Accident Investigation / Reporting Policy by dBI8Y9J


									                                         Practice Name

       Accident Reporting and Investigation Program
Accident Reporting and Investigation Program                                    Date:
Approved By:                             Position:                              Date:


To ensure that all accidents, injuries and near misses are reported immediately and investigated to
the fullest extent possible. Effective implementation of this policy will address our employees
medical needs, identify corrective actions, and prevent recurrence.


Practice Name Accident Reporting and Investigation Program applies to all of Practice Name
employees and visitors.


Accident: an unplanned or uncontrolled event that led to or could have led to injury, property
damage, impairment to the environment, or other loss.

Accident Investigation: a fact-finding procedure that reveals facts that are used to prevent
recurrences of similar accidents.

Hazard: an unintentional event that has the potential to cause damage to people, property, and/or
the environment.

Near Miss: a near miss is an unplanned event that did not result in injury, illness, or damage but
had the potential to do so.

Loss: the injury, death, financial or property damage arising from an accident.

Unsafe Condition: a physical condition within the environment that has the potential to cause or
contribute to an accident.

Unsafe Act: a violation of the accepted standard practices with the potential to cause or contribute
to an accident.

                          Accident Reporting and Investigation Program Page 1
                                        Practice Name


Human Resources
   Provide necessary care for injured employee or occupant of facility.
   Complete Employers First Report of Injury and submit to insurance carrier within 24 hours
     of the injury.
   Ensure that all accidents are investigated as soon as possible but no more than 24 hours
     after the event.
   Ensure that corrective actions are developed and implemented.
   Ensure that Accident Investigation Reports are kept on file for future reference.
   Review accident investigation report forms to ensure that all pertinent information has
     been included.
   Provide training for employees on safe work procedures and accident reporting.
   Complete necessary paperwork to report to the workers’ compensation carrier when
   Arrange for post accident drug and alcohol testing.

   Report accidents, injuries, and illnesses to their supervisors immediately.
   Report unsafe acts, conditions, or near miss incidents to their supervisors as soon as
   Be cooperative, truthful and assist during all accident investigations.

    Ensure that employee is treated immediately following an accident or incident as
    Ensure that injured employee is transported to a Practice Name –approved occupational
       health care facility or medical provider.
    Submit completed Accident Investigation Report to Human Resources within 24 hours of
       an accident.
    Assist in identifying corrective actions to be taken to prevent reoccurrence.


With the exception of the injured employee, who may or may not have received previous training,
every employee conducting accident investigations should be trained in accident and incident
investigation and identifying root causes prior to being assigned to an investigation team. The
Human Resources Manager (or other employee designated by Practice Name for maintaining
training records) will maintain a list of employees trained in accident and incident investigation
and root cause analysis as well as the training records/dates of training sessions

                         Accident Reporting and Investigation Program Page 2
                                         Practice Name


Practice Name requires that all workplace accidents or near misses be reported immediately by
the employee to their immediate supervisor. The supervisor/employee will complete the Accident
Investigation Report within 24 hours of the accident or, in the event of a serious injury, when they
are physically able.

Employees who do not report an accident or incident to their supervisor before leaving work the
day of the accident or incident may be subject to disciplinary actions.


The injured employee will be evaluated by someone trained in 1st aid and 1st aid will be
administered immediately. In the event of a serious injury, call 911 for ambulance/paramedic
assistance. Injured employees requiring treatment beyond 1st aid but not deemed to be serious
will be transported to the following facility by a designated person trained in 1st aid:

Occupation Medicine Clinic
Phone #


The supervisor, injured/involved employee, and (if applicable) the safety committee representative
form the investigation team. The Practice Manager and others (as needed) may be asked to
participate in the investigation at the team’s discretion. The team is responsible for completing the
investigation and reporting their findings on the Accident Investigation Report.

The supervisor leading the investigation team should submit a signed copy of the Accident
Investigation Report to the Human Resources Manager of the facility as a permanent record.


