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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: (months) Contractor Name (if not staff): Shift Start Time: Time Occurred: Supervisor: Date Occurred: Y/M/D Date Reported: Y/M/D If Delayed, WHY: Location: 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): NA FIELD WORK OFFICE Layout Warehouse Inspection Yard Walking Main Building NA Other (specify): NA Description of Incident (including events leading up to the incident – add more pages if necessary) – completed by investigator 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) _________________________ NA 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 NA 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 NA 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 NA 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 Enforce NA Witnesses 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: Signatures: Supervisor: Date: Comments: Management: Date: Comments: 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
"Appendix 1S Checklist 19-1 BCTS Contractor Safety _Pre-Work "