PURPOSE OF THIS GUIDE

The Workplace Health, Safety and Compensation Commission is developing resource materials to help workplace parties employers, workers including supervisors and managers, and occupational health and safety committees to carry out their responsibilities for health and safety in the workplace. This specific booklet, Accident/Incident Investigations, is designed to provide workplace parties with an understanding of their role in effective accident/incident investigations. It includes an outline for planning and the six steps involved in conducting accident/incident investigations. A sample accident/incident report form and a sample accident/incident investigation form are also included in this booklet.

ACCIDENT/INCIDENT INVESTIGATIONS

ACCIDENT/INCIDENT INVESTIGATIONS

Sources of Information
Workplace Health, Safety and Compensation Commission Prevention Services Phone: (709) 778-1552 Toll free 1 800 563-9000 or Department of Government Services Occupational Health and Safety Branch Phone: (709) 729-2706 Toll free 1-800-563-5471 or Human Resources and Social Development Labour Program, Newfoundland and Labrador office Phone: (709) 772-5022 (call collect outside St. Johns)

www.safeworknl.com
May 2006

Disclaimer The Workplace Health, Safety and Compensation Commission (the Commission) provides information and health and safety advisory services for most aspects of occupational health and safety programming. The information presented is subject to a disclaimer. It is intended to provide examples of general use and may not apply to every circumstance. While all reasonable efforts have been made to ensure the accuracy of the information presented, the Commission does not and cannot guarantee the accuracy thereof. The Commission does not warrant or assume any legal liability or responsibility for the accuracy, completeness, or usefulness of the information presented nor for any actions taken in reliance thereon. The Commission shall not be liable for any damage or loss arising out of the use of the information or the application of the concepts contained therein. All those using the information do so at their own risk and shall be deemed to indemnify the Commission from any loss or damage arising from the use of the information. The information presented is subject to jurisdictional variation and is always subject to change. Individuals or organizations responsible for working with the information presented are responsible for ensuring that all applicable standards and regulations are fulfilled. The information presented cannot and should not be considered a definitive guide to government regulations nor does it relieve individuals or organizations using the information from their responsibilities under any or all applicable legislation.

May, 2006 Legislative Requirements

The legislation is a minimum guide for developing occupational health and safety (OH&S) policies and procedures in workplaces. However, best practices should be incorporated into all areas of businesses/organizations to increase the effectiveness of the OH&S program. The majority of employers in Newfoundland and Labrador must follow provincial legislation for occupational health and safety: Occupational Health and Safety Act Occupational Health and Safety Regulations For official copies of the Occupational Health and Safety Act and the Occupational Health and Safety Regulations please contact the following: Office of the Queen's Printer Ground Floor Confederation Building, East Block St. John's, Newfoundland and Labrador A1B 4J6 Telephone: (709) 729-3649 Unofficial copies are available on-line at: http://www.gs.gov.nl.ca/ohs/legislation.stm Some employers fall under federal jurisdiction and must follow the Canada Labour Code-Part II (Code). The Code applies to the following inter-provincial and international industries: railways; highway transport; telephone and telegraph systems; pipelines; canals; ferries, tunnels and bridges; shipping and shipping services; radio and television broadcasting and cable systems; airports; banks; grain elevators licensed by the Canadian Grain Commission, and certain feed mills and feed warehouses, flour mills, and grain seed cleaning plants; the federal public service and persons employed by the public service and about 40 Crown corporations and agencies; employment in the operation of ships, trains and aircraft; and the exploration and development of petroleum on lands subject to federal jurisdiction.

Note: Part II of the Canada Labour Code, Part II does not apply to certain undertakings regulated by the Nuclear Safety and Control Act. For an official copy of the Canada Labour Code please contact: Canadian Government Publishing, Communication Canada Ottawa, ON K1A 0S9 Telephone: (613) 941-5995 or 1-800-635-7943 FAX: (613) 654-5779 or 1-800-565-7757 Internet: http://publications.gc.ca Unofficial copies are available on-line at: http://laws.justice.gc.ca/en/l-2/17632.html

Introduction ..........................................................1

More Information .................................................2

Inside this Guide

Step 3 - Analyze the information to determine the root cause .............................14 Contributing Factors ...................................14 Immediate/Direct Cause(s) .........................15 Root/Basic Cause(s) ....................................16 Step 4 - Make recommendations ...................17 Step 5 - Write the accident/incident investigation report ........................................18 Step 6 - Follow-up ..........................................19

Accident/Incident Investigations ......................3

Requirements .....................................................3 Definitions ..........................................................4 An Accident .................................................4 An Incident ..................................................4 An Accident/Incident Investigation...............4 Reporting and Investigating Accidents/Incidents............................................4 Benefits of an Effective Accident /Incident Investigation ........................................5 Procedures.........................................................5 Roles in Accident/Incident Investigation .............6 Employers ....................................................6 Investigation Team........................................7 Workers Including Managers and Supervisors ..................................................7 OH&S committees.......................................7

Role of OH&S Committees ...............................20

Accident/Incident Investigations and the OH&S Program ............................................21

Planning Accident/Incident Investigations .......................................................8

Needs of the Investigation Team ........................8 Materials Needed for the Investigation ..............9 The Investigation Kit ...........................................9

Conclusion ...........................................................22

Appendix A - Glossary .....................................24

Steps in Accident/Incident Investigations .......................................................9

Step 1 - Immediate response to the accident/incident ............................................10 Step 2 - Gather information ...........................11 Taking Notes ..............................................11 Conducting Interviews ...............................11 Interviewing Tips ........................................11 Sample Interview Questions.......................12 Tips for Taking Pictures for Evidence ..........12 Suggestions for Collecting Samples ...........12 Reviewing Documentation..........................13

Appendix B - References to Legislation ........28

Appendix C - Hazardous Occurrence Investigation Report........................................35

Appendix D - Sample Accident/Incident Report Form .......................................................36

Appendix E - Sample Accident/Incident Investigation Form ...........................................37

Accident/Incident Investigations

Introduction
As part of the internal responsibility system, all workplace parties employers, workers, including managers and supervisors, and occupational health and safety (OH&S) committees have a shared responsibility for the OH&S program to the extent of each partys authority and ability to be involved. This means everyone works co-operatively, shows ownership for the program and is committed to preventing injury, illness and property damage in the workplace. Under provincial legislation, where 10 or more workers are employed in a workplace, the employer is required to establish and maintain an OH&S program in consultation with the OH&S committee. In workplaces where less than 10 workers are employed, the employer is required to ensure a worker health and safety (WH&S) representative is in place to monitor the health, safety and welfare of workers. And, in workplaces with less than six workers employed and where it is impractical to assign a WH&S representative, the employer may designate a workplace health and safety designate to monitor the health, safety and welfare of workers. For federally regulated workplaces, employers are responsible for developing, implementing and monitoring a prescribed program for the prevention of hazards in the workplace in consultation with the health and safety committee, policy committee or the health and safety representative. For the purpose of this booklet, the duties and responsibilities of the OH&S committee will also include those of WH&S representatives and workplace health and safety designates in provincially regulated workplaces and health and safety representatives in federally regulated workplaces. This booklet is designed to assist those responsible to carry out effective accident/incident investigations in the workplace. It provides basic information about accident/incident investigations including the role of workplace parties, planning the investigation, and the steps involved in conducting the investigation. Best practice is a standard that exceeds minimum legislative requirements and supports working in the safest possible way. Carrying out investigations on all accidents and incidents, finding root causes, and implementing corrective actions demonstrate best practices. For commonly used OH&S terms, please refer to Appendix A Glossary.

