Professional Documents
Culture Documents
September 2011
9-2
places life in jeopardy; produces unconsciousness; results in substantial loss of blood; involves the fracture of a leg or an arm but not a finger or toe; involves the amputation of a leg, arm, hand or foot, but not a finger or a toe; consists of burns to a major portion of the body; or causes the loss of sight in an eye.
1. 2. 3.
CALL FOR EMERGENCY SERVICES ADVISE YOUR SUPERVISOR CALL THE BOARD'S HEALTH AND SAFETY DEPARTMENT AT 905-890-0708.
An investigative team of Joint Health and Safety Committee Members will respond as soon as possible.
9-3
EXECUTIVE SUMMARY
An Accident/Incident is an unplanned, unwanted event which disrupts the orderly flow of activities and may or may not involve injury to people or damage to equipment and materials. An essential part of the Board's Health and Safety program is the investigation of all employee accidents/incidents in the workplace. Incident Investigation Reports (GF390) records the required data and identifies corrective measures, areas of concern and can be used to identify trends. The Incident Investigation Report (GF390) also fulfils the Board's requirement under the Occupational Health and Safety Act to investigate all critical injuries and fatalities and to submit a written report to the Ministry of Labour. The attached sequencing chart details the procedure for reporting an accident/incident. The employee is responsible for notifying their Principal/Supervisor of an accident/incident. In the event of any injury, the employee is also required to contact the Benefits Department in compliance with the Workplace Safety and Insurance Act. The Principal/Supervisor or designate completes and signs an Incident Investigation Report (GF390) as soon as practical after the accident/incident and makes recommendations for corrective actions (i.e. work orders). The report is distributed as noted. If necessary the Health and Safety Department will analyze and follow up with Principal/Supervisor and the Joint Health and Safety Committee. For Healthcare (Medical aid) and Lost time incidents, a copy of the report shall be faxed to the appropriate worker co-chair for the joint health and safety committee (JHSC). This shall be done immediately upon receipt and in any case, no later than 4 days following the occurrence, by the Benefits Department. This is a requirement of the Occupational health and Safety Act For further information on conducting investigations, the Principal/Supervisor or designate should refer to the detailed Accident/Incident Investigation Procedure in the Health and Safety Manual.
9-4
Completion of Incident Investigation Report Form by Principal/Supervisor FAX WITHIN 24 HOURS TO BENEFITS DEPARTMENT @ 905-890-0421
Benefits Department to fax Health Care & Lost Time Incident Reports to Worker Co-Chair within 4 days
Principal/Supervisor
Employee
* IF INJURY IS CRITICAL (SEE PG. 9-2) AS DEFINDED BY THE OCCUPATIONAL HEALTH AND SAFETY AT, CALL HEALTH AND SAFETY IMMEDIATELY! ** IN ABSENCE OF PRINCIPAL/SUPERVISOR FORM IS STILL TO BE FAXED WITHIN 24 HOURS AND BE COMPLETED LATER BY PRINCIPAL
9-5
Table of Contents
1.0 ROLE OF ACCIDENT/INCIDENT INVESTIGATION 1.1 1.2 1.3 Purpose of the Accident/Incident Investigation Benefits of Investigating the Accident/Incident Types of Accident/Incident Investigations 1.3.1 The Employer's Report of Accidental Injury or Industrial Disease (WSIB Form # 7) Critical Injury Report Violent Incidents Contact with Student Mitigating Factors Considered, Incidents
3.0
CONDUCTING ACCIDENT/INCIDENT INVESTIGATION 3.1 3.2 Steps to Ensure Reporting of Accidents/Incidents Information Requirements 3.2.1 3.2.2 3.2.3 3.2.4 3.3 3.4 Floor Plan Equipment Inventory WHMIS Inventory Incident Investigation Report
Roles and Responsibilities Investigation Procedures 3.4.1 3.4.2 3.4.3 3.4.4 Physical Evidence Interviewing Accident/Incident Causation Analysis Recommendations
1.1
1.2
3.
