Training for Work Place Committees and Health and Safety Representatives

Training for Work Place Committees and Health and Safety Representatives

Instructor Guide

Module - 4

HAZARDOUS OCCURRENCE INVESTIGATION

AND REPORTING

Chapter 1

1.INTRODUCTION

2.RECORDING AND REPORTING

2.1MINOR INJURIES

2.2DISABLING INJURIES

2.3INCIDENT (Near Miss or Near Hit)

2.4WORK PLACE COMMITTEE OR REPRESENTATIVE INVOLVEMENT

3.HAZARDOUS OCCURRENCE INVESTIGATION PROCESS

3.1 WHY INVESTIGATE

3.2PRINCIPLES OF INVESTIGATION

3.3INVESTIGATION PROCEDURES

EXERCISE

4.REFERENCES & ACKNOWLEDGEMENTS:......

Version: Draft 1.1

Module 4 - HAZARDOUS OCCURRENCE INVESTIGATIONAND REPORTING

1INTRODUCTION

Employment accidents, injuries, illness and other hazardous occurrences must, by law, be investigated, recorded and reported by the employer. There is also a requirement that appropriate corrective action be developed and implemented to prevent or minimize the risk of recurrence. As unfortunate as they might be, employment accidents and injuries reveal certain facts, which, when properly investigated, can provide the key to preventing similar recurrences involving the same employee, or other employees.
Work place committees (and representatives) have a responsibility to review and comment upon accident and injury reports and participate in the investigation of hazardous occurrences.
An integral and important part of a good departmental OSH programme is accident prevention initiatives and an effective system of accident investigation, recording and reporting. To facilitate this, it is necessary to learn and to understand the difference between accident and injury, the types of work injuries that can occur and the importance of conducting good, complete investigations.
The terms "accident” and “injury" are frequently interchanged, without due thought being given to what these terms mean. Generally speaking, an accident refers to some event that may or may not involve a resultant injury. An example of an accident without injury might be an event resulting in property damage. Of course, other accidents, or events resulting from system failures, often result in injury to the person or persons involved. Injury can be regarded as one possible result of an accident occurring.
But what makes up “hazardous occurrences”?

/ Accident: An undesired event that results in injury or occupational illness to a person or damage to equipment, material or facilities.
Incident: An undesired event that could have but does not result in personal injury or occupational illness or damage to equipment, material or facilities. (This is often referred to as a “Near Miss” or a close call; but perhaps “Near Hit” would be a more accurate description.)
/ For purposes of recording and reporting, injuries are normally classified into two categories.
A DISABLING INJURY means an employment injury or an occupational disease that:
a.prevents an employee from reporting for work or from effectively performing all the duties connected with the employee’s regular work on any day subsequent to the day on which the injury or disease occurred, whether or not that subsequent day is a working day for that employee,
b.results in the loss by an employee of a body member or part thereof or in the complete loss of the usefulness of a body member or part thereof, or
c.results in the permanent impairment of a body function of an employee;
(With this definition a fatality is a disabling injury, albeit of the most serious kind.)
/ A MINOR INJURY means an employment injury or an occupational disease for which medical treatment is provided and excludes a disabling injury. Included in this category are injuries or illness that may require first aid, or seeing a nurse or physician for medical attention. (In other words, no time lost beyond the day of injury.)

2 RECORDING AND REPORTING

REMINDER:
As has been seen elsewhere, employees are clearly required by the code to:
Report in the prescribed manner every accident or other occurrence arising in the course of or in connection with the employee’s work that has caused injury to the employee or to any other person.
/

2.1 MINOR INJURIES

While minor injuries are not required to be reported individually to HRSDC, there is a legal requirement to include the number of minor injuries on the “Work Place Committee Report”, as well as the "Employer's Annual Hazardous Occurrence Report" form, both of which must be forwarded to HRSDC before March1st of the succeeding year.
A record of minor injuries must be kept and maintained on file by the employer for a minimum of ten years. These records must be made available to an HRSDC safety officer on request.
The information that must be contained in these records includes:

the date, time and location of the occurrence that resulted in the minor injury;
the name of the employee affected;
a brief description of the minor injury; and
the causes of the minor injury.

