Any Questions?Thank you for attending!!!
Introduce yourself and give a brief overview of the class.Point
out the location of restrooms, fire exits, smoking locations,
refreshments for those not familiar.Request that everyone silence
pagers and cell phones.Emphasize that the proper investigation of
accidents is crucial to preventing future accidents. You can also
remind the class that incident/accident investigation is a
requirement by the Office of Risk Management.Remind them if If they
have any questions as we are going through the presentation, please
speak up. Accidents-an unplanned event(s) that caused personal
injury and/or property damageIncidents- an unplanned event(s) that
could have caused personal injury and/or property damage.All
accidents with or without injury, incidents (or near misses), and
any property damage situations must be investigated no matter who
they involve whether employee, visitors, or clients. If you are
unsure if something should be investigated or not, its best to be
on the safe side and investigate it.
Examples would include but not limited toPatient in chair faints
in waiting room, yes completeTree limb falls on patients car, yes
completeVisitor trips and falls, yes complete
Make sure you never say to anyone that the state will take care
of it or the state will pay for it. Saying anything like that puts
the agency/state in a liable condition.When determining the cause,
you want to find out the facts.you are NOT trying to find fault or
place blame.The primary cause for investigating an accident is to
PREVENT recurrence of a similar incident/accident. You want to make
sure corrective action is appropriate and effective (document if
the situation merits). Some ask why investigate an incident and the
answer is simple. If something happened and no on was injured
and/or property was not damaged, how can we prevent it from
happening again (and maybe this time with serious injuries) if we
do not know about it and/or do not know what caused it. Preventing
further incidents/accidents helps to reduce the agencys costs.WHY
DOCUMENT? If this becomes a claim/lawsuit, you need the evidence to
fight liability. Documentation should always be looked at as court
worthy. Ask yourself or your LPO, would a judge accept this?
**REMEMBER**as you are investigating DO NOT admit liability or
look for blame!!!!!
ORM requires each agency to have a written incident/accident
investigation plan. This plan needs to include step by step
procedures for responding, investigating & reporting
incidents/accidents for both employees and non-employees (visitors,
clients) and property. Everything needs to be investigated.Your
employees need training in your agencys incident/accident
investigation plan. If the employees are not trained on the
procedures how will they know how and to whom to report.
You should train your employees to report ALL incidents (near
misses), accidents, etc. Make sure this is reinforced during new
hire orientation and safety meetings. All employees need to be
aware that failing to report is grounds for disciplinary
action.
You need to ensure that the person(s) responsible for the
investigation, is trained to do so. If you are not trained on how
to conduct an investigation then you cannot conduct a thorough
investigation.The next few slides go through these areas that
should be addressed in your investigation plan/procedures.
The next few slides go through these areas that should be
addressed in your investigation plan/procedures.
Remove the hazard or at a minimum block anyones admittance to
the area to prevent further injuries. If temporary measures are
taken ensure the permanent measures are implemented as soon as
possible.Remove the injured but only when no one else is put at
risk. If need professional help get it! Call 911 if necessary.Each
agency is required by ORM to post the following
information:Emergency numbers including your certified First
Responders if requiredKnow where your first aid kits are. Make sure
they are:Readily available Appropriate for the workplace Stocked
Materials are not expired
Plan needs to state: (If injured ee, must report to ORM within 5
days-for workers comp-state law)-To whom to report the
incident/accident, following the chain of command/could be more
than one person, or it is one person and that person is responsible
for reporting to others. Could be employee responsible for
reporting to someone and then that person responsible for reporting
to others. Examples- department head, agency head, departmental
safety coordinator, safety officer, supervisor, safety committee,
supervisor, ORM Loss Prevention Officer-How soon to report/or how
long you have to report the incident/accident. Immediately, end of
shift, 24 hours. Suggest not using as soon as possible because
might use the excuse well this was a soon as I could and it is 5
days after the fact. Set a certain time limit in plan. Tell your
employees what your plan says.-Method of notification- might be
different for different severities of incident/accidents. Might be
verbal with written follow-up, just written, or phone call with
written follow-up, by email, etc.-Who conducts the investigation
once the incident/accident has been reported. Supervisor, safety
officer, what does your plan state?Definition:Investigation: [n]
the work of inquiring into something thoroughly and systematically
REMEMBER YOU ARE FACT FINDING, NOT FAULT FINDING!!!Includes:Secure
the SceneGather information, data, measurements, photos,
statements, etc.Identify unsafe act/condition/contributory factors
for Root Cause AnalysisDetermine preventive measures and tools for
short & long term preventionIf people walk through the scene it
changes the conditions or they might pick up something that is
important. THINK CSI!!!It is a good idea to have an accident
investigation kit that includes:CameraTape MeasureGlovesAccident
investigation forms (DA 2000, DA 3000, DA 2041)Note pad/PensCopy of
the agencys accident investigation procedureList of emergency
numbers
When asking the questions again remember, you are on a fact
finding mission.We want to find the primary root cause of the
incident/accident to prevent it from happening again.You want as
specific & detailed an answer as possible for each question
that is applicable.1. Go to the scene as soon as possible.
