ACCIDENT RESPONSE AND INVESTIGATION

Presenters

• Torrance McDonald – City of Phoenix

• Joey Catone – City of Mesa

• Armando Sapien- City of Mesa

Rules of Engagement

• Feel free to interrupt – you’re important

• Phones

• Breaks

• Procedures Booklet

• Documents on SWANA Website

Objectives

• Understand the need to investigate

• Incident Response

• Know what to investigate

• Determine the cause(s) of accidents

• Identify the methods of investigations

• Understand the need to be thorough and comprehensive

• Identify prevention methods

The Basics

• Accident?

The final event in an unplanned

process that results in injury or illness

to an employee or property damage.

The Basics

Are accidents always unplanned?

Are accidents unplanned?

Why Conduct “Investigation”

• Save lives

• Prevent future accidents/injuries/illnesses

• Save money

• Determine the “Root Cause”

• Document Accident

• Identify corrective actions

• OSHA Regulations

OSHA Wants to Know

NOTIFY OSHA w/in 8 hours

• Fatality

NOTIFY OSHA w/in 24 hours- March 2016

• All in-patient hospitalizations (a person is admitted)

• All amputations

• All loss of eye injuries

Fatality from a motor vehicle accident on a public street or highway – NOT REPORTED

Employers do not have to report an inpatient hospitalization if it was for diagnostic testing or observation only.

What do accidents cost your company?Direct -

Insured Costs“Just the tip of the iceberg”

Indirect - Uninsured, Hidden Costs - Out of Pocket

Examples:

1. Lost time by fellow employees and supervisor.

2. Investigation of accident.

3. Schedule delays.

4. Legal fees.

5. Training costs for new/replacement workers.

6. Damage to tools and equipment.

7. Lower morale.

8. Increased absenteeism.

9. Poor customer relations.

10. Public Relations-Brand Image

Unseen costs

can sink the

ship!

OSHA’S RATIOS

2014 Frequency Analysis

Bodily Fluid Exposure 1

Bodily React (1-ASL, 1-Roll Off) 2

Chemical Exposure 2

Fire (2-FEL, 3-ASL) 5

Foreign Body in Eye (FEL) 1

Illness 1

Inhalation 1

Insect Bite 1

Lifting (2-Office Staff, 1-QA) 3

MVA (8-ASL, 5-Roll Off, 9-FEL) 22

Push/Pull (SS) 1

Repetitive Motion (5-ASL) 5

Slip/Trip/Fall (2-Operators) 2

Struck By/Against (Employee) 5

Struck By/Against w/ Equipment 69

Unknown 2

Vehicle Body Overturn (Roll Off) 1

124

Accident Investigation

• A systematic approach to the identification of causal factors and implementation of corrective actions WITHOUT placing blame on or finding personal fault.

Effective Program

Written procedures

Responsibility for conducting

investigation

Training plan

Separation from disciplinary

procedures

Written report

Follow-up procedures

Annual review of accident reports

THINGS TO REMEMBER

• Don’t move the vehicle unless directed by officer/unsafe to remain in place.

• NEVER leave the scene of the accident.

• DO NOT discuss the incident with anyone except Police Officer, Supervisor, Foreman, Safety Coordinator

Nanny’s Lawyer

TRAFFIC CONE PLACEMENT

•TWO-WAY DIVIDED ROADWAY

a) 1 cone- 100 feet in front of vehicle

b) 1 cone – 10 feet behind vehicle

c) 1 cone – 100 feet behind vehicle

•ONE-WAY DIVIDED ROADWAY

a) 1 cone – 10 feet behind vehicle

b) 1 cone – 100 feet behind vehicle

c) 1 cone – 200 feet behind vehicle

Investigation Plan - Lay the Groundwork

• Who to notify

• Who contacts police, fire, etc.

• Who conducts investigation

• Conduct investigator training

• Who receives/acts on reports

• Timetables for investigation and follow-up

Types of Accidents

Minor Accidents

• Accidents that cause minor injury/illness, requiring little or no treatment, or minor property damage.

Major Accidents

Fatality, illness, fire, explosion, collapse, and any similar event that results in significant personal injury to an employee/pedestrian/driver or in significant damage to buildings, equipment, or property.

