5.0 Incident Management

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1 5.0 Incident Management 5.1 Why are we doing it The Company is committed to the Health and Safety of its employees and others who visit the site (including contractors), and to follow up and take appropriate action when incidents occur. To successfully to this, a system is needed to make sure all incidents and injuries are reported and recorded by all staff and visitors, and that there is a process for investigation and preventative or corrective action where appropriate. Any work related illnesses and near misses (events that could have harmed someone, equipment or the environment) are also included. Where investigation identifies misconduct is a root-cause disciplinary action may be taken 5.2 What do we need to do The steps below apply to the following events: All accidents, Incidents (including near Hits, harm to the environment cause by breach of any environmental standard and damage to plant exceeding $500.00) and Work related illnesses, no matter how minor (e.g. stress, respiratory illness etc). 1. All employees must fully understand incident and accident reporting procedures. 2. If a serious event occurs it is to be reported to the Supervisor/Work Area Manager, who will notify their Manager immediately. 3. The priority is treatment for the injured employee.. 4. Where applicable, environmental damage (air, water or ground) needs to be managed. 5. Managers are responsible to complete 5.0A Incident Reporting form for all Near Hits, Incidents and Accidents and completing the Incident Register. If serious incident the form is to be completed within the shift. 6. If a serious incident (has or likely to cause serious harm), then managers are responsible to do an investigations using 5.0B Incident Investigation. 7. Where possible the Accident Report Investigation Form is to be completed by the injured employee and their Supervisor/Manager. 8. The completed forms are immediately given to the Health and Safety Officer. 5.0 Incident Management Version: 1 March 2015 Section: 5 Page 1 of 4

2 9. If it is a Serious Harm incident or Lost Time incident (LTI), the Site manager must inform the Director as soon as possible. An LTI will be determined once employee has had medical advice and depending on how bad the injury is. 10. All Serious Harm Incidents are to be reported to WorksafeNZ as soon as possible and the scene of the event must not be tampered with or changed (this is termed the scene is frozen ) until given the OK from a Worksafe inspector. Worksafe NZ must be notified about a serious harm incident As Soon As possible by phoning and send a written investigation report within 7 days. 5.3 WorkSafe NZ Serious Harm Definition Serious harm means death, or harm of a kind or description declared by the Governor- General by Order in Council to be serious for the purposes of the Act; and 'seriously harmed' has a corresponding meaning. Until such an Order in Council is made, the following types of harm are defined in Schedule 1 as 'serious harm' for the purposes of the Act: 1. Any of the following conditions that amounts to or results in permanent loss of bodily function, or temporary severe loss of bodily function: respiratory disease, noise-induced hearing loss, neurological disease, cancer, dermatological disease, communicable disease, musculoskeletal disease, illness caused by exposure to infected material, decompression sickness, poisoning, vision impairment, chemical or hot-metal burn of eye, penetrating wound of eye, bone fracture, laceration, crushing. 2. Amputation of body part. 3. Burns requiring referral to a specialist registered medical practitioner or specialist outpatient clinic. 4. Loss of consciousness from lack of oxygen. 5. Loss of consciousness, or acute illness requiring treatment by a registered medical practitioner, from absorption, inhalation or ingestion of any substance. 6. Any harm that causes the person harmed to be hospitalised for a period of 48 hours or more commencing within seven days of the harm's occurrence. In the case of a serious harm injury, the injured person must be attended to and then removed from the scene for medical attention. The Work area Manager or Site manager must tell Management as soon as possible. The Work Area manager must also notify WorksafeNZ as soon as possible (but must also be within 7 days) and their instructions followed, including that the scene must not be changed or tampered with until given the OK by WorksafeNZ. Where the Work Area manager or supervisor is unavailable, the Health and Safety Officer will be responsible. 5.0 Incident Management Version: 1 March 2015 Section: 5 Page 2 of 4

