Instructions for Investigation Report

Transcription

1 1. COMPANY 2. DEPARTMENT 3. LOCATION OF INCIDENT 4. DATE OF INCIDENT 5. TIME A AM PM 6. DATE OF REPORT INJURY OR ILLNESS PROPERTY DAMAGE OTHER INCIDENTS IDENTIFYING INFORMATION 7. INJURED S NAME 13. PROPERTY DAMAGE 16. NATURE OF INCIDENT 8. PART OF BODY 9. DAYS LOST 14. NATURE OF DAMAGE 17. INCIDENT COST, IF APPLICABLE B 10. NATURE OF ILLNESS 15. COST ESTIMATED 18. PERSON REPORTING INCIDENT ACTUAL 11. OCCUPATION 12. TIME ON TASK 19. OBJECT/EQUIPMENT/SUBSTANCE INFLICTING HARM 20. PERSON WITH MOST CONTROL OF ITEM 11 C RISK DESCRIPTION 21. TYPE OF CONTACT CONTACT WITH Struck against Struck by Caught in Caught on Caught between Slip Fall on same level Fall to lower level Overexertion Electricity Heat Cold Radiation EVALUATION OF LOSS 22. LOSS SEVERITY POTENTIAL 23. PROBABILITY OF REOCCURRENCE Caustics Noise Toxic or noxious substances POTENTIAL IF NOT CORRECTED Severe Serious Minimal High Medium Low 24. DESCRIBE HOW THE EVENT OCCURRED. D E F 25. IMMEDIATE CAUSES, WHAT SUBSTANDARD ACTIONS AND CONDITIONS CAUSED OR COULD CAUSE THE EVENT? CHECK ON BACK (25A), EXPLAIN HERE. 26. UNDERLYING CAUSES, WHAT SPECIFIC PERSONAL OR JOB FACTORS CAUSED OR COULD CAUSE THIS EVENT? CHECK ON BACK (26A), EXPLAIN HERE. CAUSE ANALYSIS G

2 25A. IMMEDIATE CAUSES (Check all that apply.) Substandard Actions 26A. UNDERLYING CAUSES (Check all that apply.) Personal Factors Substandard Conditions INCIDENT NEEDS Operating equipment without authority Failure to warn Failure to secure Operating at improper speed Making safety devices inoperable Removing safety devices Using defective equipment Using equipment improperly Failing to use personal protective equipment properly Improper loading Improper placement Improper lifting Improper position for task Servicing equipment in operation Horseplay Under influence of alcohol and/or other drugs Operating equipment without authority Inadequate or improper protective equipment Defective tools, equipment or materials Congestion or restricted action Inadequate warning system Fire and explosion hazards Poor housekeeping/disorder Hazardous environmental conditions: gases, dusts, smoke, Gfumes, vapours Noise exposure Radiation exposure High or low temperature exposure Inadequate or excess illumination Inadequate ventilation Inadequate capability Lack of knowledge Lack of skill Stress Improper motivation Job Factors Inadequate leadership/supervision Inadequate engineering Inadequate purchasing Inadequate maintenance Inadequate tools/equipment/materials Inadequate work standards Wear and tear Abuse and misuse 27. MANAGEMENT CONTROL (Check all that apply.) Program Elements P S C P S C CONTROLS 1. Leadership and administration 2. Leadership training 3. Planned inspections and maintenance 4. Critical task analysis and procedures 5. Accident/incident investigation 6. Task observation 7. Emergency preparedness 8. Rules and work permits 9. Accident/incident analysis 10. Knowledge and skill training H 11. Personal protective equipment 12. Health and hygiene control 13. System evaluation 14. Engineering and change management 15. Personal communications 16. Group communications 17. General promotion 18. Hiring and placement 19. Materials and services management 20. Off-the-job safety Legend: P Program element implementation need S Standard(s) inadequate C Compliance with standard(s) inadequate 28. REMEDIAL ACTIONS, WHAT HAS AND/OR SHOULD BE DONE TO CONTROL THE CAUSES LISTED? DEADLINE BY WHOM COMPLETE ACTION PLAN 29. SIGNATURE OF INVESTIGATOR DATE I 30. SIGNATURE OF REVIEWER DATE 31. REVIEWERS S REACTIONS TO THE INVESTIGATOR S ANALYSIS OF THE BASIC CAUSES AND REMEDIAL ACTIONS. SIGNATURE TITLE DATE J WSPS (9777) www.

3 Section A: Input the name of the company, department, location, date and time of where and when the injury or illness occurred. Questions #4 and 5: Record the date and time of when the injury/illness occurred. For example: A fall or a cut from a machine; an allergic response to a chemical. If the injury or illness did not suddenly occur but rather happened over a period of time (i.e. an MSD or a respiratory disease), you must record an approximate date you first started to notice it. Question #6: Input the date the investigation report is being filled out. Section B: In this section, record the name of the injured, his or her job title, and the duration of time he or she was working on that task. For example: Question #8: Specify the body part. Question #9: Record the number of days the worker missed due to the injury. This count should be started on the day which the injury/illness occurred (date inputted in question 4). Question #10: This indicates the type of injury that occurred, for example a burn or fracture. Specify how the injury or illness occurred. Section C: Identify any property damage by listing the piece of property that was damaged (#13); the nature of the damage (i.e. fire, explosion #14); and the cost of the damage. In #15, record the costs involved, and whether they are estimated or actual WSPS (9777) www.