The main objective for an accident investigation is to identify the root cause(s) of the accident and
develop the corrective actions to prevent the reoccurrence of the accident. Investigations should
be investigated as soon as possible after they occur so that facts are fresh in everyone’s mind.

The contributing factors of an accident may be obvious and be determined immediately with
relative ease. However, it is important to determine the underlying or root causes of an accident.

The steps taken to conduct an accident investigation in order to reach our objective are:
    Provide medical attention to injured party
    Remove or isolate the hazard at the scene
    Assemble investigation team

                          Accident Reporting and Investigation Program Page 3
                                         Practice Name

      Preserve the scene
      Observe conditions / take pictures
      Interview witnesses
      Review records
      Perform root cause analysis
      Communicate the investigation results
      Take corrective action to prevent reoccurrence
      Document findings and corrective actions taken


Evaluation of the accident will begin after the initial data is gathered and is intended to identify
contributing factors and root causes of the accident. The root cause analysis should be conducted
according to the steps identified in Appendix C.


Injured employees, witnesses and any other employees familiar with the accident or incident
should be interviewed. The purpose of the interview is to gather information regarding the
accident or incident, not to assign blame.
     Identify each witness – name, occupation, years of experience, etc.
     Conduct in a quiet and private location
     Get statements as soon as possible
     Do not provide any facts or opinions to the witness
     Explain the purpose of the investigation and put the witness at ease
     Listen, let each witness speak freely, and be professional, courteous, and considerate
     Take notes without distracting the witness. Use a tape recorder only with the consent of
       the witness and have the witness complete and sign an authorization form
     Use sketches and diagrams to help the witness
     Emphasize areas of direct observation
     Do not argue with the witness
     Record the exact words used by the witness to describe each observation


Following an investigation and analysis, a summary report should be prepared, including the
recommended actions to prevent reoccurrence. Report details will consist of but are not limited to
the following:
     Date, Time, Location
     Injured
     Witnesses (Name, Address, Phone Number, etc)
     Treating Physicians (Name, Address, Phone Number, etc)
     Activities just prior to accident or incident
     Accident description – sequence of events
     Accident results

                          Accident Reporting and Investigation Program Page 4
                                          Practice Name

       Description of any machinery involved
       Witness statements
       Diagrams and photos
       Immediate temporary corrective actions
       Recommended longer term corrective actions

The investigation team must assign a person responsible and target date for each corrective action
recommendation from the investigation. The persons assigned to perform the corrective actions
do not have to be from the team. All recommendations will be tracked to completion by the
investigation team.


       The accident investigation / reporting program will be reviewed annually by the Safety
        Committee and Human Resources. The revisions at the time of review will be recorded
        and noted on the next revised version of the policy.


            A. Employer’s First Report of Injury
            B. Accident Investigation Form
            C. Identifying Root Causes

Revision Date       Description of Revision                                     Approved By:

                         Accident Reporting and Investigation Program Page 5
            Practice Name

          Appendix A

Employer’s First Report of Injury

  (Insert State-Required Form)
          Practice Name

        Appendix B

Accident Investigation Report
                                               Practice Name

                                     Accident Investigation Form
Location                                                  State          Dept                        Phone
Employee Name                                                           DOB                  Employee #
Address                                                   City                     State                     Zip
SS#                                                Married        Yes       No     Sex        Male        Female
Job Title                                                                        Hire Date
Employee Description of Incident:

Employee Signature

                                          Incident Details
Date of Incident             Time of Incident               AM        PM       Date Reported
Incident Location (area)                                   On Employer Premise        Yes         No
Employee lost time to injury           Yes        No              First Aid Given      Yes        No
Date Worker Left Work                 Time Worker Left Work               Date Worker Returned
Medical Facility                                            Doctor
Follow Up Appointment Scheduled                                                        Yes        No
Time Off Authorized by Physician         Yes        No    If Yes, How Many Days
Treatment Given           Prescription         Irrigation             Sutures              Tetanus Shot
                          Brace                Cast                   Remove Foreign       None
   Ace Bandage            Other:
                                                Practice Name