3 5.3.1 Investigation and follow-up action All incidents must be investigated by competent staff, and can be undertaken by the Manager, H&S Officer and a Health & Safety Committee Rep. The Director/Health and Safety Officer will decide how in-depth the investigation needs to be, and the expected outcomes which include: Corrective and or preventive actions to equipment, plant and procedures that need to happen, Who is responsible for what (equipment and plant alterations/purchases, and procedure changes), Time frames to be completed by. Some incidents have the potential to be significant events, or the cause or serious harm, and therefore require more in depth investigations Once action has been undertaken, the H&S Officer will need to decide if this is sufficient or if further action is required Incident Review Corrective or preventative actions to be implemented from an investigation are the responsibility of the Manager. This could include change to processes or equipment, and therefore a review and change of procedures. All relevant employees must be informed of these changes immediately to prevent further incidents occurring. If an incident keeps recurring even after changes are implemented, the Management review team needs to re-investigate the incident, any hazards involved and actions that were recommended. It should review the suitability of the preventive action assigned to it originally.. Analysis of the incident register needs to be undertaken annually to find any reoccurring hazards to do with certain incidents How to record and review Incident Trends The Incident register is a spreadsheet in MS excel, with the following details entered when an incident occurs: 1. Date of incident 2. Type/category of incident 3. Mechanism of harm 4. Injured body part or type of damage 5. Process or activity when incident happened As new incidents are entered, the associated graphs will update automatically. At a regular timeframe or using a quarterly cycle, the Health and Safety Officer and Health and Safety committee will print out and review the trending graphs to identify trends and make recommendations for preventative measures. 5.0 Incident Management Version: 1 March 2015 Section: 5 Page 3 of 4

4 These trends and recommendations will also be presented at the Annual General Meeting, given to management and available for staff (notice boards, newsletters, s) 5.4 Fatigue and Stress If an incident report for fatigue or stress, the following steps will be followed: Employee will detail on incident form what part/s of their job and how much of it (using a percentage value) are giving them stress. Health and Safety Officer will decide whether an investigation should occur. Using a suitable provider (from preferred supplier register), specialist medical assessment shall occur and treatment commence and medical report sent to Health and Safety Officer. Medical report shall be received by Health and Safety Officer will discuss report with affected employee. Work and duties shall be managed to control stress and an action plan put in place where required. 5.5 Record Keeping Incident reports are to be retained for a period of at least 10 years. Documents associated with this Chapter: A Incident reporting form B Accident Investigation Form C Incident Register D Definition of Serious Harm E Accident Flowchart Good Investigation Techniques 7. Serious Harm Notification Form 5.0 Incident Management Version: 1 March 2015 Section: 5 Page 4 of 4

5 5.0A Incident Reporting Form Near Hit Incident Gradual Person involved: Location address of incident: Department: Treatment Nil First Aid Doctor Hospital Date of incident Time of incident: Contact Name: Staff/Contractor: Type of incident (circle) Injury Sustained Vehicle incident Property damage Service Quality Plant damage Close call Non work related Regulatory Motor vehicle Public liability/reputation Brief Description of Incident: (Describe events leading up to and including incident. Draw picture if required) Attach additional comments, diagrams, and descriptions as required. Body part injured / Plant damaged (Plant number, damage etc Draw pic) (circle) Left Right Cause(s) for this incident, 5 Whys?) Corrective Action Immediate and Planned (Steps to insure incident does not happen again) By When By Who Report Completed by Manager Reviewed and Agrees Name: Date: Sig: Name: Date: Sig: Date added to the Incident Register / / 20 Hazard identified in hazard Register Yes No 5.0A Incident Reporting Form Version: 1 March 2015 Section: 5 Page 1 of 1

6 5.0B Incident Investigation Report Injured person: Time of incident Location address of incident: Date of incident: Contact Name: Staff/Contractor: Department: Investigators Name(s): Incident Severity Rating: Has this incident happened before? Were procedures followed Was the person trained Yes / No Yes / No Yes / No Drug/alcohol test completed? Results: Negative / Positive Eye witness: Yes / No Name: Yes / No Type of incident (circle) Injury Sustained Vehicle incident Property damage Service Quality Equipment damage Close call Non work related Regulatory Motor vehicle Public liability/reputation Brief Description of Incident: (Describe events leading up to and including incident. Draw picture if required) The 5 P s - Refer to the 5 P s for contributing factors and the Root Cause in Flow Chart page 3 Tick appropriate box(s) People (human factors involved) Places (immediate work environment and surrounds) Plant (equipment, tools, facilities, materials, substances) Procedures (organisational and system issues Protection (barriers and safeguards) 5.0B Incident Investigation Report Version: 1 March 2015 Section: 5 Page 1 of 2

7 Contributing Factors (Unsafe practices or conditions that helped lead to the primary cause of the incident) Root Cause (The underlining reason(s) for this incident, 5 Whys?) Preventative Actions (Steps to insure incident does not happen again based on the Contributing factors/root Causes) By By Date Action Required When who completed Report Completed and Investigated by Manager sign off and Actions completed Name: Date: Name: Date: Sig: Sig: 5.0B Incident Investigation Report Version: 1 March 2015 Section: 5 Page 2 of 2