4 Section D: In this section, check all factors that apply to the injury or illness, in order to help identify how the injured worker came into contact with the material and/or equipment, or what form of energy caused the initial contact. Type of Contact: Check off all types of contact the worker experienced during the incident (i.e. struck by forklift, fall on same level, fell down when hit). Contact With: Check off all sources of contact during the incident, if this applies. Section E: When assessing a hazard, you are in the process of determining how serious its consequences could be and therefore setting priorities for action. For example, hazards that threaten death or permanent disability should be given the highest priority for action. To help you classify hazards according to their severity, use the following guidelines. Loss Severity Potential Severity is the magnitude of potential loss (any type). By using these definitions as a guideline, you can determine which severity level will be associated with each hazard. Level Severe Serious Minimal Description Death or permanent disability Loss of body part Extensive loss of structure, equipment or material Serious injury or illness resulting in temporary disability Property damage disruptive but less severe than above Minor injury or illness that is non-disabling Property damage that is not disruptive WSPS (9777) www.

5 Probability of Reoccurrence Probability is the likelihood that the hazardous situation or event will occur, and includes the frequency of occurrences. Using the categories of low, medium, and high, ask questions related to the hazard to determine what you feel the probability of it occurring may be. Some questions to ask are: 1. How many people are exposed to the hazard? 2. How frequent is the exposure to the hazard situation? 3. What are the current control measures? a. Low = at the source b. Medium = along the path c. High = at the worker 4. How many control measures are in place? a. Low = multiple b. High = none 5. What is the quality of the control measures? a. Low = legal requirements, standards/best practices, monitored b. High = minimum legal requirements are not being met Section F: Describe where the event occurred (location, building, etc.) and what happened. Include as much detail as possible in order to aid in determining proper recommendations on preventing this incident in the future. For Example: Worker was at the north end of the garage at 2:00 p.m. performing regular duties. Worker got splashed with chemical XYZ and got some in both eyes. At that time he was pouring 1.5L of chemical XYZ into container and was not wearing his safety goggles, as required WSPS (9777) www.

6 Section G: List all the immediate causes in box 25. Immediate causes are substandard actions or inactions and substandard conditions that contributed to the incident. Examples may include: operating equipment without authority or inadequate or improper protective equipment. Examples are provided on the back of the form (#25A). This is not an exhaustive list. Be specific. Provide as many details as possible when outlining the immediate causes. List all the underlying causes in box 26. Underlying causes relate to the immediate causes identified in the investigation. Underlying causes are the underlying factors that explain why the immediate causes were allowed to exist or occur. Examples may include: inadequate purchasing or inadequate work standards. Examples are provided on the back of the form (#26A). Be specific. Provide as many details as possible when outlining the underlying causes. Ensure all immediate causes can be traced back to at least one underlying cause. Section H: In this section, determine the level at which all Program Elements are at: P Program Element requires implementation S The existing standards are inadequate and require revision C Compliance with standards are inadequate Section I: List all actions that have been taken or need to be taken to prevent a similar incident from occurring. Recommendations must relate to the underlying causes identified in box #26. All recommendations must be clear and specific and outline the name of the person responsible for taking action and the expected completion date. Once the action has been completed, indicate the completion date in the appropriate column WSPS (9777) www.

7 Section J: In this section, the Reviewer shall briefly write down his/her reaction of the investigators findings of the basic causes of the incident and remedial actions for future prevention. Please note: whoever plays the part of the reviewer and investigator depends on the company procedure and policy. It should be stressed that this process is to be an unbiased one, and therefore, any personal reactions to the interviewer should be ignored. Only responses to the report and the analysis itself should be made. Workplace Safety & Prevention Services Workplace Safety & Prevention Services (WSPS) grants permission to approved end users to reproduce this document in whole or in part, provided its intended use is for non-commercial, educational purposes and that full acknowledgement is given to the WSPS. Approved end users are firms registered with the Workplace Safety and Insurance Board. WSPS reserves the right to extend this permission to other stakeholders and interested parties by express written permission upon application. WSPS extends no warranty to materials amended or altered by the end user. Under no circumstances is this document, or any portion thereof, to be duplicated for purposes of sale or for external reproduction or distribution. (Sample WSPS acknowledgement, Reproduced or adapted from name of solution with permission of Workplace Safety & Prevention Services, Mississauga, Ontario. ) The information contained in this reference material is distributed as a guide only. It is generally current to the best of our knowledge as at the revision date, having been compiled from sources believed to be reliable and to represent the best current opinion on the subject. No warranty, guarantee, or representation is made by WSPS as to the absolute correctness or sufficiency of any representation contained in this reference material. WSPS assumes no responsibility in connection therewith; nor can it be assumed that all acceptable safety measures are contained in this reference material, or that other or additional measures may not be required in particular or exceptional conditions or circumstances. Revised: August WSPS (9777) www.