Make workplace safety part of the job.

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1 Make workplace safety part of the job. Management Commitment and Involvement Accident Investigation (MSF 4a) YOUR BUSINESS A CULTURE OF SAFETY

2 Why develop a safety culture? Once safety is an integral part of your daily operations, you open the door to the benefits of potentially lower premium costs, fewer accidents, improved employee morale and productivity and overall bottom-line savings. Establishing a safety culture at your business takes time, patience, commitment, creative thought and follow-through. Montana State Fund s (MSF) safety service team has identified five key factors that will assist you in developing your own safety culture program at your business. These factors include: 1. Communication and Awareness of Safety 2. Compassionate and Focused Injury/Incident Response 3. Aggressive Claims Management 4. Management Commitment and Involvement 5. Employee Motivation Within these factors are units of discussion that will help you understand and implement these key factors. This specific manual discusses Key Factor #4: Management Commitment and Involvement. This unit of discusion highlights Accident Investigation. 2

3 Why Investigate Accidents? The purpose of any accident investigation is to look beyond the obvious to determine the true cause of the incident and ultimately reduce the likelihood of a similar occurrence in the future. Accident investigation is not merely a case-by-case, isolated procedure but a way for your organization to track the effectiveness of your company s investigation practices. A productive accident investigation can enhance your company s existing safety program. It can increase employee awareness and establish baseline data that will help you spot trends on where, when and how most accidents occur at your business. There are two primary reasons for your investigation: 1. To prevent recurrence 2. For legal reasons (e.g., determine responsibility/liability or filing an insurance claim for property loss) This unit brochure will emphasize reason #1. This Accident Investigation unit will help you: Identify which accidents to investigate Understand when to investigate accidents Learn how to effectively investigate accidents 3

4 Terminology Before jumping into this unit, let s define some important terms that will be used throughout this publication. Accident: An unplanned event which results in employee injury, property damage or equipment damage. The key here is an actual loss. Incident: An unplanned event that did not lead to employee injury, property damage, or equipment damage, but nearly did. An example would be an employee who walked into the path of a forklift and is nearly struck by it. Root-cause: The root-cause answers why an accident /incident occurred. In a cause and effect model it is the cause. If the cause were controlled, it would eliminate the accident or incident (effect). One theory states: if you first identify unsafe work conditions and/or unsafe work practices, then ask five why follow-up questions. By the time you reach the fifth why, the root-cause will be known. See next page for an example: 4

5 Scenario: Your customer who is touring your warehouse slips on a patch of oil and falls. This results in a fractured ankle. WHY is there oil on the floor? Because the forklift has a leaking gasket. WHY is there a leaking gasket? Because it s past due on maintenance. WHY is it past due on maintenance? Because there isn t a preventive maintenance plan. WHY isn t there a plan? Because we simply haven t created it yet. WHY didn t we create it? Frankly, it was on the list of to do s, but was considered a low priority. In this scenario, even if the leaking gasket had been repaired, the problem would likely recur because the actual root-cause of this situation is the absence of a preventive maintenance (PM) program, not the one-time fix of a leaking gasket. 5

6 Investigation What should be investigated? An investigation is a detailed account of the events surrounding any incident or accident that results in a workplace injury or potential injury. Both accidents and incidents should be investigated. However, since time is expensive, your company should determine what types of accidents and incidents you want to investigate. At a minimum, all accidents or incidents that have or could lead to a fatality, serious injury, or loss time from work should be investigated. A successful accident/incident investigation program seeks to prevent future workplace injuries. That s why it s so important to analyze every incident and every accident that your company determines necessary. When should an accident be investigated? Your company should investigate an accident as soon as it is safe to do so. This means that all energy sources/hazards are brought to a neutral or safe status before beginning a rescue (protect the lives of others), and then assure injured person(s) receive proper medical attention. Once the above actions are completed, it is then appropriate to secure the area to maintain the integrity of the accident scene and the evidence it contains. 6

7 A thorough investigation should take place as quickly as possible to obtain accurate information from the injured parties and witnesses while information is still fresh in their minds. How to Investigate an Accident The key to an effective investigation program is using a systematic approach for investigating incidents or accidents. If you want to uncover the root cause of an accident, you really need to employ an organized method of data collection and analysis. This can be broken down into the following steps: Prompt reaction and response Data collection Data analysis Corrective measures Prompt Reaction and Response There are few things more critical to the investigation process than timely reporting of injuries. Prompt reporting expedites the employee s treatment and subsequent return to health. A good supervisor needs to communicate the importance of accident reporting and investigation in a positive way to quell any fears employees may have about being injured on the job. Some employees might be afraid to report an incident fearing disciplinary action, pressure from the work group or medical treatment. When supervisors communicate the importance of accident reporting in a positive and reassuring manner, it fosters trust within the work environment. 7

