ACCIDENT/INCIDENT ACCIDENT/INCIDENT INVESTIGATIONSINVESTIGATIONS

WCB REGULATION: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

PURPOSE OF PURPOSE OF INVESTIGATIONSINVESTIGATIONS

PURPOSE:PURPOSE: to gather information on the cause(s) of an incident

to make recommendations to prevent future similar occurrences

to implement corrective measures ASAP

VIHA ACCIDENT/INCIDENT VIHA ACCIDENT/INCIDENT - INVESTIGATION POLICY- 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.

EMPLOYER EMPLOYER RESPONSIBILITIESRESPONSIBILITIES

The Employer is The Employer is responsible to ensure: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

Employers Responsibilities Employers Responsibilities ContinuedContinued

As far as possible the As far as possible the Investigation must: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

Employers Responsibilities Employers Responsibilities ContinuedContinued

As far as possible the Investigation must:

if unsafe conditions, acts or procedures are identified, recommend corrective action(s) to prevent similar incidents

Employers Responsibilities Employers Responsibilities ContinuedContinued

Following an investigation the employer must without undue delay undertake any corrective action to prevent recurrence of similar incidents

Employers Responsibilities Employers Responsibilities ContinuedContinued

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

THE INVESTIGATORSTHE 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

CONDUCTING THE CONDUCTING THE INVESTIGATIONINVESTIGATION

Process: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

CONDUCTING THE CONDUCTING THE INVESTIGATIONINVESTIGATION

Process: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

CONDUCTING THE CONDUCTING THE INVESTIGATIONINVESTIGATION

Process: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..

CONDUCTING THE CONDUCTING THE INVESTIGATIONINVESTIGATION

Process: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

INVESTIGATION INVESTIGATION TIPS AND GUIDELINESTIPS 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

INVESTIGATION INVESTIGATION TIPS AND GUIDELINESTIPS AND GUIDELINES

EQUIPMENT: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?

INVESTIGATION INVESTIGATION TIPS AND GUIDELINESTIPS AND GUIDELINES

ENVIRONMENT: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.)

INVESTIGATION INVESTIGATION TIPS AND GUIDELINESTIPS 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 ?

INVESTIGATION INVESTIGATION TIPS AND GUIDELINESTIPS 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?

INVESTIGATION INVESTIGATION TIPS AND GUIDELINESTIPS AND GUIDELINES

Potential Investigation Potential Investigation Recommendations/Outcomes: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

Example 1 - Example 1 - MSI - OVER-REACHINGMSI - OVER-REACHING

When investigating a MSIOVER-REACHING typeInjury some questions to askare: Can the worker’s reach be reduced

by storing the item on a lower shelf orin a different location?

Can this task be done in a safermanner – with less reaching andtwisting of the body?

Is this a 2-person task? Has the worker received adequate

MSI training?

Example 2 - Chemical Example 2 - Chemical BurnBurn

When investigating a Chemical Burn type 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?

Example # 3Example # 3Slip/Trip FallSlip/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?

INVESTIGATIONS… INVESTIGATIONS… Summary ChecklistSummary 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..

REMEMBER ….REMEMBER …. Accidents are Accidents are

causedcaused Accidents can be Accidents can be

prevented if causes prevented if causes are eliminatedare eliminated

The same accident The same accident will happen again if will happen again if causes are not causes are not eliminatedeliminated

OCCUPATIONAL HEALTH AND OCCUPATIONAL HEALTH AND SAFETY SERVICES - CONTACTSSAFETY 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

OCCUPATIONAL HEALTH AND OCCUPATIONAL HEALTH AND SAFETY SERVICES - CONTACTSSAFETY 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.