Minor Accidents

Major Accidents

Who Investigates?

• Major Accidents

- Local Police Department, Safety Coordinator, Supervisor, or Subject Matter Expert

• Minor Accidents

- Foremen, Supervisor

Accident Response Protocol

Incident OccursRespond & Assess

Situation scene safety

Secure SceneIncident

Investigation to include photos

Determine if Drug Testing Required

Damage AssessmentFollow Up

Communication

Complete Incident Investigation /

gather supporting reports

Discuss Incident Investigation at

Accident Review Board

Present signed Incident

Investigation to Employee

INCIDENT OCCURS

• Gather as much information as possible for Alpha page-Who? What? When? Where? Why

• If necessary, call 911, or for smaller emergencies, Police Non-Emergency #

• Contact Administrator, Administrator contacts Safety Coordinator, Deputy Director, Director

• If you are in the field, ask for assistance to send out SW Alpha

• Respond to the scene of the incident immediately

• During Summer months, take ice chest with drinks for major incidents/inoperative vehicles, floor dry for spills

Investigator’s Qualifications

• Understand important role of accident investigation

• Have authority and accountability

• Have skills to evaluate the incident

• Communicate details

Key Attributes of Competent Investigators

•Assumes all accidents have a cause

•Looks for many causes not just the first, most obvious cause

•Be a good listener

•Never attempts to find a culprit

• Is as objective as possible

•Always keeps the purpose of the investigation in mind

Accident Investigator Attitude

Two different viewpoints:

‘This is an opportunity to prevent the next accident.’

‘This is unnecessary paperwork and an improper use, waste of my time’

What Should Be In The “Investigation Kit”

Report forms First aid kit

Gloves-latex/leather Camera

Tape measure Large envelopes

Caution tape Claim Forms

Flashlight Graph paper

Scotch tape Straight Edge RulerPPE – Hard Hat/Boots LadderMeasuring StickBiohazard KitSpare batteriesDigital/Tape Recorder/Spare TapesCrawler

Actions At The Accident Scene

• Check for danger

• Help the injured

• Secure the scene

• Identify and separate witnesses

• Gather the facts

Check for Danger

WHAT ARE THE HAZARDS?

Assess Incident Scene Reminder

• Ensure personal safety, do not approach vehicle with electrical wire contact, stay at least 100 feet upwind from burning trash heap/vehicle

• If employee is injured, follow “Injured Employee Procedures”

• Secure scene-use caution tape, cones, etc.

• For motor vehicles w/ minor damages/impeding traffic, move to safe area

Policy for Injured Employees

• The foreman and/or supervisor on duty should ensure contacts are made to the:

• Employee’s family• All levels of management staff and Safety Coordinator

• If the injured employee is in the field:

• The foreman or supervisor on duty will arrive at the incident location and transport the employee for medical attention unless it is a life threatening emergency, in which case an ambulance should be called.

• The employee should be taken to the nearest Banner Occupational Health Clinic for examination/treatment.

• An injured employee should never be behind the wheel of a vehicle.

MOTOR VEHICLE ACCIDENTS

• Determine if DOT Mandatory Drug Testing is necessary.

• Fatality? Driver Cited & Vehicle Towed/Person transported by ambulance?

• Contact Information of Drug Testing Program

• Fatality? COM MVA Resulting in Fatality/Catastrophic Injury Procedures

• Reasonable Suspicion

Six Step Process

Gather

information

Analyze

the facts

• Implement

solutions

1. Preserve and document the scene

2. Seek Sources of Relevant Information

5. Recommend improvements

6. Write report

3. Develop event sequence

4. Determine causes

Preserve and Document the Scene

• Why begin immediately?

1. Materials. Things disappear as the

employer/employee is anxious to

get back to work/police need to

clear traffic obstruction.

2. Memory fails or gets altered.

What are effective methods to

secure or preserve an accident

scene?

Preserve and Document the Scene

• Caution Tape

• Barricades

• Cones

• Guarded

• Vehicles

Fact Finding

• Witnesses and physical evidence

• Employee – D & A Recognition

• Position of injured/tools and equipment

• Equipment operation logs, charts, records

• Equipment identification numbers

• LOOK FOR CAMERAS

Don’t Judge too Quickly!

