Transcript Accident Investigation for Workers’ Compensation Claims

Accident Investigation
Todd McCarley
Loss Control Representative
AMIC / MWCF
What is an “Incident”?
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Any unplanned event that
results in personal injury or
in property damage.
Not intended
Not reasonably anticipated
Why Should the Agency
Investigate?
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Assist workers’ comp claims process
To be the “eyes and ears” in the field
To gather facts on-site
To preserve evidence that may be lost
over time
To determine cause of the accident
To identify ways to prevent accidents from
recurring
Employee Must Provide
“Notice”
Why?
To notify the employer
that the employee had
an injury at work so
that the incident can
be investigated.
Who should do incident investigation ?
Below is a possible list of people.
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First –line supervisor
Employees
Safety team
Safety coordinator
Fire Chief / investigator
Police Chief / investigator
Importance of Incident
Investigation
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There are many reasons why it is important to
conduct incident investigations at your
municipality. Lets examine the most important.
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Insurance (workers’ compensation) requirements.
Consequences of not investigating incidents.
Understanding of how incident investigation leads to
improved prevention and safety systems.
Cost of incidents
Moral
Benefits of Having an Incident Investigation
Program
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Incident prevention
Identification of training needs
Identification of what’s right
Improved operations
Increase in employee morale
Increase in employee involvement
Systematic Approach to Incident
Investigation
Every time you-or someone in your
organization-conducts an incident
investigation, it is important for you to follow
a systematic approach. The following is a
six-step process for conducting incident
investigations. By following this process, you
ensure that your investigations are planned,
thorough, and get to the root cause of an
incident.
Systematic Approach to Incident
Investigation
1.
2.
3.
4.
5.
6.
Respond immediately to the incident.
Investigate the incident
Analyze the data and determine root cause.
Recommend corrective action.
Implement recommendations.
Follow up.
Incident/Accident Reports should not
be done on incidents involving
repetitive motion or illness claims
without prior consultation with Risk
Management.
Systematic approach to incident
investigation
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Lets look at the first two steps in the incident
investigation process.
1.
Respond immediately to the incident.
Before you can actually investigate an incident,
you must first take care of the emergency at
hand. The following is a summary of the first
things investigators should do when they are
notified of an incident.
Respond immediately
Step 1:
1.
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3.
Provide emergency
response.
Secure the area
Use an incident
investigation kit
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Call 911
Follow your Emergency
Response guide
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Secure, barricade, or
isolate scene
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Protect other workers and
disturb as little as poss.
Should be assembled
before hand, kept in easy
to carry container.
Investigate the incident
Step 2:
When you investigate an incident, you will need to
address the five W’s.
Where?
Where did the incident take place?
Where was the victim?
Where were the witnesses?
Where were the other items that were
involved in the incident (vehicles,
equipment, falling objects, etc.) ?
Investigate the incident
When?
When did the incident take place (date, shift,
time)?
Is this the first an incident like this has taken
place ? If not, when did the other incident(s)
take place.
Investigate the incident
Who ?
Who was involved in the incident?
Who was injured?
Who was at the scene prior to the incident?
Who were the eyewitnesses?
Who heard the incident?
Who came upon the scene after the incident?
Who might have useful information about the
incident?
Investigate the incident
What?
What happened?
What are the circumstances surrounding the
incident?
What events led up to the incident?
What factors appear to have caused this
incident?
What are the facts relating to this incident?
What are the characteristics of the injury?
Investigate the incident
Why?
Why did this incident happen?
Why has this incident happened more
than once?
Why did the equipment, environment,
management, or employees fail in this
incident?
Investigation Sources
When you investigate, you will have three primary
sources.
Inspect the incident scene first hand…..
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Look at the overall scene. Does anything seem odd or
out of place?
Collect transient or perishable evidence immediately.
Get samples of all possible material at the site.
Find all equipment pieces.
Get photos from all sights and angles.
Document the extent of damage to equipment,
material, or building facilities.
Investigation Sources
Interviewing witnesses
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Conduct the interview in a quiet and private place.
Put the person at ease by explaining that you are
looking for facts-not for someone to blame.
Give the witness an overview of what you want to
achieve in the interview.
Use open-ended questions.
Avoid blame.
Ask for suggestions on possible causes.
Thank witness for their help.
Investigation Sources
Reviewing paperwork….
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First aide reports.
Incident investigation report.
Supervisor’s report.
Injury and illness record of employee.
Training reports
Maintenance reports
Previous investigations
Data elements for investigation
There are a variety of data elements you should
look for during the investigation.
