ACCIDENT/INCIDENT INVESTIGATIONS

1. ACCIDENT/INCIDENT INVESTIGATIONS WCB REGULATION: The Employer must immediately undertake an investigation into the cause of any accident or other incident that : • resulted in injury to a worker requiring medical treatment • did not involve injury to a worker but had the potential to cause serious injury

2. PURPOSE OF INVESTIGATIONS PURPOSE: • to gather information on the cause(s) of an incident • to make recommendations to prevent future similar occurrences • to implement corrective measures ASAP

3. VIHA ACCIDENT/INCIDENT - INVESTIGATION POLICY When an accident or exposure results in medical aid, time loss from the workplace or has the potential to result in serious injury an investigation must be initiated within 72 hrs of the incident and completed without undue delay.

4. EMPLOYER RESPONSIBILITIES The Employer is responsible to ensure: • Investigations take place as soon as possible following an incident • Investigations are conducted by person(s) knowledgeable in the type of work involved

5. Employers Responsibilities Continued As far as possible the Investigation must: • determine the root cause or causes of the incident • identify any unsafe conditions, acts or procedures that contributed in any manner to the incident

6. Employers Responsibilities Continued As far as possible the Investigation must: • if unsafe conditions, acts or procedures are identified, recommend corrective action(s) to prevent similar incidents

7. Employers Responsibilities Continued Following an investigation the employer must without undue delay undertake any corrective action to prevent recurrence of similar incidents

8. Employers Responsibilities Continued Following an investigation the employer must complete the Incident Investigation report/process by: • Indicating the status of the recommendations made (i.e. resolved, ongoing, deferred etc.) • Ensure dates, times and investigation information is accurate • Indicate any concerns you have about the incident

9. THE INVESTIGATORS The Investigators: • 1- 2 worker reps who are knowledgeable in the work involved • supervisor of area (if available) • a union rep if reasonably available • a joint OHS committee member if available

10. CONDUCTING THE INVESTIGATION Process: • Manager/Supervisor immediately reviews the accident/injury report form information upon receipt • Seeks clarification of incident details if required - speaks to witnesses if needed • Ensures any immediate hazards are removed

11. CONDUCTING THE INVESTIGATION Process: Immediately initiate the investigation by establishing the investigation team, providing the Investigation report form and any information you have that would be helpful to the investigation

12. CONDUCTING THE INVESTIGATION Process: Once the investigation team has completed the investigation process review the recommendations and findings to ensure they will be effective in preventing a similar repeat incident.

13. CONDUCTING THE INVESTIGATION Process: • Implement recommendations made ASAP (or make/seek further recommendations) • Identify any concerns you have about the incident • Sign off where applicable and forward form as indicated

14. INVESTIGATION TIPS AND GUIDELINES • Gather the information: • Speak to the people involved • Determine exactly what happened • Analyse the information: • List, in chronological order, the sequence of events leading up the incident • Determine the cause(s) of the incident • Identify all contributing factors • Make recommendations • Focus on prevention of a repeat incident • Follow-up to ensure recommendations are implemented and effective

15. INVESTIGATION TIPS AND GUIDELINES • EQUIPMENT: • Was there any defects in equipment, tools or materials that contributed to the incident? • Was the equipment known to be faulty prior to the incident? Why was it not reported,repaired/replaced? • Was the equipment appropriate for the job and readily available for the task? • Have workers been trained in the use of the equipment? • Are written safe work procedures in place to operate equipment/tools?

16. INVESTIGATION TIPS AND GUIDELINES • ENVIRONMENT: • Was the location or position of the equipment, material or worker a contributing factor ? (ie. trip/slip hazards) • Was the hazardous condition/area identified previously and reported? If not, why? • Was there sufficient work space ? • Were environmental conditions a contributing factor? (Lighting, noise, ventilation, wet etc.)

17. INVESTIGATION TIPS AND GUIDELINES • PEOPLE: • Was there a written work procedure for the task? Is it adequate and current ? • Was the worker trained on the procedure and did they follow it? • Was worker distracted or rushed ? Why? • Was the required Personal Protective Equipment available and was the worker wearing it? • Was the worker wearing appropriate footwear/clothes for the task? • If assistance was needed for the task did the worker request it and was it available ?

18. INVESTIGATION TIPS AND GUIDELINES • SUPERVISION: • Was there a failure to detect, anticipate or report a hazardous condition? • Was there a failure to detect or correct deviations from the safe job procedures? • Were responsibilities adequately defined and understood by worker? • Was there failure to initiate corrective action for know hazardous conditions? • Was worker informed about potential job hazards?

19. INVESTIGATION TIPS AND GUIDELINES Potential Investigation Recommendations/Outcomes: • Equipment repairs, evaluations or purchases • Policy/Procedure/Process revisions/updates • Discussion/communication with worker(s) involved • Risk Assessment of area/concern • Provision of Personal Protective Equipment (goggles, gloves, face shield, respirator) • Work area enhancements or redesign • Training or re-training required • Update of Kardex, Care plan, ADL as needed • Evaluation of workload, work rotation or work activity

20. Example 1 - MSI - OVER-REACHING

21. Example 2 - Chemical Burn When investigating a Chemical Burntype injury some questions that can be asked are: • Was the right chemical being used for the right purpose? • Is the MSDS current and readily available? • Was Personal Protective Equipment worn as specified? (i.e. gloves) • Are there safe work procedures written for the safe use of the chemical? • Does the worker have adequate WHMIS training?

22. Example # 3Slip/Trip Fall • When Investigating a Slip/Trip type injury some questions that can be asked are: • What was the tripping hazard? • What immediate action needs to be taken? • What can be done to ensure the tripping hazard is dealt with over the long term? • Who needs to know any new information resulting from the investigation?

23. INVESTIGATIONS… Summary Checklist • Immediately review the incident report once received • Remove any immediate hazards or dangers that have the potential to cause injury • Initiate the Investigation process ASAP • Immediately follow-up on recommendations made and implement corrective measures • Ensure corrective measures are effective in preventing a similar repeat incident in future • Ensure the Accident and Injury report form is complete, signed off and forwarded as indicated • If you have questions or concerns about the Investigation process contact a Safety Advisor in your service area.

24. REMEMBER …. • Accidents are caused • Accidents can be prevented if causes are eliminated • The same accident will happen again if causes are not eliminated

25. OCCUPATIONAL HEALTH AND SAFETY SERVICES - CONTACTS • Regional Manager of Occupational Health & Safety: Michael Colussi - Ph: 519-7061 or Cell: 889-5597 • Team Leader Safety: Darren Buckler - Ph: 519-7043 or Page: 978-3674 • Safety Advisors Central Island: Tracy Larsen - Ph: 951-9506 (Parksville) Brian Kossey - Ph: 755-7691 (3097) Nanaimo

26. OCCUPATIONAL HEALTH AND SAFETY SERVICES - CONTACTS • Safety Advisors South Island: Ken Kamsteeg - Ph: 519-7044 Judi Murakami - Ph: 519-7056 Linda Gould - Ph: 519-7084 • Safety Advisor North Island: Clarence Friesen - Ph: 286-7054 Note: All contacts listed can also be contacted through the VIHA e-mail system.