1.3
1.3.1
1.3.2
1.3.3
Violent Incidents
9-7
The Boards Incident Investigation Report (GF 390) was revised to include violence as a type of incident. This is a requirement under Bill 168 which amended the Occupational Health and Safety Act. See Section 24 of the Boards health and Safety manual for details such as definitions, reporting, etc about violence. After the occurrence of a serious violent incident leading to suspension/expulsions, or report to police and, between students, staff members or non students, a Violent Incident Report form must be completed. This is different from a GF 390. See GAP 529.00, Police and School Response Protocol and GAP 533, Physical Restraint.
1.3.4
Contact with Student (striking, kicking, biting, etc), mitigating factors considered, Incidents
This definition is aligned with procedure 9.03.05.01 found in the Boards Safe Schools binder, pages 17-18, which the supervisor has considered while completing the form.
2.0
2.1
Why is an Accident/Incident Investigated The purpose of an accident/incident investigation is to prevent a recurrence of the accident/incident by identifying the root cause(s). With PREVENTION in mind, the focus of the investigation will be simplified. 3.0 3.1 CONDUCTING ACCIDENT/INCIDENT INVESTIGATION
Steps to Ensure Reporting of Accidents/Incidents An unreported accident/incident may not be investigated, nor its causes corrected. Ensure that all accidents/incidents are reported by: 1. Emphasizing the need to report all accidents including a near miss incident and property damage as deemed appropriate. Situations cannot be corrected unless they are reported, and an accident/incident could repeat itself with more serious results. Expressing appreciation when an accident/incident is reported. Reinforce dissatisfaction with late reporting.
2.
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3. Acting on all reports immediately. Investigate the accident/incident and take the required corrective measures.
3.2
Information Requirements
The following information will assist in the accident/incident investigation.
3.2.1
Floor Plan
Using current floor plans visualize the activities at the accident/incident scene and identify the location of equipment and materials that may have been involved.
3.2.2
Equipment Inventory
Know what condition and type of equipment and materials were involved in the accident/incident.
3.2.3
WHMIS Inventory
If a chemical was involved in the accident/incident, find out whether actual and potential sources of chemical exposure were properly controlled. WHMIS inventories must be updated annually and current Material Safety Data Sheets must be available. Ensure that all employees have received training in handling chemicals. Check that chemicals were labelled with pertinent information, such as identification, handling, storage, and waste disposal, according to Workplace Hazardous Materials Information System (WHMIS) requirements.
3.2.4
3.3
Employees
Employees are required to report accidents/incidents to their Principal/Supervisor. During the investigation, employees will provide the Principal/Supervisor with information and assistance which may pertain to the accident/incident or circumstances leading to the accident/incident.
3.4
Investigation Procedures
The steps in an accident/incident investigation are simple: - gather information - analyze - draw conclusions - make recommendations The accident/incident investigation process will vary depending on the nature of the accident/incident. Keep an open mind to all possible causes, as preconceived notions may lead down the wrong path with significant factors left uncovered. Make notes of ideas as they occur but try to avoid drawing conclusions until all information is gathered. For any accident, the priority is medical treatment of the injured and prevention of further injuries. When these matters are under control, the Principal/Supervisor can begin the investigation. Before attempting to gather information, examine the site and identify all witnesses.
3.4.1
Physical Evidence
Physical evidence may be subject to rapid change or obliteration. For this reason it must be recorded first. Check for the following items: - position of injured person - equipment used - material used - safety device used - position of the appropriate guards - position of the controls of the machinery - damage to equipment - housekeeping of area - weather conditions - lighting levels - noise levels A sketch or photograph can be taken of the accident/incident site for further analysis later. Broken equipment, debris and samples of materials involved may be removed for further analysis by appropriate experts.