Include photo direction slide

• City of Phoenix Training

What do you see?

Purpose of Photographs

• To show what the investigator saw to someone else.

• Record what the investigator observes so that he/she can recall details at a later date/time.

• To assist in writing the report / reconstruction.

• Should not take the place of measurements or written descriptions.

• A dozen pages of written description can not equal one photograph.

Does this help?

Photograph Basics

• Record details before moving anything, if possible.

• Also consider photographing scene after it is cleaned up.

• If pictures are taken incorrectly, valuable evidence will be lost.

• More photographs are better than not enough photographs.

Ta da!!

Problems in Photography

• Pressure to take the pictures

• Weather conditions

• Lighting

• Protecting the equipment

• Surface reflections

• Photobombs

Proper Ordering of Photographs

• Start taking photographs of things that change quickly.

• Next, record marks on the surface such as fluid, tire marks, gouges, and scrapes.

• Finish with more permanent subjects.

Scene Photography

• Overall incident scene.

• Approach path leading up to incident.

• Obstructions to view.

• Four-Point the subject.

Damage / Injury Photography

• It’s a step process that slowly gets closer.

• Document damage or injury by including the

injury in an overall photo of the subject.

• The next photo will be closer to see more

detail of the damage or injury.

• The last photo is a close-up, using a

measurable scale if available.

Step 2 – Collect the Facts through Interviews

When is it best to interview?

Whom should we interview?

Where should we interview?

Interviewing Techniques

• What should we say?

• What should we do?

• What should we not say?

• What should we not do?

INTERVIEW DO’S

• Put the witness, who is probably upset, at ease

• Emphasize the real reason for the investigation, to determine what happened and why

• Let the witness talk, you listen

• Confirm that you have the statement correct

• Try to sense any underlying feelings of the witness

• Make short notes only during the interview

• Tape record the interview

• Ask open ended questions

Interview Video Good Example

INTERVIEW DO NOTS

• Intimidate the witness

• Interrupt

• Prompt

• Ask leading questions

• Show your own emotions

• Make lengthy notes while the witness is talking

Bad Example

INTERVIEWING QUESTIONS HANDOUT

• Who? What? Where? When? Why? How?

• It’s crucial to collect evidence and interview witnesses as soon as possible because evidence will disappear and people will forget.

• Conduct interviews separately

• Make it clear that the investigation is used to avoid recurrence and not to place blame

Develop the Sequence of Events

Analyze by breaking

down the accident

processes into

component parts

Events prior to …

Event during …

Events immediately after …

Develop the Sequence of Events

Each event in the unplanned accident

process describes one:

Actor - Individual or object that is initiating

action.

Action - The thing being done

"Bob unhooked the lifeline from the harness.“

Mary Conlin Excercise

• Pass out sequence of event exercise

Root Cause Analysis

• Direct Cause – Unplanned release of energy or hazardous materials

• Indirect Cause – Unsafe acts and/or unsafe conditions

• Root Cause – policies and decisions, personal factors, environmental factors

ROOT CAUSE IS THE CAUSE THAT, IF

CORRECTED, WOULD PREVENT RECURRENCE

OF THIS AND SIMILAR INCIDENCES.

1. Injury Analysis-

Direct Causes

2. Event Analysis-

Indirect Causes

3. System Analysis-

Root Causes

3 Levels

Multiple Causation and the Accident Weed

Injury Analysis

• Acoustic

• Chemical

• Electrical

• Kinetic

• Potential (Stored)

• Radiant

• Thermal

Direct Cause:

A harmful transfer of

energy that produces

injury or illnessCuts

Burns

Strains

Accident Types

Struck by

Struck against

Contact with

Caught on-in-between

Fall to surface-fall to below

Exposure

Exertion

Event Analysis

Indirect Causes of

Accident –

Specific

hazardous

conditions or

unsafe behaviors

that result in an

accident

CONDITIONS

ACTS

Fail to enforceLack of time

Unsafe Acts

• An unsafe act occurs in approx 85%- 95 of all analyzed accidents with injuries

• An unsafe act is usually the last of a series of events before the accident occurs (it could occur at any step of the event)

• By stopping or eliminating the unsafe act, we can stop the accident from occurring

Unsafe Acts/Behaviors

• Actions we take or don't take that increase risk of injury or illness.