Employee characteristics
Time in current occupation
Frequency of activity
Training
Department
Age
Sex
Data Elements Continued
Narrative description
What the person was doing
Objects/Substances involved
Environmental conditions
Acts of others
Equipment
Type, brand, condition
specific part, improper use
History of the equipments
performance
Data Elements Continued
Task
Specific / General
With others / Alone
History of incidents in performing task
Time factors
Time on job
Day of week
Shift
Phase of workday
Data Elements Continued
Preventive measures
PPE
Machine safeguards
Use of SOPs
Labels and signs
Characteristics of injury
Body part
Severity
It was a normal day in Sharon Springs, Kansas when a Union
Pacific crew boarded a loaded coal train for the long trek back to
Salina.
Just a few kilometres into the trip, a wheel bearing became
overheated and melted off letting the truck support drop down and
grind on top of the rail creating white hot molten metal droppings
that spewed down onto the rails.
The GOOD NEWS to this is that a very alert crew noticed a small
amount of smoke halfway back in the train and immediately
stopped the train in compliance with the rules.
The BAD NEWS to this is that the train just happened to stop with
its hot wheels on top of a wooden trestle bridge built with
creosoted ties, bents and trusses.
Ooops!
Fact versus Supposition
Sonya notified her supervisor that her wrist was
very sore. She thinks she sprained it earlier
when she was moving a piece of equipment.
Donna, who works near Sonya, said the reason
was probably because Edye hadn’t placed the
equipment properly, making Sonya have to
reach too far to lift it. Edye tended to do that.
The equipment is supposed to be placed 5 to 10
inches from the table edge. When Faith Ann
measured the equipment, it was 7 inches from
the edge.
So What is a “Cause”?
It is the reason for an action or
condition; something that brings
about an effect or result. (Webster’s
dictionary)
Ask Why ?
Why…
Did Henry receive a
…because the gasket
steam burn to his arm
blew out on a flange
and shoulder ?
coupling near him.
Why…
Did the gasket blow out …because the safety
on a flange coupling
valve didn’t pop off to
near him ?
release excessive
pressure in the steam
line.
Why ?
Why…
Didn’t the safety valve
pop off to release
excessive pressure in
the steam line ?
Why…
Wasn’t the valve
inspected ?
…because the valve was
not inspected.
…Because there was no
procedure calling for
the valve to be
inspected.
Why ?
Why…
Wasn’t there a
procedure calling for
the valve to be
inspected ?
… because no one
thought it was
important.
Problem Solving
Step 3
Specify the problem completely
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Describe the situation in detail
If you have addressed the five W’s and
completed an incident investigation report,
you have already done this step.
Problem Solving
List possible causes
1.
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Include all possible causes, no matter how
small
Eliminate non-causes
Use form titled Guide for identifying causal
factors and corrective actions. (see handout)
Problem Solving
Identify possible root causes
1.
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3.
Use form titled Guide for identifying causal
factors and corrective actions. (see handout)
Look for causes related to equipment,
environment, management, and people.
Usually more than one root cause
Sources for root cause
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EQUIPMENT
PEOPLE
ENVIROMENT
MANAGEMENT
Recommend Corrective Action
Step 4
Once you have identified the root cause for an accident, it
is time to determine corrective action.
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Ask employees who will be affected by the corrective
action to help you develop the action.
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The solution must solve the problem.
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The solution must not cause additional problems.
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Must be written policy.
Implement Recommendations
Step 5
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Sell your recommendation
Identify the people supporting and opposing
you.
Communicate the recommendations and the
changes they will require.
Standardize the changes.
Place in service for a trial period.
Give time for feed back.
Give written time frame for policy to be in effect.
Standardizing the Change
Your goal should be to make your
recommendations permanent and department
wide.
 Write up new procedure as soon as possible
 Change all written documents or write a
document.
 Provide training and orientation.
 Establish feedback and consequences
appropriate for the change.
 Make your own actions consistent with the
requirements of the change.
What to Look For???
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Liquid substances or objects on a floor
Worn treads
Slippery floor (heavy wax)
Loose rungs on a ladder
Frayed or torn carpet
Type of shoes
Anything being carried
Anything out of the ordinary
Weather
Sunny and clear?
Rainy?
Foggy?
Icy?
Temperature
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Cold
Hot
Housekeeping
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Clear, unobstructed walkways
Passageways and aisles free of protruding
nails, loose boards
Debris
Unwanted Clutter
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Boxes in aisles
Obstacles/barriers
Environmental
May include the following elements:
Stairs
 Ladders (portable, extension, etc.)
 Machinery, i.e. power saws
 Any room, i.e. training, sleeping quarters
 Walls
 Furniture, such as tables or chairs
 Vehicles
 Sidewalk cracks (take measurements)
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Questions?
Thank You.