9 - 10 3.4.2 Interviewing
Interviewing the injured person and witnesses represents another source of information. This should be done as soon as practicable after the accident to ensure the information has not been influenced by others. Interview each person individually at the scene, where it is easiest to obtain a description of the events or in the peace and quiet of an office, where there will be fewer distractions. It is important to conduct the interview with the witnesses (injured person), in as calm an environment as possible. To assist in establishing a good rapport with the person being interviewed and whose own words you want for the description, here are some Dos and Don'ts: Do - put the person, who may be upset, at ease - emphasize the real reason for the investigation - let the person talk - confirm that the statement is correct - make short notes only during the interview
Don't - intimidate the person - interrupt - prompt - ask leading questions - show your emotions - make lengthy notes while the person is talking.
The actual questions you ask the person will vary with each accident/incident, but there are some general questions that should be asked: 1. 2. 3. 4. 5. 6. 7. Where were you at the time of the accident/incident? What were you doing at the time of the accident/incident? What did you see or hear? What were the environmental conditions (weather, light, noise etc.) at the time? What was the injured person doing at the time? In your opinion, what caused the accident/incident? How might similar accidents/incidents be prevented?
If you were not at the scene at the time, questions are the most straightforward approach to establish what happened. Care must be taken to assess the credibility of any statement made in the interviews. Answers to the first two suggested questions will give an indication of how well the witness was able to observe what happened. An additional technique sometimes used to determine the sequence of events is to replay them as they occurred. Obviously, great care must be taken so that further injury or damage is not incurred. A witness (usually the injured employee) is asked to re-enact in slow motion his/her actions which preceded the accident. 3.4.3 Accident/Incident Causation Analysis It is important to analyze an accident/incident to determine what cause or reason existed for the accident/incident to have occurred. In the most seemingly straightforward accident/incident, seldom, if ever, is there only a single cause. To ensure that an effective accident/incident investigation is done it is important to look at all five key elements - Tasks, Materials, Environment, Personal and Management.
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MATERIAL
TASK
ENVIRONMENT
MANAGEMENT PERSONAL
TASK
Review the actual work procedure being used at the time of the accident/incident. Look for answers to questions such as: 1. Was a safe work procedure used? 2. Had conditions changed to make the normal procedures unsafe? 3. Were the appropriate tools, materials available? 4. Were they used? 5. Were safety devices working properly? 6. Was lockout used when necessary? For most of these questions, a vital subsequent question is "If not, why not?"
MATERIAL
To seek out possible causes brought about by the equipment and materials used, ask: 1. 2. 3. 4. 5. 6. 7. 8. 9. Was there an equipment failure? What caused it to fail? Was the equipment poorly designed? Were hazardous substances involved? Were they clearly identified? Was a less hazardous alternative substance possible and available? Was the raw material substandard in some way? Should personal protective equipment have been used? Was it used?
Again, each time the answer reveals an unsafe condition, ask why this situation was allowed to exist.
ENVIRONMENT
The physical environments, and especially sudden changes to that environment, are factors which need to be identified. Note that it is the situation at the time of the accident/incident that is important. For example: 1. 2. 3. 4. 5. 6. What were the weather conditions? Was poor housekeeping a problem? Was it too hot or too cold? Was noise a problem? Was there adequate light? Were toxic gases, dust, fumes present?
9 - 12 PERSONAL
The physical and mental condition of those directly involved in the accident/incident must be explored. Bear in mind that you are not investigating the accident/incident so that blame can be laid against someone; but your inquiry would not be complete unless you consider personal characteristics. Some factors will be more permanent; others may vary from day to day: 1. 2. 3. 4. 5. Were employees experienced in the work being done? Had they been adequately trained? Were they physically capable? What was the status of their health? Were they under stress (work or personal)?
MANAGEMENT
Management holds the legal responsibility for the safety of the workplace and therefore the role of the Supervisor and higher management must always be considered in an accident/incident investigation. Answers to any of the preceding questions logically lead to further questions such as: 1. 2. 3. 4. 5. 6. 7. 8. Were safety rules in effect? Were they being enforced? Was adequate supervision given? Had hazards been previously identified? Had procedures been developed to overcome them? Were unsafe conditions corrected? Was regular maintenance of equipment carried out? Were regular safety inspections carried out?