Accident/Incident Investigations

More Information
For more information on building a health and safety program, there are several booklets and information resources available in this series.

Fact Sheets:
Introduction to an OH&S Program Leadership and Administration OH&S Committees Education & Training Safe Work Practices and Procedures Hazard Recognition Evaluation and Control Workplace Inspections Accident and Incident Investigation Disability Management Ergonomics and the OH&S Elements Worker Health and Safety Representative/Workplace Health and Safety Designate

Look for these fact sheets in the near future:

Communication Emergency Preparedness

Booklets:
Guide to Writing an Occupational Health & Safety Policy Occupational Health & Safety Committees Introduction to an Occupational Health and Safety Program Workplace Inspections Accident/Incident Investigations

Look for these booklets in the near future:

Communication Emergency Preparedness

Accident/Incident Investigations

Accident/Incident Investigations
Accident/incident investigations are an important part of the OH&S program. They include a process of fact finding to identify the root (basic) cause of accidents/incidents as a means of preventing further occurrences. Ergonomic considerations should always be part of accident/incident investigations. Including investigations in the OH&S program strengthens the internal responsibility system and is essential to building a positive health and safety culture in the workplace.

Requirements
Specific OH&S requirements for employers who are provincially regulated can be found in the Occupational Health and Safety Act and Regulations. Requirements for federally regulated employers can be found in the Canada Labour Code, Part II and the Canada Occupational Health and Safety Regulations. Contact information for obtaining provincial and federal OH&S legislation can be found at the beginning of this booklet and in Appendix B References to Legislation. The legislative references in Appendix B refer to the content in this booklet and may not be complete. Workplace parties must refer to the appropriate legislation to find complete information regarding legislative requirements for developing an OH&S program. Employers must also comply with industry-specific or hazard-specific legislation. Examples include: Asbestos Abatement Regulations; Asbestos Exposure Code Regulations; OH&S First Aid Regulations; Workplace Hazardous Materials Information System (WHMIS) Regulations; Radiation Health and Safety Act and Regulations; Mines Safety of Workers Regulations; and Workplace Health, Safety and Compensation Act and Regulations. Employers should be aware of legislation that relates to their industry and specific hazards in their workplaces. Appendix B References to Legislation contains details of the following legislation.
OH&S Act OH&S Regulations Canada Labour Code Part II Canada OH&S Safety Regulations Sections 15.3, 15.4, 15.5, 15.6, 15.7, 15.8, 15.9 Workplace Health, Safety and Compensation Act Sections 56

Sections 4 41 (1) 42.1 (1) 54

Sections 4(1) (f) (iv) 4 (1) (j)

Sections 134.1 (1) and (4) (d) 135 (1) and (7) (e) 136 (1) 136 (2)

Accident/Incident Investigations

Definitions
An Accident An accident is an unplanned/undesired event that results in a personal injury or illness, or in damage to property, process or the environment. An Incident An incident is an unplanned/undesired event that has the potential to result in an injury, illness, or property damage. An Accident/Incident Investigation An accident/incident investigation is a well planned analysis of an event that identifies the root cause and recommends corrective action to prevent the event from happening again. Despite what many people think, workplace accidents/incidents dont just happen; they result from a series of events that usually stem from an ineffective OH&S program. The aim of an OH&S program is to prevent accidents and incidents; however, as part of the internal responsibility system, when accidents/incidents do happen, there should be a process in place to find the root cause of these events.

Reporting and Investigating Accidents/Incidents

Employers must immediately report accidents resulting in serious injury or death or the potential for serious injury or death to the assistant deputy minister and the OH&S committee (OH&S Act, section 54). Employers must also report an injury to a worker for which the worker is disabled from earning full wages or the worker is entitled to medical aid (Workplace Health, Safety and Compensation Act, section 56). Federally regulated workplaces have reporting and investigation requirements in cases of work-related injuries or illnesses. Please refer to Appendix B References to Legislation under the heading Canada Occupational Health and Safety Regulations for these requirements. Appendix C Hazardous Occurrence Investigation Report contains a copy of the form employers are required to complete. A copy of this form may be found on the Human Resources and Social Development web site:
+ + + +

Go to www.sdc.gc.ca Click Forms Click List of Forms Under the heading Occupational Health and Safety, find number LAB1070 Hazardous Occurrence Investigation Report.

When developing accident/incident investigation procedures for workplaces, best practices would include an internal process for reporting and investigating all accidents and incidents. Incidents are warnings that

Accident/Incident Investigations

something is wrong in the workplace. If incidents are investigated and the root cause found, accidents can be prevented. Please refer to Appendix D Sample Accident/Incident Report Form.

Benefits of an Effective Accident/Incident Investigation

employers demonstrate their commitment to health and safety to their workers and the public; workers on the investigation team are trained in investigation techniques; workers are trained in the importance of reporting accidents/incidents; accidents/incidents are promptly reported; accidents/incidents are immediately investigated; root causes are identified; corrective actions are implemented, monitored and evaluated; workers are trained in how to prevent similar accidents/incidents; pain and suffering are reduced; findings can be used to identify accident/incident trends; and associated costs of accidents and property damage are reduced.

Procedures
Accident/incident investigations are a mandatory part of an OH&S program and should have procedures to ensure their effectiveness. Accident/Incident investigation procedures are the step by step way for completing an accident/incident investigation. All workplaces are different; therefore, the procedures should be developed with the specific workplace in mind. For example, in some workplaces, the procedures may outline the duties of groups of workers in a specific department while another workplace may outline the duties of groups based on their job titles. Duties and responsibilities depend on what works best for the individual workplace. Accident/incident investigation procedures should include a process for planning and the six steps for conducting the investigation. They also identify those responsible for each step in the procedure and those responsible for communicating the results of the investigation. Ergonomic considerations should be included in accident/incident investigations procedures.

