread? Secure the area Don t move anything except for rescue July

14 Immediate Actions Collect perishable evidence May only have one chance to capture that piece of the puzzle. Determine damage May have to enlist the help of a specialist. (IE: Structural Engineer) Witnesses Get witnesses to start writing what they saw, heard & did, in separate area ASAP. July

15 2. Determine Facts July

16 4 Major Types of Evidence 1. Paper Scene Notes, and other documents 2. Physical Samples 3. Photograph/Video 4. People Witnesses July

17 Scene Notes Sketch, include dimensions, labeled Not to Scale. Facts not Faults Made by YOU Made on scene while looking at the object Label: Date Time Place Name Recorder: phone with video/voice CAUTION Keep originals Rewrite in report form July

18 Data to Gather at Scene Your operator & equipment information List of others at the scene Other departments Contractors Visitors Witnesses Name and contact information brief statement initially Get contact information for everyone at scene, if possible, even if they say they didn t see anything July

19 Samples BAC /UA part of employment agreement? Protocol to preserve integrity of test Fluids Lube oils, coolant, hydraulic oil Caution on method of collection and preserving purity Debris Filings or foreign debris Chemicals Air Sample July

20 Photography Immediate scene picture, if possible, before things change Helps others see, & reminds you, of what you saw Log of photos don t trust your memory Overall and close ups (more is better) Size relationship use a common object to establish size Color understand that the color rendition may vary due to lighting Camera Phones for immediate pics but may not enlarge for good detail. July

21 Collecting Evidence Other Sources & After the Fact Gather & Examine Documents Maintenance records Training records Work schedule / time sheet Witness statements Accident reports Internal Police report L & I July

22 Investigation Kit Carrying case grab and go Notebook, pens, pencils, protractor, etc Camera with spare batteries (A disposable camera stored in various locations) A tool to measure grade slope Check Kit on a Tape measure (100 foot steel is recommended) Regular Basis: Flashlight, small magnifying glass Compass measures tend to Barrier tape rubber neckers not needed. things like flashlights and tape get borrowed and not returned. July

23 Investigation Kit PPE: Safety glasses, earplugs, hardhat, leather gloves, Hi Visibility vest, other PPE as circumstances of event or location dictate Rubber (latex or vinyl) gloves Sample containers (ie, cans, bags, small containers) If chemical incident is potential, monitoring/sampling equipment Accident report forms Accident team member list Necessary phone numbers calling tree July

24 Tools of the Trade PPE to protect the investigator! Hi visibility vest, retro reflective for night Hard hat, may not always be needed but adds to visibility Gloves Leather if handling debris Latex / vinyl / nitrile if spilled fluids of all kinds Footwear Walking on debris, broken glass If HAZMAT incident other PPE may be needed goggles, emergency respirator/mask Evergreen Safety Council July

25 Documentation Policy Company specific forms may be needed in addition to State required (if applicable) Policy should state deadline for when accident/incident report submitted: By end of shift Within X hours of event Have individual involved complete forms without coaching don t put words in their mouth July

26 3. Establish Causes July

27 Establish Causes Rarely single cause Be objective Fact Finding Not Fault Finding Sort Causal or Contributing Factors Equipment Environment People Employee, Management/Supervision July

28 Equipment Causal Factors Was equipment defective? Was equipment modified? Inspection procedure Competent person Did inspection detect hazard? Documented Was hazardous condition recognized / reported? July

29 Equipment Causal Factors Was correct equipment/tool/material available? Was substitute tool/equipment used in place of correct equipment? Did design create operator stress or error? Did design or quality add to hazard? July

30 People Causal Factors Was job procedure a contributing factor? Were written procedures available? Was employee trained on the correct procedure? Did the employee follow the procedure? Was employee mentally or physically capable, or any task too difficult? Need more people, tools, different size tool? Ergonomics issues; position, posture? Rest, Time on Shift/Duty, Continuous Shifts July

31 People Causal Factors Is job structured to encourage deviation? Is the safe procedure perceived as too much trouble? Was a substitute tool used: Crescent hammer How to obtain equipment or tools? Do employees know procurement steps? Tool room? Authorized to purchase or rent? Employee supposed to be where they were? Was employee in operator s intended location on equipment? Were other employees aware of location? July

32 People Causal Factors Personal Protective Equipment Was proper PPE specified and available for the job? Was proper PPE used when injury occurred? Was the PPE adequate, appropriate for conditions at the moment? July

33 Management/Supervision Causal Factors Failure by supervision? To detect, anticipate, report & correct hazards, or deviations from accepted/approved procedure Review of hazards conducted? Has management insured employees have been made aware of existing hazards and means to work safely? Supervisor s responsibility & accountability defined, understood & proper training? Has the supervisor been trained to recognize hazards and company safety policies and procedures? July

34 4. Recommend Corrective Actions July

35 Recommend Corrective Actions Consider the following when choosing Specific actions to minimize or eliminate the identified causal factors Effectiveness Time req. to implement Cost Extent of supervisory participation needed Feasibility Acceptance by employee Effect on productivity Acceptance by mgmt. July

36 Aftermath Actions to consider If this was a fatality... Positive Identification of the employee? Who is responsible to notify OSHA / State within the required 8 hour time frame? Where was the deceased taken? July

37 Aftermath Actions to consider If this was a fatality... Who notifies the family? Done in person Other notification at request of family Corporate Attorney notified How do you inform other employees to minimize the rumor-mill July

38 Aftermath Actions to consider If this was an injury requiring hospitalization... Who notifies the family? Done in person If possible have as much early medical info available for family Offer transportation to hospital July

39 Other employees Aftermath Actions to consider Will be concerned for their co-worker Need to insure accuracy of information May want to assist in some way Offer paid vacation days transferred to injured employee to help cover household expenses while recuperating. July

40 Other employees Aftermath Actions to consider Counseling available? Grief counseling and education for supervisors PTSD / CISD awareness and intervention July

41 Summary Investigation of accidents/incidents or near misses benefits the employer by preventing future accidents, saving the company time and money. Several tools can be used for an investigation such as a Job Safety Analysis. July