CTSI Loss Prevention Manual Section G Accident Investigation
Accident/Incident Investigation Introduction Accident/incident investigations help management control accidents and related costs by documenting exactly what occurred and identifying what can be done to help prevent a reoccurrence. Good accident investigations are particularly important as seriously injured employees will often sue for additional or excessive awards and settlements. The investigation report documents the circumstances at the time of the accident and can help the supervisor accurately recall the situation several years after the occurrence. This can be extremely helpful in defending a lawsuit or fraudulent claim. A good investigation identifies accident cause(s) and allows the supervisor to take steps to prevent the same accident from happening again. This pro-active approach by management to prevent accidents, rather than simply filing claims, helps reduce the total number of claims and related costs. Accident reduction also helps improve efficiency and profitability by reducing lost time, work interruption, equipment repairs, and other indirect costs that are often associated with employee accidents. It has been estimated that the indirect costs of employee accidents are often 5 to 10 times more than the direct/claims cost of the accident. How to Use This Section This section outlines suggested procedures to be followed in the event of an accident or incident involving employees, property damage, subcontractors, or the general public. The accident investigation should be completed within 24 hours of the occurrence by the Department Head, superintendent, manager, or supervisor. Accident investigation and claim forms may be included in this section by management for easy access. The accident investigation can be used to complete the claim form should filing become necessary. General liability claims may require special handling and legal counsel (see text). See Section B for sample accident investigation forms and information on how to obtain them. Loss Prevention Manual, 5/07 G-1
Accident/Incident Investigation Procedures Investigation of any accident is an important management tool for controlling accidents and their related costs. Investigations should be conducted for all employee accidents as well as those involving injury to customers while on county property. A good investigation helps identify what happened and how it might be prevented from happening again. The objective is to prevent or reduce future accidents and related claim/insurance costs. Accidents are usually the result of conditions or actions that the supervisors and employees are often in the best position to control. An accident is simply an unplanned event that interrupts operations and results in loss of time, property damage, or bodily injury. They usually arise from one of four areas: Equipment Buildings, tools, carts, machinery, vehicles, etc. Material Solvents, cleaning agents and anything else that might be used as part of the service or job. People Includes those persons that operate equipment, use cleaning materials, customers, the public, etc. Environment Includes temperature, ventilation, noise, insects, or other factors that affect the surrounding work area. Incidents are unsafe practices or conditions that have not yet resulted in an accident or loss but could unless corrective steps are taken. Incident investigations are conducted "before-thefact" or before an injury or loss occurs to help identify and correct hazards before a claim is experienced. This may be prompted by a "near miss" situation or by observations of unsafe practices that could lead to an accident. Accidents are usually persons, objects, or energy out of control. Accident investigations are conducted "after-the-fact" or after the injury or loss has occurred. The primary purpose is to pinpoint causes so that similar accidents can be prevented from reoccurring. Accident and incident investigation follow basically the same procedures. An investigation is a report of the facts, causes, and contributing factors that lead to the accident/incident and an action plan for correcting the problem. Without proper investigations and follow-up, corrective measures, accidents and their related costs can not be controlled. These costs have a direct bearing on insurance costs and productivity. Accidents must ideally be prevented in the first place, and those that do occur must be analyzed and controlled as much as possible. Loss Prevention Manual, 5/07 G-2
Investigation Procedures Situations that should be investigated are those that have or could have resulted in a serious or disabling injury, minor injuries, property damage, and "near miss" incidents. These investigations could involve employee injuries (Workers' Compensation), injuries to the general public (liability), or damage to vehicles/equipment (property). The investigation procedure followed by the manager depends on several key steps: 1. Notice of the Event - Managers will usually find out about an employee accident from the injured person or from fellow workers who observed the accident. The supervisor must insist that all accidents be reported immediately. There may be some reluctance by some to report accidents at all due to fear of discipline, "red tape," or concern that they will spoil their record. The manager can overcome these fears by keeping the process as simple as possible and explaining to all employees the importance of accident investigation and prevention. 