Using this model as guide in accident/incident investigation prevents looking at facts in isolation and assists in trying to uncover all possible causes. While this checklist is only a sample of questions, other more pertinent questions can be asked to better focus on the true root cause. After analyzing the causes it is suggested you go back through the accident/incident step-by-step from the moment of the occurrence, listing the causes as they happened in each step. Note whether your conclusions are supported by direct evidence (physical or documented) or based on eyewitness accounts, or if it is based on assumptions. This serves as a final check on discrepancies which should be explained or eliminated.
3.4.4
Recommendations
The final step is to come up with well considered recommendations designed to prevent recurrences of similar accidents/incidents. Make the recommendations as exact and specific as possible to address the causes found in the analysis.
DUFFERIN-PEEL CATHOLIC DISTRICT SCHOOL BOARD INCIDENT INVESTIGATION REPORT (To Be Completed by SupervisorlDesignate)
A. INJURED EMPLOYEE IDENTIFICATION 1. LAST NAME (FAX THIS FORM WITHIN 24 HRS TO THE BENEFITS DEPARTMENT. 905-890.0421) 3. WORK LOCATION 4, PRESENT OCCUPATION / YRS 5. DATE OF EMPLOYMENT V D M POSTAL CODE 2. FIRST NAME
PROVINCE
6. EMPLOYEE #
LI LI LI
AFFILLATION:
15. RESULT OF INCIDENT (SEE OVER) LI First Axi LI Medical Aid C Hazardous Situation LI Lost Time
Date of injury
17.
DESCRIBE THE WORKERS ACTIVITIES AT THE TIME OF INJURY/DISEASE, INCLUDE DETAILS OF EQUIPMENT OR MATERALS USED AND THE SIZE AND WEIGHT OF OBJECT BEING HANDLED:
18a. TYPE OF INCIDENT (check appropriate box see over) LI Contact with student (striking. LI Caught in on or between kicking. biting. etc). LI Slip/Fall mitigating factors considered LI Overexertion LI Struck or contact by LI Exposure LI Struck against/contact with LI Violence (complete lEb also) C Other (explain) DESCRiPTION:
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18b. TYPE OF VIOLENT INCIDENT (see over for detinition) LI Verbal threat C E-mail threat C Other written threat LI Phone call threat a Physical attack LI Attack with a weapon a Sexual violence LI Domestic violence LI Qtner iexplaini DESCRIPTION
If a selection was made from section 18a, please complete section C. If a selection was made from section 18b, please complete section D. 19. PART OF BODY INJURED. DESCRIBE PART(S) OF BODY INJURED, INDICATING. RIGHT (R) OR LEFT (L)
DESCRIPTION:
C. INVESTIGATION OF WORK-RELATED INJURY OR INCIDENT (See section ISa above) 20. WHAT CONDITION CONTRIBUTED TO THE INCIDENT (check appropriate box and explain causes) LI Unsafe equipment LI Operating without authority LI Unsafe design or arrangement LI Failure to secure or warn LI Not guarded or mproperly guarded LI Failure to use personal protective device LI Unsafe position or posture C Hazardous personal attire LI Improperly labelled or dentitled C Hazardous method or procedure EXPLANAT ON OF CAUSES. 21. ACTIONS TAKEN BY SUPERVISOR TO PREVENT RECURRENCE (check appropnate box) LI Reinstruction of person involved LI mprove personal protective equipment LI Equipment repair or replacement LI Installation of guard or safety device C Correction of congested area LI Action to improve des gnlprocedure LI Other (explain)
LI LI LI LI LI
Fire or explosion Student action Improper ventilation Slippery surface Other (explain)
LI Use Safer Materials LI Work Order Submitted C Ongoing support of employee m ligating factors considered
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SIGNATURE OF SUPERVISOR DATE OF REPORT The Supervisor s responsibie to nvestigdte the ,Jodent. to take correct ye arbors where apnlicable to omp 215 civIC vi f/sir 24 hours
ate
3rd
0. INVESTIGATION OF WORKPLACE VIOLENCE INCIDENT (See section lab above) 22. ACTIONS TAKEN BY SUPERVISOR/PRINCIPAL
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Employee GF 390
(ol lect factual data relating to the occurrence of work injury. Collect data for completion of report to the W.S.l.13. to provide complete information on which to base a decision for pa nient. Collect information required for notification 01 the MOL (Ministry of Labour). Providc a torm on which to record, investigate and take corrective action ott an incident. Ensure that corrective action is taken to eliminate recognized causative factors. Collect factual data to develop statistical records. Guide the Investigator in making an effective Investigation.