Accident/Incident Investigations

Roles in Accident/Incident Investigation

In keeping with the internal responsibility system and with best practice, workplace parties have a role in accident/incident investigations. To meet their legislative requirements for establishing and maintaining an OH&S program and conducting accident/incident investigations, employers should ensure accident/incident investigation procedures outline the responsibilities of all workplace parties. Following are examples of roles and responsibilities based on legislative requirements and best practice. Employers must immediately report accidents resulting in serious injury or death or the potential for serious injury or death to the assistant deputy minister and the OH&S committee; must report an injury to a worker for which the worker is disabled from earning full wages or the worker is entitled to medical aid; provide the resources human and financial to carry out accident/incident investigations; ensure accident/incident investigation procedures are developed and followed; ensure all workers are provided with the education and training needed to understand their responsibility to report accidents/incidents and to cooperate with those conducting investigations; review accident/incident investigation reports; ensure corrective action is implemented, monitored, evaluated and communicated; and review accident/incident investigation procedures at least every three years. Investigation Team Managers and supervisors are often the ones that carry out accident/incident investigations. However, it is a good practice, when possible, to include other workers and members of the OH&S committee on investigation teams. This practice would promote the internal responsibility system in the workplace. Those conducting the investigation are to: conduct the investigation as soon as possible after the accident/incident; follow accident/incident investigation procedures; put emphasis on finding the root cause not on finding fault or placing blame;

Accident/Incident Investigations

consider multiple causes to find all factors contributing to the event; do not jump to the obvious answer keep looking; and ensure the results of the investigation are communicated to workplace parties. Workers Including Managers and Supervisors report accidents/incidents to their supervisors immediately; co-operate with the accident/incident investigation team; participate as members of the investigation team when requested; make suggestions for corrective actions to the investigation team; and take part in training required as the result of the investigation. OH&S committees are a resource to the accident/incident investigation team; may participate as members of the investigation team; review all accident/incident investigation reports to identify trends in injury, illness and property damage; monitor implementation, follow-up, and evaluation of corrective actions; review training required as the result of the accident/incident investigation; and regularly evaluate this element of the OH&S program.

Planning Accident/Incident Investigations

Accident/incident investigation procedures should identify the members of the investigation team, their training requirements, and their responsibilities. It is beneficial to have a core team of trained individuals to carry out an investigation. Depending on the accident/incident and the potential for it recurring, the team may differ in size. Having more than one person investigating means there is less of a chance to overlook something.

Needs of the Investigation Team

The accident/incident investigation team should be trained in investigation techniques including + gathering information + interviewing skills

Accident/Incident Investigations

+ + + + + +

collecting samples analysing information contributing factors of accidents/incidents identifying immediate/direct causes identifying root/basic causes writing recommendations

+ writing reports;

know what is expected of them in the investigation process; keep an open mind about the cause; never jump to a conclusion before all the information has been analyzed; be impartial; understand that there is rarely only one cause of an accident/incident; be familiar with + work processes, + the people that work in the workplace, and + practices and procedures; have knowledge of OH&S legislation, standards, codes of practice, manufacturers specification, etc.; know the layout of the workplace; be objective and honest; and possess interviewing, analytical, organizational and report-writing skills.

Materials Needed for the Investigation

The accident/incident investigation procedure should include a list of the materials needed for an investigation plus the materials in the investigation kit. The accident/incident investigation procedure should identify required materials, equipment, and personal protective equipment (PPE); names and phone numbers of personnel such as the investigation team, first aid responders, members of the OH&S committee, management personnel, maintenance staff, security staff, etc.; and items to be included in an investigation kit.

Accident/Incident Investigations

STEPS

in

Accident/Incident Investigations
The Investigation Kit
Items usually found in an accident/Incident investigation kit + accident/incident investigation forms + 'Do Not Enter' tape + clip board + tape measure and ruler + camera, batteries, film (or video camera) + flashlight and batteries + plastic bags and containers for samples + labels and permanent marker for labelling samples + pens/pencils + eraser + notebook and graph paper CAUTION: Some workplaces may not permit the use of devices such as cameras, flashlights, etc. because, depending on the workplace and the accident, they may pose a hazard to the investigation team. Therefore, the above items should be evaluated to ensure they do not create additional hazards.

Accident/incident investigation procedures should outline a step-bystep process for carrying out each of the six steps in the investigation:

Step 1
Immediate response to the accident/incident

Step 2
Gather information

Step 3
Analyze the information to determine the root cause

Step 4
Make recommendations

Step 5
Write the accident/incident investigation report

Step 6
Follow-up

Accident/Incident Investigations

STEP1
Immediate response to the accident/incident
CAUTION: The investigation team members must ensure that:
the equipment they bring to the accident site does not endanger themselves or others; and they take particular care and follow safe work procedures so as not to be exposed to workplace hazards such as confined space, invisible gases, electrocution, engulfment, etc. as the result of helping injured workers or conducting the investigation.
The steps to be taken immediately in case of an accident/incident are: eliminate immediate hazards to ensure no one else is injured; provide emergency care to the injured; secure the accident site: + use ropes, barrier tape and/or cones or human guards if required, + remove nothing from the site without permission, and + maintain site until all information is collected; notify proper authorities governmental agencies, Workplace Health, Safety and Compensation Commission (the Commission), etc. Note: When an injury occurs in the workplace and a worker requires medical care, the employer is required to notify the Commission in writing within three days.1 The amount of information gathered and the resources needed depend on the specific accident/incident.

If a worker is injured and requires medical care, the worker must complete a Form 6 Worker's Report of Injury, and the employer must complete a Form 7 Employer's Report of Injury. These forms are available at: http://www.whscc.nf.ca/form.htm.

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Accident/Incident Investigations

STEP2
Gather information
Taking Notes
Keeping notes in a notebook throughout an investigation process keeps information together and organized. Notes should be neat and detailed, yet concise; and they should answer who, what, when, where, why and how. Good notes help to recall facts and are useful when analyzing information to determine the root cause.

Notes should include:

+ + + + + + + + + +

dates and times; names and addresses; information from interviews; observations; action taken by you and others; description of site and environmental conditions; reference to pictures, if taken; measurements; sketches and diagrams; and information about evidence gathered.

Conducting Interviews
Interview promptly and separately
injured workers; witnesses to the event; immediate supervisor; staff from departments such as maintenance, purchasing or supplies (if necessary); and anyone else who can provide information; for example, a representative of the manufacturer or a company trainer.

Interviewing Tips
maintain privacy and put the person at ease; explain why the interview is being conducted; emphasize the investigation is for fact finding, not fault finding; ask people to explain what happened in their own words; let people tell what happened dont lead the witness; try not to interrupt; ask specific questions to clarify and fill in the gaps; repeat what is reported to verify your understanding;

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Accident/Incident Investigations

thank people for their co-operation; and write-up a complete account as soon as possible after the interview to ensure the details are accurate.

Sample Interview Questions

Where were you when the accident (incident) happened? What were you doing at that time? What did you see? What did you hear? Who else was around at the time? Is there a standard procedure for the task? Are workers trained in the standard procedure? Was this the first time this task was done? Was the work being supervised at the time? Is there anything else youd like to add?

Suggestions for Collecting Samples

use a diagram of the area to note where samples were found; keep people away from area; ensure evidence is not damaged; place samples in a bag or container, seal it, and label with a permanent marker; label the evidence with
+ + + +

for Taking Pictures for Evidence

The following tips will ensure pictures can be used as evidence: + use adequate lighting; + ensure unobstructed view of the area or object; + date the photograph; + reference the measurement (i.e. place a ruler, measuring tape, another object or person, etc. next to the area or object); and
+

a reference number the date and time evidence was collected the specific location evidence was found the collectors name;

keep evidence in a secure place; and keep a record if evidence is moved.

keep the negatives.

