EMPLOYEE ACCIDENT INVESTIGATION FOR SUPERVISORS

1. EMPLOYEE ACCIDENT INVESTIGATIONFOR SUPERVISORS

2. TRAINING OBJECTIVE To provide supervisors information and tools to investigate employee accidents thoroughly to prevent them from happening again.

3. TOPICS TO BE COVERED • Definition of an Accident • Purpose of Investigation • Five Step Investigation Process • Case Studies

4. 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

5. Once An Accident Happens Ensure Safety of Others Preserve and Secure Scene Get Emergency Services – 911, If Needed Assist Employee with Completion of Incident Report Investigate As Soon As Possible

6. 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?

7. FIVE STEPS TO BASIC ACCIDENT INVESTIGATION • GATHER THE FACTS • REVIEW THE FACTS TO FIND CAUSES • DOCUMENT FINDINGS AND ACTIONS • TAKE PREVENTATIVE ACTION • FOLLOW UP

8. FIVE STEPS TO BASIC ACCIDENT INVESTIGATION1. 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

9. 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

10. 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)

11. 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.

12. FIVE STEPS TO BASIC ACCIDENT INVESTIGATION3. DOCUMENT FINDINGS AND ACTIONS • Complete the INCIDENT REPORT • State only the facts in the incident report (no opinions)

13. FIVE STEPS TO BASIC ACCIDENT INVESTIGATION4. 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

14. DOSH’s SOLUTION TO HAZARDS • Eliminate the hazard or use less hazardous processes or materials • Use operational controls - SOPs • Use administrativecontrols (policies, rules, training, signage) • Use engineering controls (mechanical means – substitution, ventilation, isolation) • Use personal protective equipment and/or safety equipment

15. 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.

16. 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.”

17. 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?

18. 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.

19. 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

20. CAUSATION SUMMARY

21. GROUP WORK

22. 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.

23. 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.”

24. 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?

25. 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.

26. 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

27. CAUSATION SUMMARY

28. 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.”

29. 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?

30. 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.

31. 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

32. CAUSATION SUMMARY

33. 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.”

34. 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?

35. 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.

36. 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

37. CAUSATION SUMMARY

38. 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.”

39. 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?

40. 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.

41. 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

42. CAUSATION SUMMARY

43. CASE STUDY - Groundsperson “I was unloading 50 pound bags of fertilizer from truck, twisted wrong and hurt my back.”

44. 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?

45. 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.

46. 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

47. CAUSATION SUMMARY

48. 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

49. 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