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 [email protected]
Paula VanderpoolProgram AssistantWorkers’ Compensation/Unemployment CooperativeNorth Central [email protected]