8 Data Collection Once the site of the accident scene has been secured and the injured employee has received treatment, the more detailed data collection process can begin. At this point, interviewing witnesses, reviewing relevant documentation, examining equipment and materials and recording other physical conditions of the accident scene should be gathered. Interviews: On-site interviews should be performed immediately to guarantee the most accurate remembrance of events. The more time that is allowed to pass, the more likely your employees will forget specific details. They may talk with other employees about the accident and their memories may become mixed between what they saw and what someone said they saw. Remember, the purpose of the interview is fact-finding, not fault-finding. This means that you are simply looking for the facts. Employees should be assured that all parties would be treated fairly in accordance with company policy. The intent is to determine the events that caused the injury in order to reduce the chances of a similar event occurring at a later date. Employees should feel comfortable to speak freely without fear of retribution. 8

9 When interviewing, ask both open-ended and yes or no questions that encourage your employee to explain what they saw in detail and allow them to expand upon the incident/accident. Yes or no questions are appropriate when determining general facts, such as, Did you see the accident occur? Open-ended questions are used when you need specific details such as, Please tell me what you saw happen. Be cautious to avoid leading questions such as, He must have been going too fast; what do you think? You should also summarize for the interviewee the story you just heard to ensure you have recorded the most accurate facts. Documentation and Records: Information can be obtained from different sources during an investigation. For example, maintenance records, training documentations and past accident investigation reports can provide insight into your investigation. Conditions and Actions: When reviewing your initial information, both the physical conditions and actions (behaviors) should be analyzed. Always consider both of these as symptoms and use them as a starting point for further analysis. See root-cause analysis outlined above. 9

10 Additional Factors: Other conditions that may contribute to an injury, but not as obvious, may include: Time of shift Time constraints or deadlines Absenteeism Morale Seasonal operations or a recent change in operations Overcoming Obstacles: Occasionally you may run across unusual circumstances or other factors that make it more difficult to conduct your investigation. These may include: No one witnessed the accident The accident occurred over the weekend There wasn t anything at the accident scene to confirm the report so you couldn t collect any data The accident was reported several weeks after it occurred Under these circumstances, it is your responsibility to continue conducting your investigation in a professional manner. Don t be discouraged or concerned that you might find yourself in the uncomfortable position of questioning an employee s credibility. This is not your role; your role is to conduct the investigation to the best of your abilities. Even if you are concerned that the accident might be suspicious, you should treat this injured employee with the same courtesy and concern you would any other injured employee. Remember you are fact-finding, not fault-finding. 10

11 Data Analysis Once the data has been collected, it must be assembled to assure all facts are reviewed. Studies have found that 80 to 90 percent of all accidents are the result of human behavior that could have been modified. Never lose sight of this when considering the cause or causes of an incident. However, don t take the easy way out and always blame your employees. Remember, you may have managers who condone violating safe work practices or inadequate safety orientation that allows employees to perform a job without knowing the correct safety practices to follow. Once the root-cause has been identified, an effective action plan can be developed to control the hazards. Because most injuries have multiple causes, it is important to complete the investigation using the systematic approach to establish effective controls. A successful action plan must have specific corrections that are assigned to specific people, with specific completion dates and follow-up steps to assure adequate completion. Corrective Measures The purpose of instituting corrective measures is to reduce the chance of future injuries resulting from the same circumstances. The term corrective measures refers to actions taken to control the hazards that caused the incident, not to reprimand or discipline employees. 11

12 The most effective controls are both physical and administrative. For example, an accident may have resulted from an unsafe work condition, from an employee who does not strictly adhere to your company s safety procedure, or both. Therefore, controls may consist of equipment and process changes, as well as behavior modification. It may also involve training improvements, personnel allocations or changes in the working conditions or environment. Corrective Measures Can Be Either Temporary or Permanent Temporary measures may need to be taken for immediate control of an obvious hazard. This control may not solve the underlying issues but provides an intermediate solution. Personal protective equipment and barriers are examples of temporary measures. Permanent controls should be implemented after the investigation process is complete. These measures should control the root-cause. 12

13 Support Roles and Responsibilities The support of your management team is an essential for the success of your health and safety program. This support can be demonstrated to your employees in the following ways: Through a safe work environment A visible and active safety committee A reassuring and positive attitude toward injured employees An open communications policy regarding safety issues A commitment to uphold the highest standards for quality Prompt response and reporting of incidents At a minimum, the injured employee s immediate supervisor should perform an accident investigation. It is, after all, the supervisor who has the most direct access to pertinent information and is most familiar with the operation and the employee. More serious accidents may require a team investigation involving people with additional expertise or authority. 13

14 The results of the investigation should be reviewed with management and the safety committee. Management needs to determine the feasibility of the controls, assign responsibility for corrective measures, and perform follow-up on implementation. Review by the safety committee can assist in promoting safety awareness and training in other departments. 14

15 Summary The benefits of an effective accident investigation procedure at your company go far beyond the analysis of events leading to a specific incident; it can result in a number of positive changes at your company which include: Demonstrate concern for the welfare of employees Increase morale Uncover improvement areas in operations and production Produce training enhancements Reduce future occurrences Reinforce management s commitment to a safe environment 15

16 Customer Service Fax: Web Address montanastatefund.com Fraud Hotline 888-MTCRIME or report online at montanastatefund.com Mailing Address P.O. Box 4759 Helena, MT

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