This last piece of information indicates that these injuries should be investigated. It stands to reason that the best person to do so is the appropriate supervisor. More details, however, will be found in the next section titled “Hazardous Occurrence Investigation Process.”
As defined above, injuries treated only with first aid are considered minor injuries. Information collected and retained differs and are as follows:
a.the date and time of the reporting of the injury or illness,
b.the full name of the injured or ill employee,
c.the date, time and location of the occurrence of the injury or illness,
d.a brief description of the injury or illness,
e.a brief description of the first aid rendered, if any,
f.a brief description of arrangements made for the treatment or transportation of the injured or ill employee, if any;
g.the names of witnesses, if applicable; and
h.the first aid attendant must sign the first aid record.
The employer shall keep this first aid record for a period of two years.
/ Note to Trainer:
Anecdotal evidence indicates that first aid registers are rarely filled out correctly - if at all. Example below is from a real case in Alberta.
An other one from BC: A worker suffered a (seemingly) minor scrap to his lower leg. Less than a week later he was in hospital diagnosed with necrotizing fasciitis (more commonly known as flesh-eating disease). Leg was amputated to save his life.
Why bother completing the first aid register?
A very minor injury that initially requires first aid treatment only may eventually require more radical treatment. Completing the first aid register protects both the employee and employer by providing a record and proof of a work related injury.
For example, a paper-cut to the hand only needs a band-aid. Three days later, this minor injury has become so infected that the employee requires serious medical intervention and loses three days from work.
With a record in the first aid register, it is easier for both the employee to claim from the provincial worker’s compensation board and the employer to conduct a proper investigation.
Question:
Are all employees aware of the importance of completing the first aid register?

/

2.2 DISABLING INJURIES

Disabling injuries, however, must be properly investigated, recorded and reported to the applicable regional office of HRSDC within fourteen days. For disabling injuries which are regarded as very serious, it is up to the responsible manager to:
a.appoint someone qualified to investigate the hazardous occurrence;
b.notify the work place committee (or 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.
/ In addition to reporting disabling injuries to HRSDC, a record should be maintained for inclusion in the Employer's Annual Report referred to in the previous section.
Furthermore, the employer must report to an HRSDC health and safety officer, by telephone or telex (fax), as soon as possible but not later than 24 hours if one of the following occurs:
a.the death of an employee;
b.a disabling injury to two or more employees;
c.an amputation or the complete loss of use of a body part;
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
/ Definition:
"qualified person" means, in respect of a specified duty, a person who, because of his knowledge, training and experience, is qualified to perform that duty safely and properly.
/

2.3 INCIDENT (Near Miss or Near Hit)

While incidents that do not fall in any of the aforementioned categories are not required to be reported to HRSDC, they are an indication that there may be a problem somewhere in the work process(es) or the “system”.
Therefore, an important, yet difficult to implement, element of an effective OHS programme is to convince employees, supervisors and managers of the importance in reporting these near hits that occur in the work place.
The recording and investigating of “close calls”, i.e. incidents that did not injure or kill someone nor caused property damage but had the potential to do so, is a clear pro-active measure that both supervisors and committees can use in determining causal factors and implementing corrective and preventive measures before injuries or damage occur.
Near hits are warnings that problems exist in the workplace.
They should be reported and investigated.
/

2.4 WORK PLACE COMMITTEE OR REPRESENTATIVE INVOLVEMENT

In all hazardous occurrences, the employer is required to notify the work place committee or representative without delay and to ensure their participation in the investigation.
Work place committees and representatives are not responsible for the investigation of an accident or injury and the subsequent reporting of that injury; that belongs to the employer through the immediate supervisor or manager. Committees or representatives are required, however, to participate in all accident investigations, and to offer comments in regard to the corrective action recommended.
Ensuring records of employment injuries and statistics are kept and maintained, and the frequent review of this information to identify accident trends, is an important committee responsibility.
IMPORTANT NOTE:
As has been noted, committees (or representatives) shall participate in investigations. However, this participation (Who from the committee participates and How he/she participates) is determined by the committee’s terms of reference!
NOTE:
Although beyond the scope of this course, the practice of submitting a Workers' Compensation Claim Form along with the accident report is common to many jurisdictions. The requirement to submit the workers’ compensation form is pursuant to the Government Employees' Compensation Act (GECA) and relates entirely to compensation benefits that may apply to the injured employee following the injury, and thus it has a purpose different from the hazardous occurrence investigation report.
Consequently, reporting requirements differ between these two documents, as do their destination when submitted to HRSDC. It is important to review the specifications relating to time limitation for submission of the claim and ensure that they are adhered to.
/

