2 TRAINING OBJECTIVETo provide supervisors information and tools to investigate employee accidents thoroughly to prevent them from happening again.
3 TOPICS TO BE COVERED Definition of an Accident Purpose of InvestigationFive Step Investigation ProcessCase Studies
4 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
5 Once An Accident Happens Ensure Safety of OthersPreserve and Secure SceneGet Emergency Services – 911, If NeededAssist Employee with Completion of Incident ReportInvestigate As Soon As Possible
6 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 ).How do we investigate employee accidents?
7 FIVE STEPS TO BASIC ACCIDENT INVESTIGATION GATHER THE FACTSREVIEW THE FACTS TO FIND CAUSESDOCUMENT FINDINGS AND ACTIONSTAKE PREVENTATIVE ACTIONFOLLOW UP
8 FIVE STEPS TO BASIC ACCIDENT INVESTIGATION 1. GATHER THE FACTS Answers what happenedLook at the accident sceneRecord information: who, what, when, and wherePreserve the accident scene and any evidenceInterview witnesses independentlyAsk open ended questions
9 THINGS TO CONSIDER WHEN FACT FINDING Environment/facilityEquipment, clothing, personal protective equipment (PPE)Procedures/practicesTraining - in procedures and safetyEmployee readiness – mental and physical
10 2. REVIEW THE FACTS TO FIND CAUSES FIVE STEPS TO BASIC ACCIDENT INVESTIGATION2. REVIEW THE FACTS TO FIND CAUSESAnswers why it happenedReview all the information you gatheredList all possible causes (direct, indirect, basic)Identify all the contributing factor(s)
11 CAUSESDirect Cause – the actual energy (movement or source) that caused injury to employee. If this energy wasn’t 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.
12 Complete the INCIDENT REPORT FIVE STEPS TO BASIC ACCIDENT INVESTIGATION 3. DOCUMENT FINDINGS AND ACTIONSComplete the INCIDENT REPORTState only the facts in the incident report (no opinions)
13 FIVE STEPS TO BASIC ACCIDENT INVESTIGATION 4 FIVE STEPS TO BASIC ACCIDENT INVESTIGATION 4. TAKE PREVENTATIVE ACTION(S)Corrective actions must address the cause(s) of the accidentLook for both short-term and long-term solutionsInclude dates for completion of the corrective actions and identify those responsibleReport corrective actions to the safety committee
14 DOSH’s SOLUTION TO HAZARDS Eliminate the hazard or use less hazardous processes or materialsUse operational controls - SOPsUse administrative controls (policies, rules, training, signage)Use engineering controls (mechanical means – substitution, ventilation, isolation)Use personal protective equipment and/or safety equipment
15 FIVE STEPS TO BASIC ACCIDENT INVESTIGATION 5. FOLLOW-UP Follow-up to ensure that corrective action has been taken and is effective at reducing accidentsMonitor the progress of both short-term and long-term corrective actions.
16 Accident Description: CASE STUDY - LadderAccident Description:“I was going to clean gutters. 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.”
17 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?
18 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 1:4 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.
19 Accident Causes – Ladder Direct causesRung FailedIndirect causesLadder overloadedImproper storage caused ladder damage (not tied down)Not inspected prior to each useImproper selection of equipmentUsing defective equipmentBasic causesSupervisor not enforcing proceduresInadequate training
20 CAUSATION SUMMARY POSSIBLE CAUSES CORRECTIVE ACTIONS FOLLOW UP Rung failedTake ladder out of service(Destroyed)ImmediatelyK. ColbyLadder overloadedProvide equipment that is suitable for the task5/17/07K. GreggImproper storage caused ladder damage (not tied down)Provide proper means and equipment for storage and provide training on ladder storageT. KinmanNot inspected prior to each useDevelop, carry out and enforce policy for inspection of ladders6/15/07B. DorrisImproper selection of equipmentProvide training on proper ladder selection5/16/07J. CollinsUsing defective equipmentProvide training on ladder inspection5/15/07G. JacobsonSupervisor not enforcing proceduresEnforce safety rules/discipline policyR. NunamakerInadequate trainingProvide training on ladder use, selection, inspection and storageL. Schneider
22 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.
23 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.”
24 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?
25 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.
26 Accident Causes – Meat Slicer Direct causesUnguarded rotating bladeIndirect causesEmployee’s hand slippedEmployee was distractedMeat cutter could be operated without guards in placeCut-resistant gloves were available but not usedBasic causesSupervisor not enforcing procedures for equipmentProcedures not in place for use of gloves (PPE)Employee was not aware that guard use was mandatory
27 CAUSATION SUMMARY CAUSES CORRECTIVE ACTIONS FOLLOW UP Unguarded rotating bladeEnsure guard is in placeImmediately by allEmployee’s hand slipped1/15/07Jo DonahoeEmployee was distractedDevelop, implement and enforce safety proceduresCharlotte HarperMeat cutter could be operated without guards in placeRetrofit guard so it cannot be disabledImmediate -Lance WellsCut-resistance gloves were available but not usedDevelop, implement, and enforce procedure for glove use5/15/07Pam MillesonSupervisor not enforcing procedures for equipmentEnforce safety rules/discipline policyImmediate –Louise MatznerProcedures not in place for use of gloves (PPE)Develop, implement and enforce procedures for glove useShirley SchaefferEmployee was not aware that guard use was mandatoryTrain staff on use of equipment and proceduresAmy Kimberling
28 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.”