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Accident/Incident Investigations

Reviewing Documentation

Examples of documentation that may need to be reviewed log books work schedules files policy and procedure manuals specific legislation manufacturers specification check lists training records formal workplace inspection reports previous records of this kind of event previous accident/incident investigation reports

Once all information about the accident/incident is gathered, it must be reviewed to determine the root cause. The information should be organized into a logical sequence of events, working back from when the accident/incident occurred. All possible causes should be listed at each step and checked to see if they are supported by the evidence. If gaps in the evidence are discovered, there may be a need to re-interview witnesses, review the documentation again, or gather further information.

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Accident/Incident Investigations

STEP3
Contributing Factors

Analyze the information to determine the root cause

There are many factors that contribute to accidents/incidents; however they can usually be broken down into four major categories: people, equipment, materials and the environment. The following are some areas that may be explored when investigating accidents/incidents to determine the root cause(s).
People (management, non-management workers, contract workers, visitors) ? knowledge, experience, skill, understanding, orientation,training ? job site analyses ? communication ? safe work practices and procedures ? documentation of hazards ? equipment ? preventative maintenance ? physical capability analysis ? workload ? workplace inspections Equipment ? design ? manufacturers specifications ? use ? preventative maintenance ? ergonomics ? job safety analysis ? safe work practices and procedures ? hazard recognition, evaluation and control ? documentation ? personal protective equipment (PPE) Materials ? manufacturers specifications ? use ? preventative maintenance ? ergonomics ? job safety analysis ? safe work practices and procedures ? hazards recognized, evaluated and controlled ? documentation

14

Environment ? lighting ? noise ? air quality ? housekeeping practices ? weather conditions

Accident/Incident Investigations

It is widely accepted that accidents/incidents occur as a result of a chain of events. There is rarely one cause. Causes of accidents/incidents are usually grouped into two main categories: immediate/direct cause(s) and root/basic cause(s).

Immediate/Direct Cause(s)
Immediate/Direct Cause(s) are events, conditions or acts that immediately precede the accident/incident. Immediate/direct causes are usually the symptoms of the root/basic cause, not the root cause itself. Immediate/direct causes are usually related to uncontrolled hazards arising from substandard conditions and/or substandard actions.

Examples of conditions:
machine guards in good working order; noise at acceptable levels; planning documented; good housekeeping practiced; and personal protective equipment maintained.

Examples of actions:
safe work procedures followed; equipment appropriately maintained and used; hazards communicated; rules followed; and personal protective equipment properly used and maintained.

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Accident/Incident Investigations

Root/Basic Cause(s)
Root/Basic Cause(s) are real or underlying cause(s) of accidents/incidents. They are not always immediately evident.

Examples of job factors: design of equipment; knowledge of workplace parties; communication practices; workplace inspections scheduled and conducted; and appropriate equipment available and used.

Examples of personal factors: orientation; communication and understanding of safe work practices and procedures; pace of work; education and training; and performance feedback.

Analyzing all information contributing factors and the immediate/direct causes increases the likelihood of finding the root cause(s). Finding the root cause(s) and implementing corrective actions will in turn prevent similar accidents/incidents in the future.

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Accident/Incident Investigations

STEP4
Make recommendations
Once the root cause of the accident/incident is identified, a set of well thoughtout recommendations should be developed as a means of preventing a similar event in the future. The accident/incident investigation procedures should outline the criteria for writing recommendations.

Recommendations should: be clearly written; be as specific as possible what, when and where; identify target dates for implementation and follow-up; and list the resources required for implementation (i.e. human, financial, equipment, materials, etc.).

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Accident/Incident Investigations

STEP5

Write the accident/incident investigation report

The purpose of the accident/incident investigation report is to communicate the investigation information and document recommendations for corrective action. Accident/incident investigation reports may be used as evidence during legal proceedings; therefore, it is important that it is fully completed. The accident/incident investigation procedures should identify who is responsible for distributing the written report and who is responsible for communicating its findings to the appropriate workers. Please refer to Appendix E Sample Accident/Incident Investigation Form. When writing an investigation report, remember to: keep the report well organized, clear and to the point; describe what happened including the sequence of events and timelines; write a short description of the investigation methods used; and describe the analysis of the cause including the immediate/direct causes and the root cause(s). The accident/incident investigation report should include: supporting documentation and other evidence; for example, summaries of interviews, pictures and analysis of evidence; recommendations for corrective actions; outline of the follow-up procedure; signatures of the investigation team; and date the report is submitted to the employer.

The accident/incident investigation procedures should identify: those responsible for distributing the investigation report; those who should receive the report or the findings of the investigation; and a mechanism for communicating the findings to appropriate staff. The report should be distributed to senior management, the OH&S committee, and the management in the appropriate work areas.

All confidential worker information should be removed before distribution of the investigation report and before communicating the investigation findings. 18

Accident/Incident Investigations

STEP6
Follow-up
Accident/incident investigation procedures should identify those responsible for: implementing corrective actions within the assigned time frame; meeting time-lines for implementing the corrective actions; adding the corrective actions to the workplace inspection checklist as a means of evaluating them; evaluating corrective actions to ensure they are effective; sharing the investigation findings with workers; and communicating the effectiveness of the corrective actions to senior management, the OH&S committee, and the staff in the affected work area.

All confidential worker information should be removed before distribution of the investigation report and before communicating the investigation findings.

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Role of OH&S Committees

The OH&S committee should receive all accident/incident investigation reports. The accident/incident investigation procedures should outline those responsible for distributing the report to the OH&S committee and those responsible for updating the OH&S committee on implementation, follow-up and evaluation of corrective actions. As part of the internal responsibility system, the OH&S committee reviews all accident/incident investigation reports to ensure: accident/incident investigation procedures are followed; root causes are identified; recommendations for corrective actions are appropriate; additional recommendations are developed and forwarded to the employer if appropriate; implementation time-lines are met; corrective actions are monitored and evaluated; communication procedures for accident/incident investigations are followed; trends in injury, illness and property damage are identified; and accident/incident investigations are an effective part of the OH&S program. In addition to the above, the employer may ask the OH&S committee to accept other duties such as being part of the investigation team. Just as with other team members, these OH&S committee members should be trained in accident/incident investigations and in hazard recognition, evaluation and control.

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Accident/Incident Investigations

Accident/Incident Investigations and the OH&S Program

Accident/incident investigations are an important part of and are closely linked to other elements of an OH&S program; for example, they:

q demonstrate the employers leadership and commitment to

preventing injury, illness and property damage by providing necessary resources to complete accident/incident investigations;

q are an important means of hazard recognition, evaluation and

control;

q identify
+ education and training needs, + safe work practices and procedures that need to be reviewed, revised or developed, and + injury, illness and property damage trends;

q involve the OH&S committee; q identify items that may need to be added to the workplace
inspections checklist;

q improve communication about OH&S in the workplace; q will need a good disability management program in place if the
accident results in an injury or illness; and

q may identify a need for review of emergency

preparedness/response equipment and procedures.