3HAZARDOUS OCCURRENCE INVESTIGATION PROCESS

3.1 WHY INVESTIGATE

An investigation is not a routine exercise in filling out forms for compensation claims or accident reporting. Nor is it a fault-finding exercise to lay blame.
Rather it is a systematic approach to discover what happened in order to prevent it from happening again. The purpose of an investigation is to:

determine all causes;
recommend corrective action; and
comply with the Canada Labour Code requirements

3.2PRINCIPLES OF INVESTIGATION

The hazard occurrence investigation (HOI) is a search for unknowns. All factors must be uncovered and evaluated to correctly determine what happened and why it happened. It is too easy to stop at what caused an injury, but one must continue to identify what caused the accident. The investigator needs to understand that there is a difference between injury causes and accident causes; rarely are they the same.
Usually the best person to assign as investigator is the supervisor of the person involved. After all, it is the supervisor who assigned the task and is most familiar with the equipment, its operation and the procedures involved and understands the type of condition or situation likely to produce accidents.
The investigator needs to have an open mind and be able to:
a.collect the facts, weigh the value of each and reach a conclusion based on the evidence;
b.explore all factors, however remote;
c.consider unsafe conditions as well as personnel actions/inactions; and
d.recommend effective corrective measures.
/

3.3INVESTIGATION PROCEDURES

Once the injured person has been treated and the site secured, the investigator can start. In broad terms, the process is:

Visit the accident scene;
Conduct interviews;
Gather evidence;
Evaluate; and
Make recommendations

/ 3.3.1Accident Scene
As soon as possible, the investigator must visit the scene of the accident in order to:

Secure the scene and prevent removal of evidence;
Familiarize with the circumstances;
Coordinate the quarantine of equipment, the identification and taking of samples, photos and records; and
Identify and interview witnesses.

/ 3.3.2Interviews
The investigator begins the process by informing witnesses of the purpose of the investigation and that their statements will be used only for prevention purposes.
The investigator should try to have the witnesses explain everything they know without influence from the investigator’s questions. Questions may refer to the history of events, human factors, equipment factors, or environmental factors. Usually, it is best to begin with general questions and ask specific questions later.
Techniques for the investigator to keep in mind:

Put the person at ease. Do not appear condescending, but remind the witness of the constructive purpose of the investigation. Reassure the witness that the main purpose is to find and eliminate the causes of the accident in order to prevent a recurrence;

Avoid collective interviews, i.e. interview one at a time so that the statement of one will not be coloured by overhearing the statement of another;

Interview at the accident scene if possible;

Ask the witness to relate his/her account of the accident. Listen carefully and do not interrupt at this time. This gives the witness an opportunity to formulate the story in his or her own mind, and gives a preview of what they know;

Have the witness tell the story again. Ask questions to fill in the blanks. Take notes, ask further specific questions if required. Avoid questions that lead the witness or imply answers. E.g. instead of asking “Was there oil on the floor?”, ask “What was the condition of the floor?”.

Do not prejudge or assume contradictory evidence indicates falsehood - people give accounts of events from their perspectives, which, to them, are correct;

Encourage the witness to give all information regardless of how obvious it may be or how insignificant it may seem.

Ask the witness for suggestions as to how the accident could have been avoided.

Confirm understanding of witness' statement by repeating back to the interviewee your understanding of the information; and

Thank all witnesses for their cooperation.