Conditions change as mentioned before. Example is lighting might
change due to time of day. Might even need to go back at the same
time of day the next day to see if there was anything different or
if after dark were all the sensor lights working? EX: Some traffic
signals cannot be seen when the sun is behind it just right (I
witnessed an accident because of this). What were the conditions
before, during, and after the accident?2. Need to get a clear
concise description of the incident/accident. Does tripped and fell
tell me anything? What were you doing, carrying anything, someone
blow a horn and scare you, squirrel ran over your feet, fell on
hands, face, knees, bootie? Get the most complete description that
you can.3. Description should be concise enough that someone else
could go back and find the location of the incident/accident again
if needed. Does parking lot give me a good location? State landmark
or measurements from landmarks so the area can be located.Take
photos of the incident/accident scene. Keep a log as you are taking
them so you do not have to try and figure out what something is
when you get back and print the pictures. Take photos from
different directions and note the direction of the view taken.Any
items related to the incident/accident should be preserved. Might
be needed at a later date. The item should be labeled as to what it
is, what incident/accident related too, (labeled do not throw away)
and stored in a secure location. Make sure you note in
incident/accident report that the item is stored. Examples could be
a chair or bench that someone fell out of because it broke for some
reason. I had a person that hot oil blew onto his face & ear
due to a defective pump. When I tried to recover the pump so we
could subrogate the claim, they had thrown it away. We could not
collect on the losses we paid.
Measurements should be taken if relevant. Distances, heights,
elevation changes, lengths of items, etc. EX: cracks in sidewalk,
potholes in parking lot, depth of stepsYou should interview
witnesses (separate witnesses) as soon as the accident scene is
secure & before the witnesses leave the accident scene. Include
all staff that may have witnessed the accident/incident (including
management) as well as the emergency response personnel. Also if
clients/visitors will give statements get those also.Get the
witnesses to write their own statements and sign and date them,
then you can interview them to fill in the blanks using the
following tips. Make sure get name and contact information
including addresses since phone can change so easily.Witness
interview tips:Select an appropriate location preferably free of
distractions/interruptions. Keep witnesses separate. Take notes
(try to record exact wording) Explain the purpose of the
investigation (reassure that you are not trying to place blame)
Make sure you do not prompt or lead the witness. Be a good listener
do not interrupt witnesses. Ask questions Who, What, Where, and How
Caution the witness not to guess. Open ended questions. Be good
listener-dont interrupt.Encourage them to write it out in their own
words then you fill in the details with questions Give full
attention to the witness Assume nothing Show courtesy and patience
In order to prevent future accidents we determine the root cause
analysis which is composed of: Unsafe Act & Why was the act
committedUnsafe Condition & Why did condition existContributing
factorsThen determine:Immediate action take to prevent
reoccurrenceLong range action to be takenWhat additional assistance
is needed to prevent recurrences*well go into more detail in the
following slides*Very important to identify so can prevent
recurrence.Basically: Its a behavior, action or non-action by an
individual.Examples of unsafe acts:Not using ppe Operating
machinery and equipment without qualifications or authorization
Operating equipment at unsafe speeds Bypass or removal of safety
devices Not following procedures Under influence of drugs or
alcoholUsing tools/equipment that is not suitable for the task
(standing on a rolling chair to change the clock time, using a
knife as a screwdriver)Failing to warn others of danger Yanking
electrical cords unplugged from a distance, which could damage
electrical components.Neglecting to clear the work area of excess
rubble and clutter that may create trip hazards.Pushing yourself
too hard by lifting too much or doing too much work.