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Accident/Incident Investigations

Conclusion
Using the information in this booklet will help workplace parties to plan accident/incident investigations, choose the investigation team, document the findings, identify the root cause(s), recommend corrective action, complete the report, and follow-up on corrective action. Accident/incident investigations are an important part of an OH&S program. The involvement of all workplace parties strengthens the internal responsibility system, is important to preventing similar occurrences in the future, and is essential to building a positive health and safety culture in workplaces.

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Appendix A
Glossary....................................................24

Appendix B
References to Legislation ..........................28

Appendix C
Hazardous Occurrence Investigation Report.....................................................35

Appendix D
Sample Accident/Incident Report Form ............................................36

Appendix E
Sample Accident/Incident Investigation Form...................................37

Appendices

Accident/Incident Investigations

Appendix A - Glossary
Accident an unplanned event that results in a personal injury or illness, damage or loss of property, process or environment. see root/basic cause performance standards developed by employers, workers and OH&S professionals which exceed basic OH&S legislative requirements and which strive toward doing work in the safest possible way. measures that are implemented to eliminate or minimize hazards in the workplace. These controls are established as either engineering (first line of defence), administrative, or personal protective equipment (used as a last resort). those unsafe objects, conditions or behaviours which occur immediately before an accident/ incident; for example, inadequate guards and barriers, defective tools, and improper lifting. These are not the root cause. occurs when actions normally considered reasonable in a particular circumstance are taken. In cases where a serious workplace injury occurs and legal action is taken, a due diligence defence can be mounted if the person charged did everything a reasonable person would do in the same situation to prevent the injury. a person who employs one or more workers [OH&S Act, section 2 (f)]. a science that seeks to adapt work or working conditions to suit the worker. The aim is the evaluation and design of facilities, environments, jobs, training methods and equipment to match the capabilities and limitations of workers and reduce the potential for fatigue, error or unsafe acts.

Basic/root cause Best practice

Controls

Direct (immediate) cause

Due Diligence

Employer

Appendix A Glossary

Ergonomics

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Formal workplace inspections

regularly scheduled examinations carried out as a means of preventing injury, illness and property damage and of ensuring a safe and healthy workplace. They are formally documented with the use of a checklist and a report that includes recommendations for corrective actions. dangerous object, event, behaviour or condition which has the potential to cause injury, illness or property damage. an undesired event that could have resulted in injury, illness or damage to property, process or environment.

Hazard

Incident (near miss; potential accident) Informal workplace inspections

daily routines used as a means of preventing injury, illness and property damage and of ensuring a safe and healthy workplace; for example, a supervisors walkthrough or a workers routine equipment check. Informal inspections are usually not scheduled or documented and do not require a checklist. a philosophy guiding OH&S legislation in all Canadian jurisdictions. It is a system where all workplace parties employers, workers including supervisors and managers, and OH&S committees share in the responsibility for workplace health and safety to the degree of each partys authority and ability to do so. employment, business, calling or pursuit but does not include an endeavour that is not included in one of the classes of occupations in the current Canadian Classification and Dictionary of Occupations [OH&S Regulations, section 2 (f)]. a committee required to be established by the employer in workplaces with 10 or more workers. The OH&S committee must consist of representatives of the employer and the workers at the workplace. Sections 37, 38, 38.1, 39, 40 and 45 of the OH&S Act describe the composition and duties of the committee, and the training and meeting requirements. Further requirements for OH&S committees can be found in section 21 of the OH&S Regulations.

Internal responsibility system

Occupation

OH&S committee

25

Appendix A Glossary

Accident/Incident Investigations

Procedures (in relation to the OH&S program) Risk

step by step way for completing of the OH&S program components.

chance of loss based on: (a) the probability of an injury, illness, damage or loss of property, process or environment; and (b) the possible severity of the injury, illness, damage or loss of property, process or environment. the real cause of an accident/incident and the reason why it occurred; for example, inadequate design, lack of knowledge or skill, physical and physiological stress, etc. The root cause is usually not immediately evident and requires investigation. an accident resulting in death, permanent or temporary disability, excessive property damage, or accidental release of pollutants with significant effects. More specifically, serious accidents are those accidents meriting in-depth investigation and are defined in the OH&S Act, section 54(3). a fracture of the skull, spine, pelvis, femur, humerus, fibula, tibia, radius or ulna; an amputation of a major part of a hand or foot; the loss of sight of a eye; a serious internal hemorrhage; a burn that requires medical attention; an injury caused directly or indirectly by explosives; an asphyxiation or poisoning by gas resulting in a partial or total loss of physical control; or any other injury likely to endanger life or cause permanent injury. A serious injury does not include injures to a worker of a nature that may be treated through first aid or medical treatment and the worker is able to return to his or her work either immediately after the treatment or at his or her next scheduled shift [OH&S Act, section 54(3)]. includes a superintendent, foreman or other worker authorized or delegated to exercise direction and control over workers of an employer [OH&S Regulations, section 2 (j)].

Root/basic cause

Serious accident

Serious injury

Appendix A Glossary

Supervisor

26

Accident/Incident Investigations

Unsafe act

departure from an accepted, normal or correct procedure or practice which has actually produced injury or property damage or which has the potential for producing such loss. departure from a standardized, accepted or normal physical state to create circumstances which increase the likelihood of an accident. a person engaged in an occupation [OH&S Act, section 2 (m)]. a place where a worker or self-employed person is engaged in an occupation and includes a vehicle or mobile equipment used by a worker in an occupation [OH&S Act, section 2 (n)]. an employer-funded no-fault insurance system that promotes safe and healthy workplaces, provides returnto-work programs and offers compensation to injured workers and their dependants. those who perform work or are responsible for the performance of work in a workplace. They include employers, workers including managers and supervisors, and the OH&S committee.

Unsafe condition

Worker

Workplace

Workplace Health, Safety and Compensation Commission Workplace parties

27

Appendix A Glossary

Accident/Incident Investigations

Appendix B References to Legislation

Important Note:
The legislative references included in this section are not official versions. For official versions of the legislation, please see below. The legislative references in Appendix B refer to the content in this booklet and may not be complete. Workplace parties must refer to the appropriate legislation to find complete information regarding legislative requirements for developing an OH&S program.
Provincial legislation contact information:
For official copies of the Occupational Health and Safety Act and the Occupational Health and Safety Regulations please contact: Office of the Queens Printer Ground Floor Confederation Building, East Block St. Johns, Newfoundland and Labrador A1B 4J6 Telephone: (709) 729-3649 Unofficial copies are available on-line at: http://www.gs.gov.nl.ca/ohs/legislation.stm

Federal legislation contact information:

For an official copy of the Canada Labour Code please contact: Canadian Government Publishing, Communication Canada Ottawa, Ontario K1A 0S9 Telephone: (709) 772-5571 Bookstores: (613) 954-5779 or 1-800-667-2868 Fax: (613) 654-5779 or 1-800-565-7757 Internet: http://publications.gc.ca Unofficial copies are available on-line at: http://laws.justice.gc.ca/en/l-2/17632.html

OH&S Act

Appendix B - References to Legislation

4. Employers general duty An employer shall ensure, where it is reasonably practicable, the health, safety and welfare of his or her workers. 41. Worker representative (1) Where less than 10 workers are employed at a workplace, the employer shall ensure that a worker not connected with the management of the workplace is designated as the worker health and safety representative to monitor the health, safety and welfare of workers employed at the workplace.