                                          Part of Body Injured
   Head              Arm        R    L        Trunk       R L         Hip       R    L    Foot     R   L
   Face              Elbow      R    L        Shoulder    R L         Thigh     R    L    Toe      R   L
   Eye     RL        Forearm    R    L        Chest       R L         Knee      R    L    Ribs     R   L
   Nose              Hand       R    L        Back        R L         Leg       R    L    Skin     R   L
   Neck              Finger     R    L        Abdomen     R L         Ankle     R    L    Other    R   L

                               Nature of Injury (mark all that apply)
   Abrasion             Puncture               Chemical             Inhalation           Burn
   Bruise-Crushed       Fracture               Hearing              Fatality             Other
   Laceration           Poisoning              Sprain               Heat/Cold
   Amputation           Dermatitis             Strain               Foreign Object

                                         Investigation Supervisor
Date of Investigation                               Investigator Name
Employee’s Supervisor                               Supervisor’s Phone
Who was immediately in charge at time of injury?
Employee task trained?         Yes        No Yes, explain:
Equipment Involved        Type                      Model                       Mfg.

                               Cause of Injury – (mark all that apply)
   Body Motions         Hot/Cold               Flame/Smoke          Ladders              Slip/Trip/Fall
   Bldg/Structure       Conveyors              Furniture            Machines             Flying Object
   Chemicals            Electrical –HV         Hand Tool            Notices              Flash
   Vehicles             Electrical - LV        Hoisting             Particles            Other
   Falling Objects
                                                Practice Name

                                 Cause of Incident – (mark all that apply)
                       Material                                      Poor
   Equipment                                    Excessive Speed                            Horseplay
                     Handling                                      Housekeeping
   Lack of                                      Procedure             Housekeeping
                         Slippery Surface                            Fatigue               Other
Attention                                    Failure

                                            Root Cause Analysis
Description of Incident:

                               Steps Taken to Prevent Similar Occurrence
   Reinstruction of Employee                                Formal Disciplinary Action
   Reminder Instruction to All Employees                    Installation of Guard Device
   Personal Protective Equipment Required                   Counseling of Employee

Supervisor Signature:                                                     Date:

             Send report to:
       Practice Name

     Appendix C

Identifying Root Causes
                                     Practice Name

Identifying Root Causes

Identifying the root cause of an incident is one of the most important aspects of incident
investigation. The root cause of an incident is the primary event without which the incident
would not have happened. Another way to think of a root cause is: If the root cause had been
prevented, the incident would not have happened. It is not always possible to identify the
root cause of an incident, but we can usually get very close by analyzing the contributing or
causal factors.

Whether an incident is due to operations or maintenance problems, technical problems,
industrial hygiene concerns, reliability concerns, natural phenomenon or sabotage, there are
many ways to analyze the causes and categorize the root causes. Listed below are some root
cause categories commonly used:

-      Equipment - Was a hazardous condition a contributing factor? Examples of
       hazardous conditions include: missing or defective equipment/parts, equipment/parts
       not inspected or deficiencies not reported properly, incorrect or improperly designed
       materials, tools, or equipment used, etc.

-      Communications - Were communications given in an understandable manner? In a
       timely manner? Fully understood by the receiver?

-      Environment/Ergonomic - Was the location or position of equipment, materials, or
       employees a contributing factor? Examples include: illumination, noise levels, air
       contaminants, temperature extremes, ventilation, vibration, radiation, weather,
       location/position/layout of equipment, position of employee, barriers/ warning lights
       and signs, etc.

-      Job Oversight & Supervision - Were the job and the workers selected, prepared and
       supervised properly?

-      Management System - Was a management system defect a contributing factor?
       Examples include: failure to detect, anticipate or report hazardous conditions, lack of
       or inadequate standards or policies, lack of auditing or communications with
       employees, etc.

-      Procedures - Were written, up-to-date job procedures in place and used properly?
       Examples include: missing or inadequate written procedures, sequence wrong, etc.