• Examples:• Failing to comply with rules

• Failing to report injuries

• Failing to supervise

• Ignoring hazards

1. Task

• Ergonomics

• Safety work procedures – missing?

• Condition changes

• Process

• Materials

• Workers – Unsafe behavior

• Appropriate tools/materials

• Safety devices (including lockout)

2. Material

• Equipment failure

• Machinery design/guarding

• Hazardous substances

• Substandard material

3. Environment

• Weather conditions

• Housekeeping

• Temperature

• Lighting

• Air contaminants

• Personal protective equipment

4. Human Factor

• Level of experience

• Level of training

• Physical capability

• Health

• Fatigue

• Stress

5. Management/Process Failure

• Visible active senior management support for safety – LEADING BY EXAMPLE

• Safety policies – do they exist

• Enforcement of safety policies - LOTO

• Adequate supervision – work observations

• Knowledge of hazards

• Corrective coaching of Operator

• Preventive maintenance

• Regular audits

No accountability policy

No, or outdated policyInadequate human-machine interface

No inspection policy

No, or inadequate, standardsNo, or outdated procedures

Inadequate training

La

ck

of

vis

ion

No

mis

sio

n s

tate

me

nt

No work direction (supervision,

selection, preparation)

• Implementation

• Design

Root Causes of the

Accident – Common

behaviors or

conditions that

ultimately result in

an accident

System Analysis

Developing Solutions & Getting Results

The last two steps help you develop

and propose solutions that correct

hazards and design long-lasting system

improvements.

Lack of safety leadership

Lack of supervision

Lack of Training

Missing guard

Rules not enforced

Poor work proceduresPurchasing unsafe equipment

No follow-up/feedback

Poor safety

managementPoor safety leadership

Didn’t follow procedures

Poor housekeeping

Horseplay

Ignored safety rules

Defective tools

Don’t know howNo Safety Data Sheet

(SDS)

The “Accident Weed”

Hazardous

Conditions

Hazardous

Practices

Did not report hazardEquipment failure

Root Causes

Step 5 – Develop Recommendations

Use Control Strategies

Engineering Controls

Management Controls

Personal Protective Equipment

Interim Measures

Engineering Controls

• Eliminate/reduce hazard by design, enclosure, substitution, replacement, etc.

• 3 principles

1. Removal or substitution

2. Enclosure

3. Barriers or local ventilation

Management Controls

Eliminate/reduce exposure by

controlling behavior

Two primary strategies:

• Safety rules and safe work

practices/ procedures

• Scheduling

Personal Protective Equipment (PPE)

• Used along with engineering and management controls

• Legal requirements

• Limitations

Write The Report

• How and why did the accident happen?

• A list of suspected causes and human actions

• Use information gathered from sketches, photographs, physical evidence, witness statements

Step 6 - Write a Report

The report should include:

• An accurate narrative of “what happened”

• Clear description of unsafe act or condition

• Recommended immediate corrective action

• Recommended long-term corrective action

• Recommended follow up to assure fix is in place

• Recommended review to assure correction is

effective.

Preparing a Recommendation

1. Pinpoint the problem• Hazardous condition, unsafe behavior, etc.

• System components

2. Find out problem history

3. Pinpoint the solution• Engineering, administrative, PPE

• System improvements

Write The Report

• When and where did the accident happen?

• What was the sequence of events?

• Who was involved?

• What injuries occurred or what equipment was damaged?

• How were the employees injured?

Answer the following in the report:

Step 4- Report Writing Material

• Injured Employee Packet

- (green packet material)

• City of Mesa Incident Report

• Solid Waste Incident Investigation Form

Conclusions of Report

• What should happen to prevent future accidents?

• What resources are needed?

• Who is responsible for making changes?

• Who will follow up and insure changes are implemented?

• What will be the future long-term procedures?

Report conclusions should answer the following:

The report is an open document

until all actions are complete!

Follow Up!

Take corrective action

Conduct follow up evaluation

Conduct annual review of reports

Discuss Mary Alice Conlin Case

• Mary Alice Conlin Handout