Accident. and Incident Investigations. Investigation Procedures. Self-study Review and Answer Sheet

Transcription

1 Accident and Incident Investigations Investigation Procedures Self-study Review and Answer Sheet Accident On-Line Module (Paper Report for Guidance)

2 Purpose Investigations are important tools for identifying potential safety hazards. The purpose of the investigation is not to find fault or lay blame, but rather to identify all contributing factors and determine the root cause of each accident/incident, so controls can be put in place to prevent future recurrences. Millard Refrigerated Services classifies an accident as an unplanned event that causes injury to an employee. An incident is classified as an unplanned event that causes injury to others while on Millard s property and/or causes property damage. Communication Expectations Associates are required to immediately report all accidents/incidents to his/her supervisor and/or manager. The employee must participate in the investigation when ever possible. Supervisors will notify their manager of all accidents/incidents when it happens. Supervisor must complete section A of the investigation report on-line at Accident module. Managers will notify their General Manager of all accidents/incidents when it happens. Managers must immediately call the General Manager on all serious accidents or major incidents. Managers must ensure that section A of the investigation report is completed by the end of the supervisors shift with the investigation folder provided to the General Manager. General Managers will review section A in the on-line system to ensure it is through and clearly establishes how the accident/incident occurred. The General Manager will notify all members of the Management Team with details about the accident/incident, so the appropriate managers can obtain and bring the required documents to the manager s review meeting. General Manager will verbally notify their RVP, SVP, SVP HR and the Manager of Loss Prevention of all serious injuries and major incident as soon as reasonably possible. Section A should be completed in the On-Line module should be completed within 12 hours of the reported accident. Section B should be completed in the On-Line module should be completed within 24 hours of the accident. Manager Loss Prevention: Will review section A and section B for each accident. 2

3 Management Review Team All investigations must be reviewed by the management team within 24 hours. The review team will consist of the following members, General Manager, Assistant General Manager, Operations Manager/Superintendent, Office Manager, Engineer, reporting Supervisor, where available the Human Resource Manager and the injured person. The Corporate Manager of Loss Prevention will participate in selected Management Team s Review. The Management Review Team: Will review each accident and incident report. Complete section B of the investigation report within 24 hours. Responsible for the development and tracking of Action Steps and Plans of Action until completion. Verifying all information entered in the on-line system is accurate and complete. Training Requirements (see self-study at end of this procedure) All plant managers and supervisors must complete the self-study to ensure a solid understand of the procedural requirements. New managers and supervisors must complete the self-study training as part of their initial orientation. Managers and supervisors need to understand that the primary reason for conducting an investigation is to identify potential safety hazards so corrective actions can be implemented to prevent recurrence of similar accidents. Serious Injury When an injured worker is hospitalization for more then 24 hours, part of the body is lost or permanent disfigurement occurs. Major Incident Large amount of property damage, ammonia release causing evacuation, Non-Millard person seriously injured while on Millard s property, substantial chemical spill, etc. Completing Investigation Report 3

4 Section A Completed by the Supervisor Mark the appropriate box: WORKER INJURY INVESTIGATION OTHER INVESTIGATION General Information: Items 1 through 15 are Self-explanatory. Contributing Factors: Items 16 and 17 mark all applicable boxes under each item that was a contributor to the accident. Item 18 is used if other contributing factors such as inadequate procedures, failure to train, etc. if noted. Worker Statements: must be obtained from the injured worker(s) and witness(es). The Statements must be signed and dated. Each statement must be on a separate worker statement form. If additional statement forms are needed, make copies. Description of Accident/Incident: identify who, what, when and how to answer why the accident or incident occurred. Fully describe what happen. This is where the contributing factors are determined. For property damage list the items damaged and extent damage. For chemical spills record the chemical and amount spilled. Obtain owner information if the damaged property is not owned by Millard. Conclusion: After reviewing all the facts of your investigation, this is the section you would provide your conclusion on how and why the accident/incident occurred. Photographs and Sketches: are useful ways for recording the accident scene. (Never photograph the injured person s body). Photographs and sketches make a permanent record of the location of equipment, tools, stock and other objects in the accident zone. Panoramic and directional photos along with sketch are important ways to record the accident scene. Sketches have the advantage of focusing only on the elements relevant to the accident. They can be helpful when interviewing witnesses. Property damage only investigations, remember to photograph the damaged property. Section B Completed by the Management Team Action Steps: The management team will need to thoroughly examine all supporting documents, each contributing factor and the root cause to determine if there are any procedural weaknesses, training weaknesses or policy violations in connection with the accident. A management person(s) must be assigned the responsibility of completing each action step for obtaining procedural documents, training record, maintenance records, PM files, pre-shift inspection sheets, etc. This information is necessary for determining potential procedural and/or training weaknesses or safety policy violations. 4