2. Go to the Scene Immediately - Failure to respond right away prevents proper management of the accident scene and could result in a poor, inaccurate investigation. The first task is to attend to the injured and provide first aid/medical attention. If possible, the accident should be discussed with the injured party while the situation is still fresh. Witness statements should be obtained as soon as possible and the manager should emphasize fact-finding rather than fault-finding. Facts should be gathered from all available sources and hasty conclusions should be avoided until all the facts are in. If necessary, simulate the accident up to the point of injury/damage. For accidents involving serious injury or substantial property loss, physical conditions should be noted with photographs taken from different angles to further confirm what was found. Several photographs should be taken employing a general view and showing the relationship of the accident to surrounding equipment or articles. Articles that have direct relationship to the accident should also be photographed with a ruler or some other reference laid alongside to show the size of the object. Basic information should be included on the back of each photograph as follows: Data identifying the photographs with a particular accident. Data identifying who took the photograph, the date, and time. Data to orient the camera position with the accident scene. Posed photographs can also be used to illustrate or refute the statement of a witness or accident victim. A person with the same general, physical characteristics of the injured party could be placed in the same spot and position as directed by the witness. Marks or pointers should be used to clarify important aspects of the photograph. 3. Interview Witnesses - Witnesses should be interviewed separately and as soon after the accident as possible to get unbiased versions of what happened. The manager should conduct the interview in private and try to put the employee as much at ease as possible. Basic questions to be asked include - What was the injured doing? What unsafe actions (by the injured or others) were observed? Loss Prevention Manual, 5/07 G-3
Were there any unsafe conditions? How could the accident have been prevented? The supervisor should ask the witness to verbally and visually walk them through the accident. The story should be told back to the witness to ensure the accuracy of the statement and all facts should be recorded so they are not lost or forgotten. The interview should be ended on a positive note with the manager thanking them for their help. 4. Review the Facts - The manager should examine all of the accident elements Equipment (Maintained? Proper for the job? Properly used?) Materials (Correct for the job? Stored/handled properly?) People (How many? Was that enough? Properly trained?) Environment (Did the work area contribute to or cause the accident?) Other sources of information may include recollections of past occurrences and causes, inspections/observations of similar occurrences/places, and other persons who do similar work in the same area. Records should be checked to see if this has happened before, including maintenance records if a piece of equipment was involved. 5. Determine Accident Causes - The manager/investigator must be thorough and systematic to ensure accuracy. System or procedure flaws are the most common, general cause of accidents. The investigation should identify the causes and factors that lead to the system failure. Immediate Accident Causes: Unsafe Acts - are involved in approximately 90% of all accidents and may be committed by the injured, management, or others. Unsafe acts may be committed deliberately, unknowingly, or may result from something uncontrollable. Unsafe acts are usually short in duration, don't happen continually, and have reasons that vary from employee to employee and job to job. People commit unsafe acts for several reasons including incentive (get it done with a short cut), poor work habits, lack of knowledge, and physical or mental impairments (fatigue, medication impairment, etc.). Common unsafe acts include removing safety devices, using unsafe equipment, working at an unsafe speed, and horseplay. Unsafe Conditions - are involved in approximately 10% of all accidents and can be associated with hazards caused by people, equipment, or processes either directly or indirectly. Common causes of unsafe conditions are unsafe acts (persons create an unsafe situation), normal wear and tear, poor product/equipment design, and by-products (steam, smoke, vapors, light). Unsafe conditions tend to remain until they are corrected or an accident occurs and, once corrected, they usually stay that way. Common unsafe conditions include missing or broken guards, unexpected movement of materials/equipment, poor housekeeping, defective tools, and hazardous attire (loose clothing, jewelry, long hair, improper footwear). a. Other Accident Causes: Loss Prevention Manual, 5/07 G-4
