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Appendix 1S Checklist 19-1 BCTS Contractor Safety _Pre-Work


									                                              Incident Investigation
                                                  Checklist 15-2

Fatalities – immediately contact WCB, BCGEU President, local BCGEU office,
Deputy Minister, and BC Public Service Agency.
Infectious disease exposure – copies to BC Public Service Agency at 604-775-0697.
MFR vehicle accidents require PHH vehicle accident report.                                        Tracking # ____________

 Report Type
    Incident                    Harm to people, equipment
   Close Call                   An undesired event that under slightly difference circumstances could have resulted in
                                personal damage or property loss
 Incident Type
    First Aid                    A minor injury requiring only first aid treatment
    Medical Aid                  An injury requiring treatment by a health care professional
    Lost Time                    A disabling injury where the injured person is unable to report for the next regular shift
    Property Damage              Accidental loss to equipment, material, and/or the environment
 Investigation Type / Severity Level (refer to safety manual)
                       A level 1 investigation includes injuries which are non-time loss with no medical attention and
         Level 1       equipment damage less than $5000. (The supervisor is required to ensure completion of
                       investigation for this level)
                       A level 2 investigation includes loss of time injuries which do not involve loss of life or limb more
         Level 2       than $5000, but less than $100,000. (The Internal Investigation Team is required to investigate
                       this level)
                       A level 3 investigation is required when a catastrophic event occurs. This includes major disabling
                       injuries, fatally injured workers, and equipment damage in excess of $100,000 or a close call with
         Level 3
                       the risk of this type of injury or damage. (An offsite Professional Investigator is required to
                       investigate this level)
 Incident Category:       Injury        Occupational Disease         Equipment Malfunction          Motor Vehicle
     Property Damage         Other
 General Information – completed by supervisor
 Ministry:                                        Employee’s Name:                             Yrs of Service:
 Occupation:                                      Hrs worked past 24hrs:                       Time on Present Job:
 Contractor Name (if not staff):
 Shift Start Time:                                Time Occurred:                               Supervisor:
 Date Occurred: Y/M/D                             Date Reported: Y/M/D                         If Delayed, WHY:
    Motor Vehicle DOT – Motor vehicle incident on a Department of Transportation controlled highway                       NA
    Motor Vehicle Non-DOT – Motor vehicle incident on a Non-Department of Transportation controlled highway                 NA
 Accessibility:      ATV        Vehicle        Snowmobile       Walking in bush        On road        Aircraft/Helicopter   NA
 Weather:      Clear         Heavy rain         Light rain      Cloudy         Fog        Snow         NA
 Temperature:       +1˚C to +9˚C         +10˚C to +20˚C       +21˚C to +30˚C        +30˚C        NA
                    0˚C to -10˚C         -11˚C to -19˚C       -20˚C to -29˚C        <-30˚C         NA
 Program – completed by supervisor
    MFR:        Administration            C&E           Engineering          Range          Revenue
    BCTS:       Scaling          Stewardship           Tenures
                Administration         Engineering         Planning         Practices (Silviculture)      Practices (TSL)
    TSL:        Administration           Engineering         Harvesting
    Contractor:       Administration            Engineering         Planning          Silviculture        Harvesting

            File:                                       Rev. Dec 2008                                  Page 1 of 4
                                            Incident Investigation
                                                Checklist 15-2

Type of Project – completed by supervisor
             HARVESTING                                     ROADS                        MAJOR STRUCTURES
  Falling                                      Construction                             Construction
  Cable                                        Maintenance                              Maintenance
  Helicopter                                   Deactivation/Rehabilitation              Deactivation
  Yarding/Loading                              Other (specify):                         NA
  Forwarding                                   NA
  Other (specify):
             FIELD WORK                                     OFFICE
  Layout                                       Warehouse
  Inspection                                    Yard
  Walking                                       Main Building
  NA                                            Other (specify):
Description of Incident (including events leading up to the incident – add more pages if necessary) – completed by

