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 HappensEnsure Safety of

Others

Preserve and Secure Scene

Get Emergency Services – 911,

If Needed

Investigate As Soon As Possible

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 INVESTIGATIONFIVE STEPS TO BASIC ACCIDENT INVESTIGATION

1. GATHER THE FACTS1. 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/facilityEquipment, clothing, personal

protective equipment (PPE)Procedures/practicesTraining - in procedures and safetyEmployee readiness – mental and

physical

FIVE STEPS TO BASIC ACCIDENT INVESTIGATIONFIVE STEPS TO BASIC ACCIDENT INVESTIGATION

2. REVIEW THE FACTS TO FIND 2. REVIEW THE FACTS TO FIND CAUSESCAUSES

Answers why it happened

Review all the information you gathered

List all possible causes (direct, indirect, basic)

Identify all the contributing factor(s)

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.

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 short-term 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 – LadderDirect 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 SUMMARYPOSSIBLE CAUSES CORRECTIVE ACTIONS FOLLOW UP

Rung failed Take ladder out of service(Destroyed)

Immediately K. Colby

Ladder overloaded Provide equipment that is suitable for the task

5/17/07 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 for inspection of ladders

6/15/07 B. Dorris

Improper selection of equipment

Provide training on proper ladder selection

5/16/07J. 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 SlicerAccident 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 SlicerDirect 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 SUMMARYCAUSES CORRECTIVE ACTIONS FOLLOW UP

Unguarded rotating blade Ensure guard is in place Immediately by all

Employee’s hand slipped Ensure guard is in place 1/15/07Jo Donahoe

Employee was distracted Develop, implement and enforce safety procedures

1/15/07Charlotte Harper

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

Immediate – Louise Matzner

Procedures not in place for use of gloves (PPE)

Develop, implement and enforce procedures for glove

use

5/15/07 Shirley Schaeffer

Employee was not aware that guard use was mandatory

Train staff on use of equipment and procedures

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 – BusDirect 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 SUMMARYCAUSES CORRECTIVE ACTIONS FOLLOW UP

Improper body movement

Develop procedures and train drivers on procedures

12/15/05R 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

12/15/05P 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, OngoingT Kinman

Inadequate training in pre-trip 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?

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.

Investigation Findings – Student

Accident Causes – StudentDirect 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 SUMMARYCAUSES CORRECTIVE ACTIONS FOLLOW UP

Student hit teacher Evaluate and make necessary changes to remove trigger(s)

03/01/07L. Wallis

Teacher was walking in front of student and

touched student

Develop, implement and enforce safety procedures

6/30/07E. Rudeen

Teacher was not able to de-escalate the

student

Provide other personnel trained in de-escalation to assist sub

when needed

ImmediatelyL Muchlinski

Inadequate practices regarding staff

selection

Evaluate sub selection process 06/30/07C. Bailey

Inadequate training Evaluate and modify sub training policies

06/30/07L. Bush

Inadequate experience/skills

Evaluate sub selection process 06/30/07C. Bailey

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 – ChairDirect causesChair broke

Indirect causes Improper use of equipmentFailure to use proper equipment

Basic causesSafety procedures not in place Inadequate training

CAUSATION SUMMARYCAUSES CORRECTIVE ACTIONS FOLLOW UP

Chair broke Take out of service (tag or destroy)

ImmediatelyJ Cornaggia

Improper use of equipment

Train staff on use of equipment 4/15/06J Klundt

Failure to use proper equipment

Enforce safety rules/discipline policy

ImmediatelyR Johnson

Safety procedures not in place

Develop, implement and enforce safety procedures

3/17/06D Heider

Inadequate training Train staff on use of equipment and procedures

4/15/06M 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 SUMMARYCAUSES CORRECTIVE ACTIONS FOLLOW UP

Twisted back – bodily motion

Enforce safety rules/discipline policy

ImmediatelyD Glaser

Failure to seek assistance Enforce safety rules/discipline policy

ImmediatelyD Schell

Lifting improperly - swinging, too heavy, no

help

Retrain in proper lifting techniques

3/1/07T Triplett

Loading/placing supplies improperly

Develop proper loading/storage procedures,

train employees

2/29/07R Nunamaker

Injury repeater Enforce safety rules/discipline policy

ImmediatelyD Schell

Insufficient supervision/enforcement

policies

Enforce safety rules/discipline policy

ImmediatelyD Schell

Unsafe layout for loading/unloading

Relocate storage area 6/30/06M 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 ReisterProgram ManagerWorkers’ Compensation/Unemployment CooperativeNorth Central ESD509-667-7100suzanner@ncesd.org

Paula VanderpoolProgram AssistantWorkers’ Compensation/Unemployment CooperativeNorth Central ESD509-667-7110paulav@ncesd.org