i. Job Factors - can involve poor indoctrination, inadequate training, no training follow-up (do they practice what you have preached?), failure to follow safety rules (why?), communication breakdowns, lack of material handling equipment, failure to follow the Safety Program. ii. Personal Factors - can involve poor morale caused by job change, fatigue (from a second job or task beyond their capabilities), drinking (before or during work), drugs (prescription, illegal, or over-thecounter), or stress (from off-the-job and/or on-the-job problems). 6. Corrective Action - Once the immediate and basic accident causes are identified, the manager must determine what corrective measures will be taken to help prevent accident recurrence. These corrective actions generally fall into three categories: a. Physical Change - to the workplace or equipment is the most effective type of corrective measure when it can be used. In general, it's easier to replace/repair the broken machine cover (and more effective) than to train all employees in how to avoid contact with the running parts. b. Procedural Change - regarding how certain jobs or tasks are done followed by employee training and enforcement by the manager. c. Retrain the Injured Employee - and all other employees who may be exposed to the same hazard or situation. 7. Report to Management - All appropriate investigation and claim forms must be filled out completely and accurately by the manager. These reports should indicate all the facts, the conclusions reached as a result of the investigation, and what followup/corrective measures will be taken. Accident investigation and claim report forms should be written so that someone unfamiliar with the situation can understand it. These readers may include claims adjusters, consultants, OSHA, and attorneys (if the claim results in a lawsuit). The manager may be called upon to recall the details of the accident several years after it occurred. It is, therefore, in the manager's own, best interest to develop as accurate and detailed reports as possible to ensure that the four parts of any investigation are covered: Identification of the Accident (When? Who? Where?) Description of the Accident (What? How?) Cause of the Accident (Why?) Corrective Measure/Remedy All preliminary accident investigation and claims report forms should be completed within 24 hours of the occurrence. Additional information secured after the initial report is submitted should be forwarded as soon as possible. The best way to minimize and control the financial impact of the accident after it occurs is by prompt reporting, claims handling, and settlement. 8. Follow-up and Prevention - The final step in the accident investigation process involves making use of the information collected and preventing additional accidents. This requires on-going effort by the manager. Loss Prevention Manual, 5/07 G-5
General Liability Accidents General liability accidents require special handling because unless they are handled properly, they may result in a lawsuit. The potential financial loss is much greater than employee accident claims because there is no Workers' Compensation system that puts a "cap" on the financial settlement. Injured parties will tend to rely on the legal system to resolve any claims, particularly when you fail (or appear to fail) to respond in what they consider a prompt and fair manner. In addition to compensatory awards, there is also a potential for punitive damages. Managers who are aware of a potential, personal injury/liability claim situation involving their operations should adhere to the following general procedure: Never admit to guilt or county wrong-doing. A sympathetic or reassuring statement made at the accident scene could cause serious damage in court. Let the courts determine who is at fault. Prompt notification of the accident is essential. This should involve a joint effort by all employees and supervisors. You can best avoid an expensive claim or lawsuit by prompt investigation, claims handling, and settlement. This does not mean that every potential liability situation will result in a claim. A prompt investigation confirming or refuting county responsibility is critical and will determine what approach will be taken by the manager, claims adjuster and insurance carrier. Statements should be obtained from the injured parties as soon as possible. These should be detailed and provide a full description of the apparent injuries or damage. If possible, these statements should be taken in the presence of another, third person who could be used to corroborate what was said. Witness statements should be obtained from both employees and the public, if available. The full name of each witness, including their address and telephone number, should be obtained. Photographs should be taken of accident scene elements, particularly those that reflect favorably on the county. This might include shots of the scene that clearly show there was no hazard. Follow-up activities will include contact with the injured parties to show concern and interest in their recovery. This must be handled carefully, sometimes at the direction of legal counsel. The purpose of the contact is to reassure the injured party that you are not ignoring their situation and, by so doing, help diffuse any anger that might prompt them to retain an attorney. Prompt communication is essential and the manager should keep the CTSI claims adjuster, and (if involved) legal counsel up-to-date on any new developments, contacts from the injured party, etc. Loss Prevention Manual, 5/07 G-6