5 Root Cause: is the primary cause of the accident. To determine if the root cause has been identified ask the question: If the root cause was removed, would the accident still have occurred? If the answer is no, then you probably have identified the root cause. If the answer is yes, then you probably have only identified a contributing factor (still important), but not the root cause of the accident. The review must continue until the root cause is identified. Plan of Actions: will focus on the implementation of procedural changes and training enhancements as identified by the action steps. The plan of action needs to eliminate each identified contributing factor and root cause from recurring in the future. The management team will develop written procedural changes and training enhancements to strengthen any identified weaknesses. Procedural changes involving safety must be reviewed with the Loss Prevention Department. A person(s) must be assigned to and responsible for the implementation of each segment of the plan of action. Due dates must be established and completion dates recorded. The management team must monitor the implementation and completion of the plan of action. Disciplinary Action: resulting from a policy violation shall be in accordance with company policy. Evaluating Accident Trends The management team will need to track their accidents/incidents to determine if any recognizable trends are emerging. If accident/incident trends/patterns are forming, then additional investigation work must be executed to identify the reason for the emerging trends. Trends are an indication that a potential safety hazard still exists and the management team must determine if any additional strengthening of any procedural or training processes is still required. General Investigation Information Investigation Procedures It is important to look beyond the immediate and superficial explanations to find the true basic cause of the accident. This doesn t mean that temporary action should not be taken to remove the immediate hazard. A systematic approach to the investigation should continue until all contributing factors and the root causes have been identified and corrective actions taken to prevent recurrence of similar accident. 5

6 Secure and Manage the Accident Scene The first priority is to provide medical attention for anyone who was injured in the accident. Management is responsible for ensuring that the accident scene is secured so that there is no risk of further injury. Securing the scene also preserves evidence that may be important in the investigation. The accident scene for all serious accidents must be secured until the accident scene is photographed and accurately diagramed. No person may interfere with, disturb, destroy, alter, or carry away anything at the scene of, or connected with, the occurrence. There are exceptions for the purpose of saving life, relieving suffering, maintaining an essential service or utilities, or preventing unnecessary damage to equipment or property. Investigating the Accident/Incident Survey the accident scene: The first step is to survey the accident scene. The investigator should itemize the things that need to be explained and make a list of people who were present at the site of the accident. This is the time to take photographs and measurements and write down the immediate facts. If the accident resulted in serious injuries the accident scene must be preserved in accordance with the above requirements. Interview Witnesses: All eyewitnesses must be interviewed as soon as possible while details are still fresh in their minds and the eyewitness(es) must provide a written statement on what they witnessed. Everyone working in the general area must be interviewed to determine if they have any relevant information pertaining to the accident. Physical Investigation: Physical evidence includes details of equipment damage, product damage, breaks, rips, burned marks, signs of impact, etc. Photographs and diagrams are important. Details of the work environment, such as visibility, noise level, temperature, floor conditions, work/stock arrangement, etc must be noted. At this stage, documents such as equipment specifications, maintenance records and work procedures may also be taken into account. Organize the Facts: All information must be organized and reviewed for a thorough analysis. Separate fact from opinion where possible. Identify gaps in the information and re-interview witnesses and confirm facts. Ask the questions: Who? What? When? Where? How? To answer Why. Prepare Report: A comprehensive investigation report is required. The report must be clear, to the point and logical. All supporting documents such as pictures, diagrams, inspections, training records, pre-shift inspection, etc must be attached to the investigation report. 6

7 Interviewing Techniques Interviewers should try to put the witness at ease and be courteous. The interviewer should explain that the purpose of the interview is to prevent a recurrence and avoid any suggestion that blame is being assigned. Interviews should be conducted separately and privately, so that people are not influenced or intimidated by the presence of others. The purpose of conducting the interviews is to find out what the person knows about an accident or about possible causes. The interview may also identify additional people to be interviewed. Interview questions should be simple and to the point. Ask the person to explain what happened, or what they know about the possible causes of the accident. Don t ask questions that suggest the answer. Don t tell the person what the answer should be or what may be expected. Don t interrupt. Instead, ask clarifying questions later. Try to avoid questions that invite a yes or a no answer. Make careful notes during the interview and if necessary ask the person to repeat their answer to ensure proper notation. At the end of the interview, review the key points and confirm that they are accurate. At the end of the interview, arrange to stay in contact in case the person remembers additional details later. Thank them for their help, and let them know that they have helped prevent a recurrence. Accident and Incident Investigation On-Line Module Once your investigation is complete, you will log-on to Select the Accident tab and proceed with entering the accident in the on-line module. IF ASSISTANCE IS NEEDED WITH THE ON-LINE MODULE YOU MAY CONTACT CORPORATE. OSHA Notification Requirements The SVP HR or Manager Loss Prevention will notify OSHA if an accident results in a fatality or the hospitalization of 3 or more workers (One person in California). Notification must be completed within 8 hours of the accident. General Managers must supply the SVP HR or Manager Loss Prevention with your local OSHA office phone number, which is located on page # 6 of your Emergency Action/Response Plan (EARP). If the local OSHA office can t be contacted then call National OSHA office at See the OSHA recordkeeping section of your safety manual to determine accident recordability. 7