An injury of such minor nature that treatment can be carried out by First-aider.
Health Care (Medical Aid) Injury -A work related incident, which requires medical treatment but does not result in ne lost front work. hazardous Situation An incident caused by an unsafe act, an unsafe condition or a combination of both in the work environment which could have resulted in property loss andor physical harm.
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A work-related injury, which results in time, lost from work beyond the day of the injury.
TYPES OF INCIDENT / DEFINITIONS OF CODES: Contact with student an incident in which the employee is subject to an unwelcome or inappropriate action by a student mitigating factors considered. See Section 9. Accident/Incident Investigation Procedure in the Health and Safety Manual
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2.
Struck or Contact By a struck or contact by incident is one in which a person has been contacted either abruptly or forcefully by some object in motion, (e.g. Box falls oIl shelf, employee jabs needle into finger, person pushing cart runs into another person); or has been contacted non-forcefully by some subsiance or agent which has an injury-upon-contact characteristic, (eg. Employee is splashed by hot or corrosive solution).
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3.
Struck against / contact with a struck against / contact with incident is one in which a person contacts either abruptly and forcefully, some object in his suiToundings, (e.g. Employee strikes leg against desk. person bumps head against cupboard door); or comes into contact non-forcefully with some substance or agent capable of producing injury on the basis of mere non-forceful contact (eg. electrical shock, hot pipe, employee places hand in scalding or corrosive liquid).
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4.
Caught in, on or betsseen a caught in, on. or between incident is one in which:
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a)
b) c)
a person is trapped in some type of enclosure, or a part of a persons body is caught fast in sonic type of opening, e.g., a person is caught in an elevator, locked into a refrigerated room, shut into some type of vessel such as a boiler; a person or some part of his clothing is caught on some protruding object, e.g.. person catches had on a sharp edge, catches loose clothing on a revolving spindle or on some protruding object: a person is pinched, crushed or otherwise caught between either a moving object and a stationary object or between two or more moving objects, e.g., person jams fingers between wheeled cart and doorway, person catches arm in elevator door, jammed between loaded moving cart and a wall.
5.
Slip/Fall a fall incident can be subdivided into two categories a foot level fall or a fall to below .A slip or a trip should also be recorded under this category. A foot level fall occurs when a person slips or trips, e.g. a person slips on a foreign matter on floor. A fall to below occurs when a person falls to below the level on which he was standing or walking, e.g., a person falls from a ladder, window, chair or on stairs. Oxer-eertion / strain An over-exertion, strain incident is one in which a person put cxcessie strain on some part of his body. e.g.. employee strains his hack or some other part of his body, e.g.. an employee strains back or some other part of hi body lifting equipment, supplies, etc.
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a.
Exposure An exposure incident is one in s hich the employee is exposed to harmful conditions. i.e.: toxic gases, tiimes or vapors: a) contagious conditions: b) c) estreiues of heat or cold: d) oxs gen dctic tent atmospheres: e) radioactive radiation: 1) intense light brightness.
x.
Workplace Violence titeans: I he exercise of physical force by a person againsi a sorker. in a sorkplace. that causes or could cause physical injury to the worker An attempt to exercise physical force against a worker, in a workplace, that could cause physical injury to the worker A statement or hehas iour that it is re:isonahle for a worker io interpret as a threat to exercise ph\ sical force against the sorkcr, in a workplace. that could cause physical iniuru to the n orker.
1-or furt.her DuftdrinPeei Catholic District School Board procedural infonnation on. Accidents i.ncident 0 ot on. I leclth md S. r .s it on rrtr to St .1 ul