Transcript Employee Accident Investigation for Supervisors

EMPLOYEE ACCIDENT
INVESTIGATION
FOR
SUPERVISORS
TRAINING OBJECTIVE
To provide supervisors
information and tools to
investigate employee
accidents thoroughly to
prevent them from
happening again.
TOPICS TO BE COVERED




Definition of an Accident
Purpose of Investigation
Five Step Investigation Process
Case Studies
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
Once An Accident Happens
Ensure Safety of
Others
Preserve and Secure
Scene
Investigate As Soon
As Possible
Get Emergency
Services – 911, If
Needed
Assist Employee
with Completion of
Incident Report
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?
FIVE STEPS TO BASIC ACCIDENT
INVESTIGATION





GATHER THE FACTS
REVIEW THE FACTS TO FIND CAUSES
DOCUMENT FINDINGS AND ACTIONS
TAKE PREVENTATIVE ACTION
FOLLOW UP
FIVE STEPS TO BASIC ACCIDENT INVESTIGATION
1. 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
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
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)
CAUSES
 Direct 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.
FIVE STEPS TO BASIC ACCIDENT INVESTIGATION
3. DOCUMENT FINDINGS AND ACTIONS
 Complete the INCIDENT REPORT
 State only the facts in the incident
report (no opinions)
FIVE STEPS TO BASIC ACCIDENT INVESTIGATION
4. 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
DOSH’s
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
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 shortterm and long-term corrective
actions.
CASE STUDY - Ladder
Accident 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.”
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?
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.
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
CAUSATION SUMMARY
POSSIBLE CAUSES
CORRECTIVE ACTIONS
Rung failed
Take ladder out of service
(Destroyed)
Ladder overloaded
FOLLOW UP
Immediately
K. Colby
Provide equipment that is suitable for 5/17/07
the task
K. Gregg
Improper storage caused ladder
damage (not tied down)
Provide proper means and equipment
for storage and provide training on
ladder storage
5/17/07
T. Kinman
Not inspected prior to each use
Develop, carry out and enforce policy 6/15/07
for inspection of ladders
B. Dorris
Improper selection of
equipment
Provide training on proper ladder
selection
5/16/07
J. Collins
Using defective equipment
Provide training on ladder inspection
5/15/07
G. Jacobson
Supervisor not enforcing
procedures
Enforce safety rules/discipline policy
Immediately
R. Nunamaker
Inadequate training
Provide training on ladder use,
selection, inspection and storage
5/17/07
L. Schneider
GROUP WORK
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.
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.”
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?






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.
Accident Causes – Meat Slicer
Direct causes
 Unguarded rotating blade
Indirect causes
 Employee’s 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
CAUSATION SUMMARY
CAUSES
CORRECTIVE ACTIONS
FOLLOW UP
Unguarded rotating blade
Ensure guard is in place
Immediately by all
Employee’s hand slipped
Ensure guard is in place
1/15/07
Jo Donahoe
Employee was distracted
Develop, implement and enforce
safety procedures
Meat cutter could be operated
without guards in place
Retrofit guard so it cannot be
disabled
Immediate Lance Wells
Cut-resistance gloves were
available but not used
Develop, implement, and enforce
procedure for glove use
5/15/07
Pam Milleson
Supervisor not enforcing
procedures for equipment
Enforce safety rules/discipline
policy
Procedures not in place for use
of gloves (PPE)
Develop, implement and enforce
procedures for glove use
Employee was not aware that
guard use was mandatory
Train staff on use of equipment
and procedures
1/15/07
Charlotte Harper
Immediate –
Louise Matzner
5/15/07
Shirley Schaeffer
Immediate Amy Kimberling
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.”
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?
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.
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
CAUSATION SUMMARY
CAUSES
CORRECTIVE ACTIONS
FOLLOW UP
Improper body movement
Develop procedures and train
drivers on procedures
12/15/05
R Nicholson
Failure to use proper
equipment – step ladder
Enforce safety rules/discipline
policy
Immediately
T Head
Wearing inappropriate
footwear
Develop, implement and
enforce safety procedures
12/15/05
P Pocinich
Lack of step ladders
available and not close by
Ensure adequate number of
step ladders and ensure they
are readily available
11/30/05
B Petersen
Employee was distracted
Safety awareness training
Immediate,
Ongoing
T Kinman
Inadequate training in pretrip inspections for all types
of buses
Train staff on use of all
equipment and procedures
3/16/07
J Peterson
No designated bus wash
area
Designate bus wash area
6/30/07
J Mills
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.”
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?
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.
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
CAUSATION SUMMARY
CAUSES
CORRECTIVE ACTIONS
FOLLOW UP
Student hit teacher
Evaluate and make necessary
changes to remove trigger(s)
03/01/07
L. Wallis
Teacher was walking in
front of student and
touched student
Develop, implement and enforce
safety procedures
6/30/07
E. Rudeen
Teacher was not able to
de-escalate the student
Provide other personnel trained in
de-escalation to assist sub when
needed
Inadequate practices
regarding staff selection
Evaluate sub selection process
06/30/07
C. Bailey
Inadequate training
Evaluate and modify sub training
policies
06/30/07
L. Bush
Inadequate
experience/skills
Evaluate sub selection process
06/30/07
C. Bailey
Immediately
L Muchlinski
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.”
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?
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.




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
CAUSATION SUMMARY
CAUSES
Chair broke
CORRECTIVE ACTIONS
FOLLOW UP
Take out of service (tag or destroy) Immediately
J Cornaggia
Improper use of
equipment
Train staff on use of equipment
4/15/06
J Klundt
Failure to use proper
equipment
Enforce safety rules/discipline
policy
Immediately
R Johnson
Safety procedures not in
place
Develop, implement and enforce
safety procedures
Inadequate training
Train staff on use of equipment
and procedures
3/17/06
D Heider
4/15/06
M Mayberry
CASE STUDY - Groundsperson
“I was unloading 50
pound bags of
fertilizer from
truck, twisted
wrong and hurt my
back.”
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?
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.
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
CAUSATION SUMMARY
CAUSES
CORRECTIVE ACTIONS
FOLLOW UP
Twisted back – bodily motion
Enforce safety rules/discipline
policy
Immediately
D Glaser
Failure to seek assistance
Enforce safety rules/discipline
policy
Immediately
D Schell
Lifting improperly swinging, too heavy, no help
Retrain in proper lifting
techniques
Loading/placing supplies
improperly
Develop proper loading/storage
procedures, train employees
2/29/07
R Nunamaker
Injury repeater
Enforce safety rules/discipline
policy
Immediately
D Schell
Insufficient
supervision/enforcement
policies
Enforce safety rules/discipline
policy
Immediately
D Schell
Unsafe layout for
loading/unloading
Relocate storage area
3/1/07
T Triplett
6/30/06
M Wallace
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
Questions?
Contact Info:
Suzanne Reister
Program Manager
Workers’ Compensation/Unemployment Cooperative
North Central ESD
509-667-7100
[email protected]
Paula Vanderpool
Program Assistant
Workers’ Compensation/Unemployment Cooperative
North Central ESD
509-667-7110
[email protected]