Safe Work Procedures: Established         Yes  No Adequate   Yes     No      Used in Training    Yes   No
Contributing Factors – completed by investigator
Acts:                                                     Conditions
   Operating without authority                              Inadequate guards or barriers on equipment/tools
   Operating at unsafe speed for conditions                 Defective tools, equipment or materials
   Short-cutting safety devices or methods                  Hazardous environmental conditions:
   Using unsafe equipment                                   e.g. gas/smoked/dust/fumes
   Using equipment unsafely                                 Inadequate or excess illumination
   Improper loading                                         Unsafe clothing
   Working on moving or dangerous equipment                 Congested or restricted action
   Distraction, teasing, horseplay                          Unguarded work area, uncontrolled traffic
   Failure to use personal protective devices               Unsafe design or construction
   Physical disability                                      Lack of protective equipment
   Insufficient hazard assessment                           Inadequate warning system
   Failure to warn                                          Fire and explosion hazard
   Failure to secure                                        Poor housekeeping or disorder
   Improper lifting                                         Noise exposure
   Improper placement                                       Radiation exposure
   Improper position for task                               Inadequate ventilation
   Failure to follow work procedures                        Contaminated materials
   Other (specify) ______________________________           Dangerous natural conditions
   NA                                                       Design of tools/equipment inadequate
                                                            Other (specify) _________________________

          File:                                     Rev. Dec 2008                               Page 2 of 4
                                           Incident Investigation
                                               Checklist 15-2

Root Causes – completed by investigator
Basic Causes                                                 Job Factors
  Inadequate training                                            Inadequate leadership/supervision
  Inadequate planning                                            Inadequate engineering
  Inadequate assessment                                          Inadequate maintenance
  Stress                                                         Inadequate tools/equipment
  Fatigue                                                        Inadequate work standards
  NA                                                             Inadequate orientation or instruction
Describe what specific personal or job/system factors caused or could have caused this event (add more pages if
necessary) – completed by investigator

Incident analysis – completed by investigator
Parts of body                                                               Nature of injury
    Ankle(s)                                              R    L                Burns                   Slips/falls
    Arm(s) (above wrist, not elbows)                      R    L                Foreign body            Strain/sprain
    Back (including muscles, spine, spinal cord)          R    L                Fracture                Wound
    Elbow(s)                                              R    L                Hernia                  Other (specify)
    Eyes                                                  R    L                Skin disease
    Finger(s)                                             R    L                NA
    Foot/feet                                             R    L
    Hand(s)                                               R    L
    Head – front area (not including eyes)                R    L            Describe:
    Head – back area (not including eyes)                 R    L
    Internal injuries                                     R    L
    Knee(s)                                               R    L
    Leg(s) (not knee(s))                                  R    L
    Shoulders                                             R    L
    Wrist(s)                                              R    L
    Other: (specify) _________________________            R    L
Treatment – completed by supervisor
    First Aid (OFA)                          Medical Attention                       Lost Time              (days)
Work Time Lost: (hours)                   Date off work: Y/M/D                   Date return to work: Y/M/D
Occupational First Aid Attendant:                             Doctor:
Date of Treatment: Y/M/D
Corrective Action
Unsafe acts                                                        Unsafe conditions
    Stop the worker              Revise safe work procedures          Advise: (recommend to)                   Correct
    Study the job                Develop safe work procedures         Operations/Woodlands Manager             Remove
    Re-train                     Other: (specify)                     Response Center Manager                  NA
(tell, show, try, check)
    Follow up                                                      Comments:                                   Other

          File:                                     Rev. Dec 2008                                Page 3 of 4
                                            Incident Investigation
                                                Checklist 15-2

 Name:                                                  Contact Info:
 Name:                                                  Contact Info:
 Name:                                                  Contact Info:
 Name:                                                  Contact Info:
 Action Plan – What immediate actions are necessary to prevent recurrence – completed by investigator

 Action Plan – What long term actions are necessary to prevent recurrence – completed by investigator

 Action Plans – All action plans are to be forwarded to the Safety Contact and placed into the Corrective Action Log
              Action Plans:                   Open                                Date: Y/M/D
          (database users only)               Closed                              Date: Y/M/D
 Lead Investigator:                                           Occupation:
 Worker Representative                                        Occupation:
 Other Investigators:                                         Occupation:
 Other Investigators:                                         Occupation:
 Other Investigators:                                         Occupation:
 Other Investigators:                                         Occupation:
 Supervisor:                                                  Date:

 Management:                                                 Date:

 Date File Closed: Y/M/D

Copy – 1 to file    Copy – 1 to Supervisor/TSM          Copy – 1 to Safety Contact       Copy – 1 to Worksafe BC

            File:                                     Rev. Dec 2008                               Page 4 of 4

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