-      Training -Was adequate training conducted and fully understood by employees?
                                     Practice Name

The incident investigation team first determines the sequence of events in the incident. Then
the team identifies the potential causes and the root cause, if possible. Lastly, the team
makes recommendations to prevent reoccurrence and documents their results. The questions
on the next few pages are designed to help the team systematically analyze the incident and
identify the root cause.
                                     Practice Name

Identifying Root Cause

“No” answers should be considered as causal factors and a potential root cause(s).
                                                                                Yes   No
 Part 1 - Equipment
 1.     Was there no failure of the equipment involved in the incident? (If yes, go
        on to Part 2)
 2.     Was equipment maintained in a safe and operable condition?
 3.     Was there a written maintenance schedule for the equipment?
 4.     Was the maintenance schedule followed?
 5.     Was this a repeat failure of the equipment? (If yes, go to Management
 6.     Was the equipment designed and reviewed according to written
 7.     Did the specifications address the means by which the equipment failed?
 8.     Was the equipment or parts defective? (If yes, determine if the root cause
        exists in how the equipment was obtained, manufactured, handled, stored,
        or tested prior to use.)
 9.     Was this an expected failure?
 Part 2 – Communications
 1.     Were communications adequate? (If yes, continue to Part 3)
 2.     Were communications timely?
 3.     Were communications clear, fully understood by recipient, the right
        length, not confusing, communicated in area/location where they could be
        fully understood?
 Part 3 - Environmental/Ergonomic
 1.     Were environmental or ergonomic factors adequate? (If yes, continue to
        Part 4)
 2.     Were the following conditions adequate: labeling, the arrangement or
        placement of the machine and employee, instruments, displays, warning
        lights, the awareness of the operator, duplicate machines/equipment the
 3.     Was housekeeping good, the work environment a comfortable
        temperature, good lighting, acceptable noise level, not cramped/crowded,
                                   Practice Name

                                                                                  Yes   No
      no other contaminants or health hazards?
4.    If the operating system is complex did the operator possess the knowledge
      he or she needed to operate safely and was the operator monitoring no
      more than 3 critical functions at once?
5.    In the operating system were errors detectable by the operator and could
      he or she adequately recover from errors?
Part 4 - Job Oversight and Supervision
1.    Were job oversight and supervision adequate? (If yes, continue to Part 5)
2.    Was there a good, understandable work package? Adequate job
      preparation? Pre-job briefing and walk-through? Lockout performed?
      Job scheduled appropriately?
3.    Was the worker qualified to perform the task?
4.    Was the worker in good physical and mental condition to perform the
      task? (Not tired, upset, under the influence of drugs or alcohol)
5.    Was there adequate supervision during the work?
Part 5 - Management System
1.    Were management systems (standards, policies, work rules, audits and
      evaluations, corrective actions taken as necessary) adequate? (If yes,
      continue to Part 6)
2.    Were written standards available in the work place? Fully communicated
      to employees? Clear and complete? Technically accurate? Enforced
3.    Were audits and evaluations conducted per specified frequencies?
4.    Were audits and evaluations detailed enough to detect deficiencies and
      conducted by an objective person?
5.    If corrective action had already been specified but not yet implemented,
      were the reasons/time frames for delay reasonable?
                                   Practice Name

                                                                                  Yes   No
Part 6 – Procedures
1.    Were written procedures present and followed correctly? (If yes, continue
      to Part 7)
2.    Was the procedure available and convenient to use?
3.    Was the procedure followed correctly?
4.    Was the format clear? Less than one action per step? Graphics clear?
      Computations/specifications clear? Checklist clear? Equipment
      identification clear?
5.    Was the procedure free of typographical errors? Facts correct? All
      potential situations covered? The correct version of procedure used?
Part 7 – Training
1.    Was training and employee understanding of training adequate? (If yes,
      go back and identify the root cause and corrective actions for each ?no?
2.    If there had been a decision not to conduct training, had the task been
3.    Did the lesson plan address the situation which led to the incident?
4.    Was there adequate practice and testing to ensure the employee
      understood the training?
5.    Was there adequate continuing education to ensure the employee
      continued to be able to do the job safely?

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