28

Accident/Incident Investigations

42.1 Workplace designate (1) Notwithstanding section 41, where less than six persons are engaged at a workplace and the designation of a worker health and safety representative is impracticable, the employer may designate a workplace health and safety designate to monitor the health, safety and welfare of workers employed at the workplace. 54. Reporting accidents (1) Where an accident takes place at a workplace (a) that results in serious injury to a person or results in the death of a person; or (b) that had, or continues to have, the reasonable potential of causing serious injury to or the death of a person the employer, or principal contractor shall immediately notify the assistant deputy minister of the accident. (2) Where an accident is reported under subsection (1), notification shall immediately be given to the committee, the worker health and safety representative or the workplace health and safety designate. (3) In this section and section 55 "serious injury" means (a) a fracture of the skull, spine, pelvis, femur, humerus, fibula or tibia, or radius or ulna; (b) an amputation of a major part of a hand or foot; (d) a serious internal hemorrhage; (e) a burn that requires medical attention; (f) an injury caused directly or indirectly by explosives; (g) an asphyxiation or poisoning by gas resulting in a partial or total loss of physical control; or (h) another injury likely to endanger life or cause permanent injury, but does not include injuries to a worker of a nature that may be treated through first aid or medical treatment and the worker is able to return to his or her work either immediately after the treatment or at his or her next scheduled shift. (c) the loss of sight of an eye;

29

Appendix B - References to Legislation

Accident/Incident Investigations

OH&S Regulations
4. Occupational health and safety program (1) An occupational health and safety program required under section 36.1 of the Act shall be signed by the employer and by the person or persons responsible for the management of the employers operations in the province and shall include (f) a system for the recognition, evaluation and control of hazards that includes: (iv) procedures for the prompt investigation of hazardous occurrences to determine the cause of the occurrence and the actions necessary to prevent a recurrence, (j) maintenance of records and statistics, including occupational health and safety committee minutes, reports of occupational health and safety inspections and investigations, with procedures to allow access to them by persons entitled to receive them under the Act.

Canada Labour Code, Part II

134.1 Policy Health and Safety Committees (1) Establishment mandatory For the purposes of addressing health and safety matters that apply to the work, undertaking or business of an employer, every employer who normally employs directly three hundred or more employees shall establish a policy health and safety committee and, subject to section 135.1, select and appoint its members. (4) Duties of policy committee A policy committee (d) shall participate to the extent that it considers necessary in inquiries, investigations, studies and inspections pertaining to occupational health and safety; 135. Work Place Health and Safety Committees (1) Establishment mandatory For the purposes of addressing health and safety matters that apply to individual work places, and subject to this section, every employer shall, for each work place controlled by the employer at which twenty or more employees are normally employed, establish a work place health and safety committee and, subject to section 135.1, select and appoint its members.

Appendix B - References to Legislation

30

Accident/Incident Investigations

(7)

Duties of committee

A work place committee, in respect of the work place for which it is established (e) shall participate in all of the inquiries, investigations, studies and inspections pertaining to the health and safety of employees, including any consultations that may be necessary with persons who are professionally or technically qualified to advise the committee on those matters 136. Health and Safety Representatives (1) Appointment of health and safety representative Every employer shall, for each work place controlled by the employer at which fewer than twenty employees are normally employed or for which an employer is not required to establish a work place committee, appoint the person selected in accordance with subsection (2) as the health and safety representative for that work place (2) Selection of person to be appointed The health and safety representative for a work place shall be selected as follows: (a) the employees at the work place who do not exercise managerial functions shall select from among those employees the person to be appointed; or (b) if those employees are represented by a trade union, the trade union shall select the person to be appointed, in consultation with any employees who are not so represented, and subject to any regulations made under subsection (11). The employees or the trade union shall advise the employer in writing of the name of the person so selected

Canada Occupational Health and Safety Regulations

Reports by Employee 15.3 Where an employee becomes aware of an accident or other occurrence arising in the course of or in connection with the employees work that has caused or is likely to cause injury to that employee or to any other person, the employee shall, without delay, report the accident or other occurrence to his employer, orally or in writing. SOR/89-479, s. 1.

31

Appendix B - References to Legislation

Accident/Incident Investigations

Investigations 15.4 (1) Where an employer becomes aware of an accident, occupational disease or other hazardous occurrence affecting any of his employees in the course of employment, the employer shall, without delay, (a) appoint a qualified person to carry out an investigation of the hazardous occurrence; (b) notify the work place committee or the health and safety representative of the hazardous occurrence and of the name of the person appointed to investigate it; and (c) take necessary measures to prevent a recurrence of the hazardous occurrence. (2) Where the hazardous occurrence referred to in subsection (1) is an accident involving a motor vehicle on a public road that is investigated by a police authority, the investigation referred to in paragraph (1)(a) shall be carried out by obtaining from the appropriate police authority a copy of its report respecting the accident. (3) As soon as possible after receipt of the report referred to in subsection (2), the employer shall provide a copy thereof to the work place committee or the health and safety representative. SOR/89-479, s. 1; SOR/94263, s. 56; SOR/2002-208, s. 31. Telephone or Telex Reports 15.5 The employer shall report to a health and safety officer, by telephone or telex, the date, time, location and nature of any accident, occupational disease or other hazardous occurrence referred to in section 15.4 that had one of the following results, as soon as possible but not later than 24 hours after becoming aware of that result, namely, (a) the death of an employee; (b) a disabling injury to two or more employees; (c) the loss by an employee of a body member or a part thereof or the complete loss of the usefulness of a body member or a part thereof; (d) the permanent impairment of a body function of an employee; (e) an explosion; (f) damage to a boiler or pressure vessel that results in fire or the rupture of the boiler or pressure vessel; or (g) any damage to an elevating device that renders it unserviceable, or a free fall of an elevating device. SOR/89-479, s. 1; SOR/94-263, s. 57; SOR/2002-208, s. 38.

