PowerPoint - North Central ESD

							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 Happens
 Ensure Safety of
                       Get Emergency
     Others
                      Services – 911, If
Preserve and Secure       Needed
       Scene
                       Assist Employee
Investigate As Soon   with Completion of
    As Possible        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 INVESTIGATION

      1. 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/facility
Equipment, clothing, personal
 protective equipment (PPE)
Procedures/practices
Training - in procedures and safety
Employee readiness – mental and
 physical
       FIVE STEPS TO BASIC ACCIDENT INVESTIGATION
2. REVIEW THE FACTS TO FIND CAUSES

 Answers why it happened

  Review all the information you gathered
  List all possible causes (direct, indirect,
  basic)
  Identify all the contributing factor(s)
                 CAUSES
 Direct 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 – Ladder
Direct 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 SUMMARY
      POSSIBLE CAUSES                    CORRECTIVE ACTIONS                 FOLLOW UP
          Rung failed                  Take ladder out of service          Immediately
                                              (Destroyed)                  K. Colby
      Ladder overloaded           Provide equipment that is suitable for 5/17/07
                                                the task                 K. Gregg
Improper storage caused ladder    Provide proper means and equipment       5/17/07
   damage (not tied down)          for storage and provide training on     T. Kinman
                                             ladder storage
Not inspected prior to each use   Develop, carry out and enforce policy 6/15/07
                                        for inspection of ladders       B. Dorris
    Improper selection of           Provide training on proper ladder      5/16/07
         equipment                              selection                  J. Collins
  Using defective equipment       Provide training on ladder inspection    5/15/07
                                                                           G. Jacobson
   Supervisor not enforcing       Enforce safety rules/discipline policy   Immediately
         procedures                                                        R. Nunamaker
     Inadequate training             Provide training on ladder use,       5/17/07
                                    selection, inspection and storage      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 Slicer
Accident 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 Slicer
Direct 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 SUMMARY
           CAUSES                      CORRECTIVE ACTIONS                 FOLLOW UP
  Unguarded rotating blade            Ensure guard is in place       Immediately by all

   Employee’s hand slipped            Ensure guard is in place       1/15/07
                                                                     Jo Donahoe
   Employee was distracted        Develop, implement and enforce     1/15/07
                                         safety procedures           Charlotte Harper
Meat cutter could be operated      Retrofit guard so it cannot be    Immediate -
   without guards in place                    disabled               Lance Wells
  Cut-resistance gloves were      Develop, implement, and enforce    5/15/07
    available but not used            procedure for glove use        Pam Milleson
   Supervisor not enforcing        Enforce safety rules/discipline   Immediate –
  procedures for equipment                     policy                Louise Matzner
Procedures not in place for use   Develop, implement and enforce     5/15/07
       of gloves (PPE)               procedures for glove use        Shirley Schaeffer
Employee was not aware that        Train staff on use of equipment   Immediate -
 guard use was mandatory                    and procedures           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 – Bus
Direct 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 SUMMARY
          CAUSES                     CORRECTIVE ACTIONS               FOLLOW UP
 Improper body movement          Develop procedures and train      12/15/05
                                    drivers on procedures          R Nicholson
   Failure to use proper         Enforce safety rules/discipline   Immediately
  equipment – step ladder                    policy                T Head
   Wearing inappropriate            Develop, implement and         12/15/05
         footwear                  enforce safety procedures       P Pocinich
    Lack of step ladders          Ensure adequate number of        11/30/05
 available and not close by      step ladders and ensure they      B Petersen
                                     are readily available
 Employee was distracted           Safety awareness training       Immediate,
                                                                   Ongoing
                                                                   T Kinman
 Inadequate training in pre-       Train staff on use of all       3/16/07
trip inspections for all types    equipment and procedures         J Peterson
          of buses

  No designated bus wash            Designate bus wash area        6/30/07
           area                                                    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?
Investigation Findings – Student

  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.
   Accident Causes – Student
Direct 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 SUMMARY
        CAUSES                   CORRECTIVE ACTIONS                FOLLOW UP

  Student hit teacher         Evaluate and make necessary        03/01/07
                              changes to remove trigger(s)       L. Wallis
Teacher was walking in      Develop, implement and enforce       6/30/07
 front of student and              safety procedures             E. Rudeen
   touched student
Teacher was not able to     Provide other personnel trained in   Immediately
de-escalate the student      de-escalation to assist sub when    L Muchlinski
                                         needed

  Inadequate practices       Evaluate sub selection process      06/30/07
regarding staff selection                                        C. Bailey
  Inadequate training       Evaluate and modify sub training     06/30/07
                                        policies                 L. Bush
      Inadequate             Evaluate sub selection process      06/30/07
   experience/skills                                             C. 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 – Chair
Direct causes
 Chair broke

Indirect causes
 Improper use of equipment
 Failure to use proper equipment

Basic causes
 Safety procedures not in place
 Inadequate training
            CAUSATION SUMMARY
        CAUSES                   CORRECTIVE ACTIONS              FOLLOW UP


      Chair broke          Take out of service (tag or destroy) Immediately
                                                                J Cornaggia

    Improper use of         Train staff on use of equipment    4/15/06
      equipment                                                J Klundt

 Failure to use proper       Enforce safety rules/discipline   Immediately
      equipment                          policy                R Johnson

Safety procedures not in    Develop, implement and enforce     3/17/06
         place                     safety procedures           D Heider

  Inadequate training       Train staff on use of equipment    4/15/06
                                     and procedures            M 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 SUMMARY
          CAUSES                   CORRECTIVE ACTIONS              FOLLOW UP

Twisted back – bodily motion   Enforce safety rules/discipline   Immediately
                                           policy                D Glaser
 Failure to seek assistance    Enforce safety rules/discipline   Immediately
                                           policy                D Schell
    Lifting improperly -          Retrain in proper lifting      3/1/07
swinging, too heavy, no help            techniques               T Triplett
 Loading/placing supplies      Develop proper loading/storage    2/29/07
       improperly               procedures, train employees      R Nunamaker
      Injury repeater          Enforce safety rules/discipline   Immediately
                                           policy                D Schell
        Insufficient           Enforce safety rules/discipline   Immediately
 supervision/enforcement                   policy                D Schell
          policies
      Unsafe layout for            Relocate storage area         6/30/06
     loading/unloading                                           M 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 Reister
Program Manager
Workers’ Compensation/Unemployment Cooperative
North Central ESD
509-667-7100
suzanner@ncesd.org

Paula Vanderpool
Program Assistant
Workers’ Compensation/Unemployment Cooperative
North Central ESD
509-667-7110
paulav@ncesd.org