/ 3.3.3Evidence
This may be any object, conditions, event, statement etc, which may yield information about the occurrence. It can be compromised or lost unless care is taken. When applicable, to preserve evidence, the investigator ensures that:

the accident scene is protected and documents, orders, log books, personnel records, etc., are secured;

fluid (petroleum, oils, lubricants) and material (wood, metal, cloth, etc.) samples are taken;

articulated or “working” parts are marked to identify settings, position or extension in which they are found;

photographs, sketches are made before evidence is disturbed (keep a photo log);

disassembly of components is recorded in detail;

parts requiring investigation are preserved in their original state;

fractured or worn mating surfaces are not fitted together, otherwise significant marks may be destroyed;

witnesses are available until the investigation is completed;

medical examinations are conducted immediately;

evidence that cannot be analyzed locally is properly identified, packed and shipped for examination at another facility; and

accurate records of all the above are kept

/ 3.3.4Sequence of Events Leading to The Accident
The clearer the picture developed by the investigator, the easier it is to identify all cause factors. This step-by-step description of the events leading to the occurrence is a crucial element in the analysis process. Making sure the occurrence is documented in enough detail to enable anyone unfamiliar with the situation to clearly understand what and how it happened provides excellent clarity.
For example, “’Charlie’ tripped over a box and broke his ankle” does not help identify all cause factors as well as the following sequence of events:

At break time, ‘Charlie’ got up and was heading to the employee lounge to meet some associates;
Supervisor had an urgent need for extra materials;
She stopped ‘Charlie’ and asked for a favour;
‘Charlie’ obliged and hurried to the stockroom;
As he turned the corner, he did not notice the box partially blocking the dim hallway;
He tripped over it, twisting and fracturing his ankle;
The box was one of seven that had been left in the hallway for the past three weeks after a late night delivery

/ CLARITY IS IMPORTANT:
Do not just describe the occurrence itself; include a description of events that led up to the occurrence.
Anyone reading the sequence of events should be able to understand what was going on and what happened.
/ 3.3.5Evaluate
An investigation is not complete until all data is analyzed and a final report is completed. In practice, the investigative work, data analysis, and report preparation proceed simultaneously over much of the time spent on the investigation.
Hazardous occurrences seldom have a single cause. The most apparent and immediate cause will probably be either a substandard workplace condition or a substandard work activity. But a good investigator will normally identify system or procedural failures resulting in either the worker or the workplace not being properly prepared.
The process of analysis must consist of sifting through the evidence to discover all the underlying causes. This can be achieved by subjecting all the known facts and events that lead up to the hazardous occurrence to a rigorous series of “what”, “when”, “how”, “why”, and “if not, why not” questions. In order to identify areas requiring preventive measures, all causes should be recorded in as much detail as possible.
For example, a disabling injury where “’Charlie’ tripped over a box and broke his ankle” can easily – and too often – lead to simply recommending that ‘Charlie’ must pay closer attention to his environment. This indicates fault finding and goes nowhere near addressing the root cause(s). A probing investigator will ask more questions such as:

Where was the box?
Why was it in the hallway?
How long was it there?
Did others notice it? If yes, why was it not moved?
Is there an inspection process in place? If yes, was the problem noted? If yes, why was it not fixed? If no inspection, why not?
Are the storage facilities adequate? If not, has it been reported? What is being done about that?
Was he in a hurry? If yes, why?
Is there adequate lighting?
Etc

/ 3.3.6Recommendations
Once the cause factors have been identified, the investigator recommends preventive and/or corrective measures based on the findings of the investigation. The basic aims are as follows:

treat the cause and not just the effect;
ensure that the measures will enhance and not restrict overall operational effectiveness; and
ensure preventive measures eliminate or control all causes.

Simply recommending that the individual(s) involved be briefed contributes little. It merely indicates fault finding. If human factors (inaction or action - human error) is a cause, revising job procedures, training of all employees doing similar tasks, closer supervision and publicity of the accident, to name a few, would be more meaningful and certainly more productive.
If shortcomings in equipment, facilities or other resources are causes, then modifications, substitution or acquisition would be valid recommendations.
For example, in the above mentioned sequence we can clearly see that the injury (broken ankle) was caused by tripping. But the accident (tripping over a box) had many more cause factors that must be addressed in the recommendations.
REMEMBER:
Accidents very seldom have only one cause. It is usually a series of conditions, actions and events that come together to result in an accident. A good investigator will continue to look for factors that have not only contributed to an accident, but have resulted in an unsafe condition that can cause harm later under similar circumstances.
/ Notes to Trainer:
This exercise is based on the Labour Programme video “So It Won’t Happen Again”.
Distribute blank copies of your departmental HOI form (or the HRSDC Hazardous Occurrence Investigation Report form)
Have participants complete all parts of the form in their groups.
When it is time for presentations, however, have each group present one or two different parts of the form on flipcharts.