8 Accident/Incident Investigation Self-Study This self-study is to make it easy for the Supervisor to the General Manager to learn the key concepts of Millard s investigation format. The self-study will help you develop a solid understanding of the Accident and Incident Investigation Reporting requirements. Each member of management must receive a copy of the Accident/Incident Investigation procedures and Investigation Report when complete this self-study. Once the self-study is completed it must provided to your manager for review and kept on file in your facility for future reference. Self-study: Directions for answering each question or statement Read each statement or question carefully. Answer each question by marking the correct response or filling the blank(s). Immediately compare your answer to the answer key. If your answer is wrong, find out why you were wrong, cross out the incorrect response, and write in the correct one. If your answer is correct, proceed to the next question. Work at your own pace. Remember: Because you are provided the answers, this is not a test, but a method of learning. Question # 1: Investigations are important tools for identifying potential safety hazards. The purpose of the investigation is to: Identify all contributing factors of each accident/incident Determine the root cause of each accident/incident Determine the controls to prevent future recurrences All of the above (See answer 9) Question # 2: Associates are required to immediately report all accident/incidents to their supervisor or manager. False (See answer 4) Question # 3: Supervisors will notify their manager of all accidents/incidents when it happens. False (See answer 2) Question # 4: The supervisor must complete section A of the investigation report by the end of their. Upon completion of section A the accident investigation folder must be provided to the. (See answer 21) Question # 5: Managers will notify their General Manager of all accidents/incidents when it happens. False (See answer 7) 8

9 Question # 6: Managers must ensure that of the investigation report is completed by the end of the supervisors shift with the investigation folder provided to the General Manager. (See answer 12) Question # 7: Managers must call the General Manager on all serious accidents and major incidents. (See answer 18) Question # 8: General Managers will review upon receipt, check for and send to Corporate Claims Department within of the accident. (See answer 3) Question # 9: General Manager will verbally notify their RVP, SVP, SVP HR and the Manager of Loss Prevention of all serious injuries and major incident as soon as reasonably possible. False (See answer 1) Question # 10: All investigation folders must be reviewed by the management team within hours. (See answer 5) Question # 11: The Management Review Team will: Review each accident and incident report. Complete section B of the investigation report within 24 hours. Keep a copy of each investigation folder in-house for future reference. the complete investigation report to the Manager Loss Prevention and Claims Department with 24 hours. Development and track the action steps until completion. Development, implementation and track the plan of action to completion Verify all supporting documents are reviewed and accurate. All of the above. (See answer 10) Question # 12: All managers and supervisors must understand the requirements established in the Investigation Procedure? False (See answer 6) Question # 13: New managers and supervisors must be trained on this requirement during their initial orientation. False (See answer 8) Question # 14: The management review team will need to each investigation report to ensure the plan of action is fully implemented. (See answer 14) Question # 15: Supervisors completes of the investigation report and the management team completed of the investigation report. (See answer 19) Question # 16: The management team will need to track their plant s accidents/incidents to determine if any recognizable trends are emerging. 9

10 False (See answer 16) Question # 17: Worker statements must be obtained from the and. The statements must be and. (See answer 17) Question # 18: Each statement must be on a worker statement form. (See answer 26 Question # 19: The description section of the investigation report is where the supervisors fully describe what happen. False (See Answer 15) Question # 20: The supervisor s conclusion of how and why the accident or incident occurred is stated in the description section of the investigation report. False (See answer 11) Question # 21: Photographs and Sketches are useful ways for recording the scene. (See answer 25) Question # 22: For each accident and incident investigation report the management team will need to thoroughly examine all supporting documents, each contributing factor and the root cause to determine if there are any procedural weaknesses, training weaknesses or policy violations in connection with the accident. False (See answer 13) Question # 23: A management person(s) must be assigned the completing each action step. (See answer 22) of Question # 24: Action steps may include obtaining procedural documents, training record, maintenance records, PM files, pre-shift inspection sheets, etc. This information is necessary for determining potential and/or weaknesses or policy violations. (See answer 23) Question # 25: The is the primary cause of the accident. (See answer 20) Question # 26: Preassembled investigation folders will include; Red Folder Investigation flow chart Copy of the investigation report Drug test consent form (See answer 24) 10

11 Signature: Date Completed: Answer Key for the Self-study for the Accident/Incident Investigation Procedures 1. True 2. True 3. section A, completeness, 12 hours 4. True True 7. True 8. True 9. All of the above 10. All of the above 11. True 12. section A 13. True 14. track 15. True 16. True 17. injured worker, witness(es), signed, dated 18. immediately 19. section A, section B 20. Root cause 21. shift, General Manager 22. responsibility 23. procedural, training, safety 24. Red folder, Investigation flow chart, Copy of the investigation report, Drug test consent form 25. accident 26. separate 11