8 5.0D Definition of Serious Harm 1. Any of the following conditions that amounts to or results in permanent loss of bodily function, or temporary severe loss of bodily function: respiratory disease noise-induced hearing loss neurological disease cancer dermatological disease communicable disease musculoskeletal disease illness caused by exposure to infected material decompression sickness poisoning vision impairment chemical or hot metal burn of eye penetrating wound of eye bone fracture laceration crushing 2. Amputation of body part. 3. Burns requiring referral to a specialist registered medical practitioner or specialist outpatient clinic. 4. Loss of consciousness from lack of oxygen. 5. Loss of consciousness, or acute illness requiring treatment by a registered medical practitioner, from absorption, inhalation, or ingestion, of any substance. 6. Any harm that causes the person harmed to be hospitalised for a period of 48 hours or more commencing within 7 days of the harms occurrence. 5.0D Serious Harm Version: 1 March 2015 Section: 5 Page 1 of 1

9 5.0E Incident / Close Call Flowchart Incident/Close Call Occurs WHY Personal Factors Job Factors External Factors PEOPLE DID NOT FOLLOW PROCEDURES OR ACCEPTABLE PRACTICES BECAUSE... PLACE OF WORK WAS INADEQUATE BECAUSE... PLANT AND/OR EQUIPMENT FAILED BECAUSE. PROCEDURES FAILED BECAUSE. PROTECTION FAILED BECAUSE. MANAGER/ SUPERVISOR DID NOT PROVIDE PROPER GUIDANCE BY... PEOPLE DIRECTLY INVOLVED Lighting/ Ventilation Was Poor It Was Poorly Maintained They Were Inadequate PPE Was Not Suitable Or In Poor Condition Not Ensuring People Had The Right Skills, Knowledge &/or Tools & Equipment Not Communicating Clear Performance Standards Tolerating or Reinforcing The Short Cutting Of Standard Procedures Made An Honest Mistake Performed The Task Without Proper Care Or Attention Chose To Take A Short Cut To Save Time Or Reduce Effort Were under the influence of Alcohol and/or Drugs Poor Design/ Layout Of Workspace Facilities/ Utilities Were Inadequate / Untidy It Was Operated Outside Its Design Limits A Design Failure Lack Of Planning / Coordination Of Activities Guarding/ Barracading Was Inadequate Warning Devices / Detection Systems Failed External Agency / Person Unpredictable Failure Of Equipment DEVELOP ACTIONS THAT DEAL WITH THE ROOT CAUSE IMPLEMENT ACTIONS VERIFY/ VALIDATE ACTIONS 5.0E Incident Flow Chart Version: 1 March 2015 Section: 5 Page 1 of 1

10 5.1 Investigation Tips Get into an open frame of mind, as what you think happened might not be what really happened. Don t let judgements about people get in the way or make assumptions when you don t have the full story. Your aim is to get full and accurate information, and stop the interview if an employee is giving information that is detrimental to the investigation. Equipment to take: Pens and notebook Measuring tape Camera Recording device on phone Copies of accident report forms, checklists Personal protective equipment Tips to get the best information Conduct an investigation as soon as possible following the event to gather all the necessary facts, determine the true causes of the event, and develop recommendations to prevent a recurrence. Get there as quickly as possible. Take a scribe to note all the information discussed and to ask other questions (Another set of eyes) Ensure area is safe to enter. Make sure injured person has first-aid or medical attention required. Look for witnesses. Record the scene with lots of photos from every angle up close and from a distance (ideally date and time printed) or sketches. Safeguard any evidence. Establish what happened. Investigate The investigation should answer six questions: 1. Who? 2. What? 3. When? 4. Where? 5. Why? 6. How? 5.1 Investigation Tips Version: 1 March 2015 Section: 5 Page 1 of 2

11 Interview Interview all people involved. Ask open ended questions, Look for all the causes. Do not fall into the trap of blaming the employee or volunteer, even if the person admits causing the event. Investigate the procedures, supervisor's directives, training, machinery, weather, you get the idea. The organization's accident, incident and near-miss reporting forms will give guidance. Document Properly document all accident investigations using the organization's approved investigation form. The form should make it simple to remember what questions to ask, be easy to understand and complete, and be filed and retained in chronological order. Protect Privacy Ensure investigation reports and information are not to be released to anyone without authorization. Review Review all accident, incident and near-miss investigations occurring since the last safety committee meeting at the next safety meeting. An example of how to set out an investigation is in a fish bone model Record Keeping All investigations are to be completed using the model above and reported on Section 5.0B Investigation report. 5.1 Investigation Tips Version: 1 March 2015 Section: 5 Page 2 of 2

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