Physical location/equipment/surrounding factors (The Environment
around you)Examples of Unsafe Conditions:wet or slippery floors
Defective or broken tools, equipment, or suppliespoor
housekeeping/storage poor ventilation cluttered hallways, stairs,
exits, and entrances defective electric wiring, lighting or outlets
Inadequate guards on machinery and equipment congestion of the work
place Fire and explosion hazardsNo training on how to use
ppe/equipment/tools exposure to harmful chemicals or biological
agents improper storage or disposal of materials and tools
Inadequate or no warning signs No policy or procedure in place
These are things you cannot control, it was not the action of
the person injured or the physical/cultural environment.
Nature---Rain, lightening, tornado, icy conditionsAnimals---deer,
dogs, squirrels, buzzards (I hit one in the state car)Other
people---a vehicle incident where someone else hit you, another
person attacked you/startled you, supervisor demands overtime with
no breaks and you are fatigued and your mental awareness is unsafe
for the work, These are areas/items that can be used to prevent
incident/accidents. These are basically administrative.1.JSAs-the
development and proper use of with employees2. Ensure policies,
procedures, rules are develop to provide instruction and revise
them as needed. Make sure policies/procedures include provisions
for discipline if policies/procedures are not followed.3. Enforce
the policies, procedures, rules that are develop. If not enforced
do not help protect the employees or the agency.4. Obtain
additional training when needed even if needed from an outside
source.5. Train your employees -new employees, on new equipment,
new procedures, change in procedures, or when employees are
observed not following correct procedures.6. Encourage the
employees do the right thing. Tell them why it is a good thing,
praise them for doing the correct thing.7. Ensure that the work
conditions are safe, if not make sure you get corrected. If
management does not show interest in doing its tasks in the correct
manner do you think the employees will care.8.As stated.These are
basically physical items.When tools worn out/broken replace
them.Redesign the work area to reduce hazards. Example is put a
hazardous job in an out of the way location in shop to reduce the
amount of traffic through the area while the task is
performed.Clutter always causes problems, tripping hazards for one,
fire prevention, and an added benefit is you can find something
when you look for it.As statedEnsure the proper signs are posted.
Just dont over do so employees are desensitized to posted
notices.Remove from service and throw away or lock up where cannot
be gotten and used anyway.Better lighting and ventilationLimit the
number and people that go through an area, especially hazardous
areas.Ensure that there are methods to implement the controls that
are selected. A method of control is only effective if it is put
into effect.After method is implemented follow-up later to ensure
that the control is producing the desired effect. Has it helped
prevent any further incidents/accidents or reduced the severity of
the ones that did occur. If the control is not working you need to
re-evaluate the situation and determine if another method needs to
be put into effect or if changes need to be made the to current one
being used.We want to prevent any further incidents/accidents or at
a minimum reduce the severity.If the JSA was inadequate and it was
revised, check to see if ees are following new procedure, if
requested a safety meeting held on accidentfollow up & make
sure it was held, if need new equipment check to see if bids are
being obtained & equipment purchased, etc.Do not put report in
a file & wait for LPO to review during audit. Someone needs to
follow up that corrective action was taken as recommended in the
report and is it working.
The agencys plan needs to specify the reports that are to be
completed. The DA2000 SHALL be completed for employees only. The DA
3000 SHALL be completed for clients/visitors, DA2041 for vehicle
accidents within 48 hours, E-1 for accidents with injuries are to
be submitted to workers comp within 5 days.Plan needs to state who
is responsible for completing the reports or even if different
sections are to be completed by different individuals. Who reviews
for completeness and accuracy.Timeline for when & who reports
are to be submitted to (Safety coordinator, HR, ORM, STARS) . Is
there more than one person or do you submit them to a certain
individual and the individual is responsible for making copies and
distributing to other individuals (need to know)
Handout copies of DA 2000 & DA 3000. Go over new DA 2000
should be completed for all incident/accidents regardless of
whether there was injury or property damage. Remember if we know
about incidents maybe we can prevent them from becoming accidents.
Discuss each area to be completed and new root cause analysis
section. 1st page is general information-but important.Page 2 is
Management section with the root cause analysis is a major function
of the LP program. Without determining the cause of the
incident/accident, future accidents/claims cannot be prevented.