29 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? Bywho?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 weregetting down?What type of shoes were you wearing?Have there been similar incidents? Explain.What was the weather?
30 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 areaaround the bus was still wet.Shoes being worn did not have good tread on soles toprevent slipping. ($3 slip-ons)Another driver came up and started talking as driver wasgetting down.
31 Accident Causes – Bus Direct causes Improper body movement Indirect causesFailure to use proper equipment - step ladderWearing inappropriate footwearLack of step ladders available and not close byEmployee was distractedBasic causesInadequate training in pre-trip procedures for all types of busesNo designated bus wash area
32 CAUSATION SUMMARY CAUSES CORRECTIVE ACTIONS FOLLOW UP Improper body movementDevelop procedures and train drivers on procedures12/15/05R NicholsonFailure to use proper equipment – step ladderEnforce safety rules/discipline policyImmediatelyT HeadWearing inappropriate footwearDevelop, implement and enforce safety proceduresP PocinichLack of step ladders available and not close byEnsure adequate number of step ladders and ensure they are readily available11/30/05B PetersenEmployee was distractedSafety awareness trainingImmediate, OngoingT KinmanInadequate training in pre-trip inspections for all types of busesTrain staff on use of all equipment and procedures3/16/07J PetersonNo designated bus wash areaDesignate bus wash area6/30/07J Mills
33 Accident Description: CASE STUDY - StudentAccident Description:“A severely Autistic high school student struck me in the back while I was walking him to the time out room.”
34 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 circumstancesIs 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?
35 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 student’s behavior.Substitute teacher was not informed of how to handle the situation.Teacher was holding student’s hand and leading him to the room, she was in front of him.Teacher put her arm around student.
36 Accident Causes – Student Direct causesStudent hit teacherIndirect causesTeacher 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 studentBasic causesInadequate practices regarding staff selectionInadequate trainingInadequate experience/skills
37 CAUSATION SUMMARY CAUSES CORRECTIVE ACTIONS FOLLOW UP Student hit teacherEvaluate and make necessary changes to remove trigger(s)03/01/07L. WallisTeacher was walking in front of student and touched studentDevelop, implement and enforce safety procedures6/30/07E. RudeenTeacher was not able to de-escalate the studentProvide other personnel trained in de-escalation to assist sub when neededImmediatelyL MuchlinskiInadequate practices regarding staff selectionEvaluate sub selection process06/30/07C. BaileyInadequate trainingEvaluate and modify sub training policiesL. BushInadequate experience/skills
38 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.”
39 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?
40 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.
41 Accident Causes – Chair Direct causesChair brokeIndirect causesImproper use of equipmentFailure to use proper equipmentBasic causesSafety procedures not in placeInadequate training
42 CAUSATION SUMMARY CAUSES CORRECTIVE ACTIONS FOLLOW UP Chair broke Take out of service (tag or destroy)ImmediatelyJ CornaggiaImproper use of equipmentTrain staff on use of equipment4/15/06J KlundtFailure to use proper equipmentEnforce safety rules/discipline policyR JohnsonSafety procedures not in placeDevelop, implement and enforce safety procedures3/17/06D HeiderInadequate trainingTrain staff on use of equipment and proceduresM Mayberry
43 CASE STUDY - Groundsperson “I was unloading 50 pound bags of fertilizer from truck, twisted wrong and hurt my back.”
44 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?
45 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.
46 Accident Causes – Groundsperson Direct causesTwisted back– bodily motionIndirect causesFailure to seek assistanceLifting improperly – swinging, too heavy, no helpLoading, placing supplies improperlyBasic causesInjury repeaterInsufficient supervision/enforcement policiesUnsafe layout for loading/unloading
47 CAUSATION SUMMARY CAUSES CORRECTIVE ACTIONS FOLLOW UP Twisted back – bodily motionEnforce safety rules/discipline policyImmediatelyD GlaserFailure to seek assistanceD SchellLifting improperly - swinging, too heavy, no helpRetrain in proper lifting techniques3/1/07T TriplettLoading/placing supplies improperlyDevelop proper loading/storage procedures, train employees2/29/07R NunamakerInjury repeaterInsufficient supervision/enforcement policiesUnsafe layout for loading/unloadingRelocate storage area6/30/06M Wallace
48 SUMMARY Purpose of Investigation Five Step Investigation Process ● Establish the facts● Ensure similar incidents do not occur● Reduce the number and severity of lossesFive Step Investigation Process● Gather the facts● Review the facts to find causes● Document findings and actions● Take preventative action● Follow up