Appendix B - References to Legislation

32

Accident/Incident Investigations
Records 15.6 (1) The employer shall, within 72 hours after a hazardous occurrence referred to in paragraph 15.5(f) or (g), record in writing (a) a description of the hazardous occurrence and the date, time and location of the occurrence; (b) the causes of the occurrence; and (c) the corrective measures taken or the reason for not taking corrective measures. (2) The employer shall, without delay, submit a copy of the record referred to in subsection (1) to the work place committee or the health and safety representative. SOR/89-479, s. 1; SOR/94-263, s. 58; SOR/2002-208, s. 32. Minor Injury Records 15.7 (1) Every employer shall keep a record of each minor injury of which the employer is aware that affects any employee in the course of employment. (2) A record kept pursuant to subsection (1) shall contain (a) the date, time and location of the occurrence that resulted in the minor injury; (b) the name of the employee affected; (c) a brief description of the minor injury; and (d) the causes of the minor injury. SOR/89-479, s. 1. Written Reports

(a) a disabling injury to an employee; (b) an electric shock, toxic atmosphere or oxygen deficient atmosphere that caused an employee to lose consciousness; (c) the implementation of rescue, revival or other similar emergency procedures; or (d) a fire or an explosion

33

Appendix B - References to Legislation

15.8 (1) The employer shall make a report in writing, without delay, in the form set out in Schedule I to this Part setting out the information required by that form, including the results of the investigation referred to in paragraph 15.4(1)(a), where that investigation discloses that the hazardous occurrence resulted in any one of the following circumstances:

Accident/Incident Investigations

(2) The employer shall submit a copy of the report referred to in subsection (1) (a) without delay, to the work place committee or the health and safety representative; and (b) within 14 days after the hazardous occurrence, to a health and safety officer at the regional office or district office. SOR/89479, s. 1; SOR/94-263, s. 59; SOR/2002-208, s. 33. 15.9 Where an accident referred to in subsection 15.4(2) results in a circumstance referred to in subsection 15.8(1), the employer shall, within 14 days after the receipt of the police report of the accident, submit a copy of that report to a health and safety officer at the regional office or district office. SOR/89-479, s. 1; SOR/2002-208, s. 38.

Workplace Health, Safety and Compensation Act

56. Duties of employer (1) An employer shall, within 3 days after the occurrence of an injury to a worker in his or her employment as a result of which the worker is disabled from earning full wages or the worker is entitled to medical aid, notify the commission in writing of (a) the occurrence of the injury and nature of it; (b) the time when the injury occurred; (c) the name and address of the worker; (d) the place where the injury occurred; (e) the name and address of the doctor who looks after the injury; and (f) other particulars required by the commission. (2) An employer shall make further and other reports respecting the injury and workers that may be required by the commission. (3) Where an employer fails to notify the commission of the occurrence of an injury the commission may in relation to compensation paid in respect of that injury charge the cost of the claim against the experience record of that employer.

Appendix B - References to Legislation

34

Accident/Incident Investigations

Appendix C Hazardous Occurrence Investigation Report

Human Resources Dveloppement des
ressources humaines Canada
1. TYPE OF OCCURRENCE / GENRE DE SITUATION Explosion
2. Department file no. N de dossier du ministre

Development Canada

SCHEDULE 1 / ANNEXE 1 (section 15.8 / article 15.8) HAZARDOUS OCCURRENCE INVESTIGATION REPORT RAPPORT D'ENQUTE DE SITUATION COMPORTANT DES RISQUES

Disabling Injury Blessure invalidante Other Autre

Loss of Consciousness vanouissement Regional or District Office Emergency Procedure Bureau rgional ou de district Mesures d'urgence
Employer ID No. Numro d'identification de l'employeur

Specify / Prciser Postal code / Code postal

3. Employer's name and mailing address / Nom et adresse postale de l'employeur

Telephone number / Numro de tlphone

() Site of hazardous occurrence Lieu de la situation comportant des risques Date and time of hazardous occurrence Date et heure de la situation comportant des risques: Weather / Conditions mtorologiques

Witnesses / Tmoins

Supervisor's name / Nom du surveillant

4. Description of what happened / Description des circonstances

pl
Age / ge Occupation / Profession Years of experience in occupation / Nombre d'annes d'exprience dans la profession Sex Sexe Direct cause of injury / Cause directe de la blessure Signature Date Telephone Number / Numro de tlphone

e
( ) Signature Date Telephone Number / Numro de tlphone

Brief description and estimated cost of property damage / Description sommaire et cot estimatif des dommages matriels

5. Injured employee's name (if applicable) / Nom de l'employ bless (s'il y a lieu)

Description of Injury / Description de la blessure

Was training in accident prevention given to injured employee in relation to duties performed at the time of the hazardous occu rrence? L'employ bless a-t-il reu une formation en prvention des accidents relativement aux fonctions qu'il exerait au moment de a l situation comportant des risques? Yes / Oui No / Non Specify / Prciser

6. Direct causes of hazardous occurrence / Causes directes de la situation comportant des risques

7. Corrective measures and date employer will implement / Mesures correctives qui seront appliques par l'employeur et date de leur mise en oeuvre

Reasons for not taking corrective measures / Raisons pour lesquelles aucune mesure corrective n'a t prise

Supplementary preventive measures / Autres mesures de prvention

8. Name of person investigating / Nom de la personne faisant l'enqute

Title / Titre

9. Work place committee's or health and safety representative's comments / Observations du comit local ou du reprsentant

Work place committee member's or health and safety representative's name Nom du membre du comit local ou du reprsentant

Title / Titre

() 10. COPIES 1 and 2 to Health and Safety Officer, COPY 3 to the Work Place Committee or Health and Safety Representative 4 to the Employer COPIES 1 et 2 pour l'agent de sant et de scurit 3 pour le comit local ou pour le reprsentant, COPIE 4 pour l'employeur LAB 1070 (02-01) B

See reverse for INSTRUCTIONS au verso

35

Appendix C Hazardous Occurrence Investigation Report

sa

Accident/Incident Investigations

Appendix D Sample Accident/Incident Report Form

This report must be completed for all workrelated incidents/accidents. Please immediately notify your manager/supervisor. Complete the employee section and distribute as noted below. Accurate information is required so appropriate follow-up can occur to prevent future incidents. PLEASE NOTE, all serious injuries must also be immediately reported to the Dept. of Government Services (OH&S Branch). Category/Status (Internal Use Only)

Near Miss (No injury)

Medical Care

Lost Time

Recurrence

Original Injury Date

Who and When?

Confidentiality: The information contained in this report is considered confidential & will only be used for analyzing trends, injury prevention initiatives and WHSCC claims management. Your last name: The date and time of incident/accident D______ M______ Y ______ _______ am/pm Title:

Permanent Temp Your first name: The date/time stopped work:(if applicable)

Part Time Full Time Casual/On call Your employee number: What was your job classification at time of accident/incident?

The incident/accident was reported to:

Where?

Which site did the incident/accident occur? (kitchen, office, etc) Where did it actually occur?(Be as specific as possible: room, corridor, workstation, facility) Describe what happened (mention events leading up to how it occurred and if machinery/equipment/tool were involved)

Appendix D Sample Accident/Incident Report Form

This incident/accident resulted in (more than one may need to be checked):

Near miss

What Happened?