-The unsafe act, unsafe condition, and contributing factors must be
determined if future incident/accidents are to be prevented. You
could have just an unsafe act or unsafe condition or you could have
both. There could be contributing factors and again there might not
be any.-the why was act committed (if have unsafe act then must
answer why was act committed) and why did condition exist (if have
unsafe condition then must answer why did condition exist) can help
with determining the root cause-example where not wearing safety
glasses was the unsafe act and the reason why act was committed is
because the glasses fog up. You would then need to look into why
the glasses fog up and determine a solution for this.-the action
lines help document what action was taken to prevent future
problems.Contact your LPO or the Baton Rouge office if you need
help to investigate or complete the root cause analysis section.You
might not be the one to complete this form, but it should be done
whenan employee needs medical after an incident/accident. This
report must be turned in through STARS, either by you or your HQ.
This report must be completed and turned into the ORM Workers Comp
Claim unit within 5 days of the injury or 1st report of medical
attention. This is completed anytime there is an injury with
medical costs and/or time off.
Even if this report is completed, the DA 2000 must still be
filled out for investigative purposes and determining the root
cause of the accident.New DA 3000 shall be used for all visitors
and clients when they claim something has happened at our state
locations. Complete this form and keep on file at your site. If a
claim is filed to ORM by the visitor/client, General Liability will
contact you for this form. It can be used in place of the official
General Liability Claim Form and can be used to report property
damage. Form is available at the ORM website. Form has statements
about attaching other information if available, please attach as
much as possible including descriptions of what happened and where.
Details!!!!
Next slide gives some suggestions.*Remind class that this class
is presented by the Loss Prevention Unit and all agencies should
submit all information and direct all questions regarding claims to
the ORM-Claims Department.* THIS IS FOR WORKERS COMP. As an agency
you probably submit the completed forms to someone who enters into
STARS. Make sure to keep a copy of everything.Other types of claims
have to be faxed in currentlyORM - Claims is comprised of:General
LiabilityRoad Hazards (DOTD Claims)PropertyMedical
MalpracticeTransportationWorkers' CompensationPrisoner ClaimsCivil
Rights Claims
Rick Lejeune and Walter Lockhart are the 2 supervisors that
handle transportation claims.The DA 2041 must be faxed or emailed
to ORM Transportation Claims within 48 hours of the accident. Once
a copy of the police report is received, forward it to the ORM
Transportation Unit with a copy of your DA 2041 for identification
purposes (unless you already know the claim number, then include
it). Make sure you keep a copy of the fax confirmation sheet or the
sent email receipt as documentation for audit question
2.4.4.1.1.
If the accident occurs in a personal vehicle while on State
Business, follow the same procedures and write PERSONAL VEHICLE on
the top of the DA 2041. Keep in mind that your personal insurance
is the primary insurance when an accident occurs, but a claim
should still be filed.Sample of the vehicle accident form. A copy
should be kept in every state vehicle. If you drive your personal
vehicle on a regular basis for state business you might want to
keep a copy of the form in your personal car.This is if you get
called to an accident to investigate it. If you dont go to the
scene make sure the employees know to call the police. DO NOT LEAVE
THE SCENE OF AN ACCIDENT WITHOUT CALLING THE POLICE.MAKE SURE
EMPLOYEES KNOW NOT TO ADMIT ANY LIABLITIY OR STATE THAT THE STATE
WILL TAKE CARE OF EVERYTHING.
Employees can use the accident form to record witness names and
contact information.As stated.Official report number will probably
not be available at the accident scene. Will probably have to wait
several days for that and to obtain a copy of the police report. DO
NOT wait to send in the DA2041 until you receive the police report.
Send in the DA2041 and then when you get the police report send it
in with another copy of the DA2041 or reference to that accident.
Make note of lenses used, distance from objects, date taken, film
used.
Might need to use a flash even if sun is shining.Take pictures
from all 4 sides, angles. Get pictures of damage and non-damaged
areas. Picture of license plate could also be helpful.
You can also take pictures of some of these items in addition to
noting them in writing.
Note type of pavement.
For witnesses- Look at nearby stores, residences, bus stops,
etc. If going back a day or so after the accident go same time of
day to look for witnesses, someone might have a routine they
do.
Note is one of the witnesses was a passenger in any one of the
vehicles.If not to scale note so.Give a legendNote direction of
NorthNote where everything is, signs, poles, lights, witnesses,
etc.(1) Act is an action or non-action by the individual, condition
is the physical/cultural environment around that individual
(2) Depends on your agencys accident investigation plan (usually
supervisor)
(3) Incident - Is an event that could have caused injury or
damage to property. There were no injuries/property damaged. An
incident should be reported and investigated as an accident. The
reason is to correct the situation before it causes an
injury/property damage.
(4) Depends on your agencys accident investigation plan