Information Supplement A Accident Investigation Guidelines The accident investigator or county supervisor should try to expose the root causes of the accident in an attempt to identify and implement a corrective measure that will help prevent a reoccurrence. In the interview/investigation process, there are essentially six, key questions to ask: WHO was injured? WHERE did the accident occur? WHEN did the accident/incident occur? WHAT was the injured party doing? HOW was he/she injured? WHY was there an unsafe act and/or unsafe condition? By using these six basic questions as a guideline, the county supervisor or manager should be able to understand and analyze what happened. In most instances, the manager should be able to identify at least one (if not several) measures that could be taken to eliminate or reduce the potential for accident reoccurrence. A more detailed outline interview/investigation questions is listed below: 1. "What happened?" What was the employee doing (sorting, pressing, etc.)? What was the employee working with (specific equipment, solvent, etc.)? What type of accident was it (slip, trip, fall, caught-in, etc.)? What type of injury (fracture, cut, burn, etc.)? What part of body was injured? 2. "Why did it happen?" A. Equipment What equipment was used? Proper equipment selected for the job? Equipment used properly? Arranged properly? Maintained properly? B. Material What type of material was being used or involved? Was this the proper material for the job/application? Was the material placed properly? Handled properly? Loss Prevention Manual, 5/07 G-7
Processed properly? C. People Was the right person selected for the job? Was the job suited to the person's ability? Was the person adequately trained? Was attitude a contributing factor? D. Environment Proper lighting? Too hot or too cold? Too much noise or vibration? Did chemicals play a part? Weather hazard? Plants, animal, insects? 3. "What should be done?" Based on conclusions from "why did it happen" and how such actions will improve operations 4. Corrective Actions Any corrective actions indicated should include those actions already implemented. 5. Distribute the investigation report to key persons as needed. Investigation results should be shared with other supervisors who may have employees faced with similar injury/accident exposures. Loss Prevention Manual, 5/07 G-8
Information Supplement B Common Accident/Incident Causes Immediate Causes Unsafe Acts (90% of all accidents) Operating without authority Failure to make secure Operating at unsafe speed Failure to warn or signal Nullifying safety devices Using defective equipment Using equipment unsafely Taking unsafe position Servicing hazardous equipment Riding hazardous equipment Horseplay Failure to use protective equipment Unsafe Conditions (10% of all accidents) Inadequate guards and devices Inadequate warning system Fire and explosion hazards Unexpected movement hazards Poor housekeeping Projection hazards Congestion/close clearance Hazardous vapors or fumes Hazardous placement of storage Unsafe equipment defects Inadequate illumination or noise Hazardous personal attire Other Causes Personal Factors Lack of knowledge Personal habit Peer pressure "Machismo Hostility Job Factors Inadequate work standards Inadequate purchasing standards Normal wear and tear Lack of skill Mental or physical problems Convenience Immaturity Save time or effort Inadequate design or maintenance Improper work habits Abnormal usage Loss Prevention Manual, 5/07 G-9
More Effective Accident Control A thorough investigation, applying these objectives... To determine all contributing casual factors. To determine the fundamental or basic reason for the existence of each contributing factor. and following these guideposts... In case of injury, make sure worker is properly cared for before doing anything else. When practical, have scene kept as undisturbed as possible. Investigate as promptly as possible. Whenever possible, go to scene of accident for initial investigation. As applicable, have someone else get photographs, make drawings or measurements. Interview all witnesses separately. Reassure each witness of the investigation s real purpose. Get witnesses initial version with minimal interruption; ask for complete version step-by-step; have them describe and point without doing. Apply empathy in interviews; make no attempt to blame, fix or find fault. Be objective; do not have fixed opinions in advance. When a witness finishes the initial explanation, ask questions to fill in any gaps. Avoid questions that may lead a witness or imply answers wanted or unwanted. Summarize your understanding with a witness after the interview. Express sincere appreciation to anyone who helped in the investigation. will reduce injuries and damage, mistakes and accidents! Using good remedial action... To determine all contributing casual factors. To eliminate or control the reason for the existence of each contributing cause. Loss Prevention Manual, 5/07 G-10
and following these guideposts... (Select appropriate actions) Institute formal training program Give personal re-instruction Institute proper job instruction program Institute safety tipping program Order job analysis on specific jobs Revise existing job analysis Institute new or improve existing inspection programs Institute pre-use checkout of equipment Establish or revise indoctrination for new or transferred employees Repair or replace equipment Improve biomechanic design of equipment (ergonomics) Establish biomechanic requirements for new equipment (ergonomics) Improve basic design or establish design standards Improve identification or color code for safety Install or improve safeguards Eliminate unnecessary material in the area Institute a program of order or improve clean-up Institute mandatory protective equipment program or improve existing coverage or design Use safer material Establish purchasing standards or controls Institute incident recall programs Create safety incentive program Improve physical examination program will reduce problems and delays, mistakes and waste! Adequate time spent today on proper investigation and effective remedial action is a cost reduction effort on tomorrow s losses. Loss Prevention Manual, 5/07 G-11