Damage to equipment/ property

Damage to environment

If you were injured, was there any immediate treatment required? If so, please describe briefly.
Mark with (?) if item is applicable Allergic Reaction Assisting Patient for X-ray Assisting Patient from floor/chair Bathing Pt. (bed/tub) B/BF Exposure Bed Making Catching Falling Object Catching Patient Changing Patient Walking Patient Chemical Exposure Type _____ Crushed/Pinched b/w Objects

sa

If you have been injured, please check which most accurately describe the type of injury. Abrasion(s) Burn(s) Loss of materials B/BF Exposure Contusion Injury requiring Fracture(s) medical aid only Infectious Contact Irritation (respiratory) Injury leading Needle Puncture to lost time Laceration(s) No Injury Strains(s) & Sprain(s) Other ____________ Part of Body Injured (if applicable): Left Right Respond to an Emergency Code (specific) Sharpe Object Type:__________________ Struck by Object Slipped/Fell on ______________________ Transferring Patient Bed Stretcher Transferring Patient Other Transporting Patient ______ Wheelchair ______ Bed ______ Stretcher Working at computer workstation Other:____________________________ Recurrence of previous injury

What were you doing at the time?

Employee Signature:_____________________________ Home Phone:_______________ Date: Date first lost shift: D____ M ______ Y _____ Anticipated RTW Date: D ____ M _____ Y _____ RTW Date D____ M______ Y_____ Name of Attending Physician:_______________________________ Date Seen: D ____ M _____ Y _____ Address of Physician: Manager (or designate) is responsible for completing the Incident/Accident Investigation portion of the form. Please complete the section located on the lower portion of the yellow and pink copies. (Reference: Staff Accident/Incident Investigation Policy X05). Employee is responsible for completing the Incident/Accident Report portion and forwarding the white copy to the appropriate Human Resources. Report must be completed and forwarded to Human Resources within 24 hours of the incident/accident.

36

Special Instructions

HR use only

Dressing Patient Ft/Bk slide with transfer board Hot Object/Surface Infectious Disease Exposure Lifting Equipment/Supplies Lifting/Lowering Bedrails Moving/Pushing/Pulling Equipment/Supplies No Specific Task Needle Stick Puncture Patient Aggression/ Non Cooperation Repositioning Patient in Bed Repositioning Patient in Chair

pl

Accident/Incident Investigations

Appendix E Sample Accident/Incident Investigation Form

Attach all supporting documentation and evidence, ie. summaries of interviews, pictures, and analysis of evidence. Instruction: This form must be completed by the store manager and a member of OH&S committee whenever an accident/incident occurs. The assistant manager or authorized designate for the store will be responsible for completing this form in the absence of the store manager. The store manager must ensure a copy of the completed report is forwarded to the Human Resources Manager, and the OH&S committee.
Accident/incident resulted in: ___ injury ___ illness ___ property damage ____ near miss ____ first aid ___ medical aid ___ recurrence ____ other (check all that apply)

Store Location

Department

Location of Incident (Be specific eg. aisle 10)

Date of incident Time_________ am pm

Date reported accident/incident

ACCIDENT/INCIDENT INFORMATION
Supervisor:_____________________________ Date of first missed shift:__________________ No. of days lost__________ Approximate date of onset, if no specific date of injury:______________________________________________________

e
Age: ____________

Nature of injury:_______________________________ Body part(s) affected:_____________________

Name (last name first please print)

___________________________________________

sa m

EMPLOYEE INFORMATION

Home Address:_______________________________

pl

Object/equipment/substance inflicting damage/injury:________________________________________

Home phone number:___________________

Sex: M / F

________________________________

________________________________ Occupation/Position: __________________________________

Date of employment:___________________________ Experience (time) in job:________________________

Evaluation of loss Potential if not corrected

Loss severity potential Major Minor Serious

Probability of occurrence High Moderate Low

Describe how the event occurred.

Immediate causes: What substandard acts/practices and conditions cause d or could cause the event? See end of form.

Basic causes: What specific personal or job/system factors led to the immediate causes?

Basic causes: What specific personal or job/system factors caused or could cause this event? See end of form.

Remedial actions: What has and/or should be done to control the causes listed?

37

Appendix E Sample Accidence/Incident Investigation Form

Accident/Incident Investigations

Prevention of Accident/Incident Recurrence

Describe what action is planned or has been taken to prevent a recurrence of the accident, based on the key contributing factors (immediate) (long term)

Signed by Supervisor________________________ Supervisors Name Signed by Person Involved:____ _______________ Signed by HR: Signed by Store Manager: _

______________________________ _________________________

Date: ______________________ __________

REPORT FORM DEFINITIONS

INJURY physical harm or damage to a person. ILLNESS unhealthy condition in mind or body. FIRST AID INJURY a minor injury requiring only first aid treatment.

Appendix E Sample Accidence/Incident Investigation Form

MEDICAL AID INJURY an injury requiring treatment by a health care professional.

LOST TIME INJURY a disabling injury where the injured person is unable to report for the next regular shift. RECURRENCE an accident or incident which has occurred mor e than once.

PROPERTY DAMAGE ACCIDENT accidental loss to equipment, material, and/or the environment. INCIDENT (NEAR-MISS) an undesired event that could have resulted in personal injury, property damage or loss.

IMMEDIATE CAUSES check all as appropriate

Actions Conditions

Operating equipment without authority Inadequate guards or barriers Failure to warn Inadequate or improper protective equipment Failure to secure Defective tools, equipment or materials Operating at improper speed Congestion or restricted action Making safety devices inoperable Inadequate warning system Removing safety devices Fire and explosion hazard Using defective equipment Poor housekeeping, disorder Failure to use PPE Hazardous environmental conditions, gases, smok e, dusts, fumes Improper loading Noise exposure Improper placement Radiation exposure Improper lifting High or low temperature exposure Improper position for task Inadequate or excess illumination Servicing equipment in operation Inadequate ventilation Horseplay Under influence of alcohol and/or other substances

BASIC CAUSES check all as appropriate

Personal Factors Job Factors

Inadequate capability Lack of knowledge/training Lack of skill Stress Improper motivation

sa

38

pl

Inadequate leadership/supervision Inadequate engineering Inadequate purchasing Inadequate maintenance Inadequate tools/equipment Inadequate work standards Wear and Tear Abuse and/or misuse

HOW TO REACH US
St. John's
146-148 Forest Road P.O. Box 9000 St. John's, NL A1A 3B8 Prevention Services Inquiries (709) 778-1552 Prevention Services Fax (709) 778-1564 Toll Free 1 800 563-9000

Grand Falls-Windsor
26 High Street P.O. Box 850 Grand Falls Windsor, NL A2A 2P7 Telephone: (709) 489-1600 Fax (709) 489-1616 Toll Free 1 800 563-3448

Corner Brook
Suite 201, Fortis Towers 4 Herald Avenue P.O. Box 474 Corner Brook, NL A2H 6E6 Telephone: (709) 637-2700 Fax (709) 639-1018 Toll Free 1 800 563-2772

www.whscc.nl.ca
Department of Government Services OH&S Branch
(709) 729-2706 Toll Free: 1-800-563-5471

Human Resources and Social Development

Labour Program, Newfoundland and Labrador Office Phone: (709) 772-5022 (call collect outside St. Johns)

Newfoundland & Labrador Employers Council

(709) 368-6532 Toll Free: 1-888-738-5900

Newfoundland and Labrador Federation of Labour

(709) 754-1660