Title: Incident Reporting and Investigation Policy Review Date: 02/02/2011

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1 I. PURPOSE & SCOPE All employees are required to report all incidents injuries, or events to their direct supervisor immediately no matter how minor they may seem. Foremen s, Supervisors, Project Supervisors, and Project Managers are required to report any and all incidents, injuries or events following this policy. The purpose of the incident reporting and investigation policy is to provide a uniform method for reporting all incidents, so all managers and key stakeholders can assist in the management of the incident. All incidents including but not limited to personnel injury, equipment, vehicle, near misses, and/or events that caused or may have caused damage to Elkhorn Holdings, Inc. property, client s property and/or danger to the general public. All incidents no matter how small shall be reported then investigated following the guidelines of this policy. II. Reporting Guidelines for Incidents All incidents no matter how insignificant it may seem, shall be reported to your supervisor and the safety team as soon as possible using the following protocol: 1. Treat the injured 2. Secure the scene 3. Call your supervisor 4. Send to management team as listed below. Information should include at minimum: o What happened to create the incident o Who was involved o What medical attention was given o Ho much damage resulted A. Management Team The initial should be sent to the following management team members, Chief Executive Officer, Chief Operating Officer, Chief Financial Officer, all Business Unit Managers, all General Managers, Division Mangers, HSE Director, Director of Human Capital, Equipment Manager. Include project supervision and area management team. B. Investigation Reports All reports and communication about any incident shall be communicated to the management team until the investigation is closed or all medical care has been completed. An initial written report and the BJSA the team was following, is to be distributed within 24 hours to the management team. All recordable injuries and doctor assisted first aids; need to have the supplemental document, Occupational Report of Injury sent to the HSE Director. OSHA recordable incidents shall be reported as defined by the osha regulations for that State. The Client shall be notified within 24 hours. Document No: Revision 2 Page 1 of 7

2 C. Further Investigation All Recordable injuries, all vehicle incidents, DOT violations, serious near misses and HIPO near misses will require a management review following Elkhorn s serious incident review policy. D. Root Cause Analysis (RCA) All Recordable Injuries require a RCA report following the TapRoot process. The RCA team will be lead by a safety professional, supervision member of the project and a representative of the service area, additions to this team maybe requested by the management team or the local service area management. Incidents, near misses, and/or disciplinary actions for non-conformance to safety polices in the judgment of the management team or HSE Director that would lead to help reducing incidents on other Elkhorn projects should have a RCA completed under their guidance. A. Investigation Guidelines An investigation must produce information that leads to corrective action that can prevent or reduce the exposure to risk for all projects while performing similar tasks. Investigations should be directed toward fact finding, not fault finding. Investigation findings that could have a bearing on legal liability should be extensively investigated and documented. 1. Investigation Team Members The initial investigation team should consist of direct supervisor for those involved, a safety representative if available, and another supervisor not involved if available. Investigating team must be lead by a individual trained in incident investigation techniques. RCA s shall be led by personnel trained in Systems Improvement s Taproot root cause analysis and investigation. 2. Investigation Techniques a) The investigation should begin as soon as possible. All necessary notifications shall be given before the start of an investigation. b) Secure the scene at once, without disturbing any physical evidence. c) Separate witnesses and those involved to reduce collaboration of statements. d) Gather the proper equipment necessary to perform investigation. Equipment may include some or all of the following items; writing equipment such as pens/paper, measurement equipment such as tape measures and rulers, cameras, small tools, audio recorder, PPE, marking devices such as flags, equipment manuals. e) When possible discuss the incident with the person that was directly involved. Document No: Revision 2 Page 2 of 7

3 f) Discuss the incident with other personnel that were present and may have witnessed the incident. g) Remember to include materials, equipment and supervisors that may be involved. h) Questions to ask while interviewing may include What were you doing at the time of the incident? How were you doing the job? Why do you think the incident occurred? i) Gather signed statements from involved individuals and witnesses Who all parties involved What concise/specific When time frame or time line Where specific location Why timing, equipment failure, material, human interaction, etc. j) Gather all BJSA s, copies of permits, inspection reports, for inclusion with the report. 3. Starting The Investigation Before starting the investigation, please review the following points with the investigation team. These items are intended to help set the tone of what is to be accomplished by the investigation. 1. The overall purpose of the incident investigation is to discover the underlying cause of the accident or near miss and to prevent it from reoccurring in the future. 2. The purpose of the investigation is to gather facts, not to assign blame or find individuals at fault. 3. Prioritize improvements with the system over the individual 4. The team has been given authority to make recommendations for improvement, and/or corrective actions. 5. The team is responsible for producing a report of its findings and recommendations, assigning responsibility, along with deadlines for implementation of those findings and or corrective actions. IV. Completing the Incident Report Form The following steps are to help completing the near miss/vehicle/equipment/incident form found in the safety manual. The incident investigation team should gather all of the information required to complete the form following these guidelines. A. Kind of incident; Investigation team chooses which type of incident occurred. Document No: Revision 2 Page 3 of 7

4 Near Miss; when an action, behavior or condition almost created an incident, injury or damage to property. Vehicle; actions by our driver/custodian or other driver creates damage to Elkhorn vehicle or other vehicle, and /or property Equipment; actions by our operator causes damage to equipment, or property either Elkhorn s or other entity. Incident; actions, behaviors, or conditions that have caused a non-injury contact with an employee or other person in the area. Damage to property caused by actions not involving a vehicle or equipment. First Aid; An injury to an employee or other person that requires first aid treatment following OSHA guidelines for recordkeeping, but does not require any medical treatment by a healthcare professional. Doctor Assisted First Aid; an injury that requires first aid treatment, or diagnosis performed by a healthcare professional, following OSHA s recordkeeping guidelines. Recordable injuries; All injuries that are a OSHA recordable following the recordkeeping guidelines will be classified by the HSE Director and/or management team. Including but not limited to medical injuries resulting in restricted time and days away from work. B. Date, Time, Day of the Week As close to the original date, time and day of the week of the incident being investigated. C. Location of Incident The incident information required for reporting, tracking, etc. Area; Which Elkhorn service area the incident happen in Projects; Which project the incident happened on, project name or number or which project the employee s involved are assigned. Location; where on the project the incident happened, or which road the vehicle was traveling on. Supervisor; the direct supervisor of the employee(s) involved Project Manager; direct manager of the project or service area where the incident occurred. Document No: Revision 2 Page 4 of 7

5 D. Equipment Involved Elkhorn Owned Equipment; identification of Elkhorn owned equipment or vehicle that was involved. Truck/equipment Number; Unit Number of vehicle or equipment involved or damaged. License Plate Number; plate number assigned to the involved vehicle or equipment if required. State; State vehicle or equipment is licensed in. Non-Elkhorn Involved Vehicle or Equipment; identification of non Elkhorn owned equipment or vehicle that was involved in the incident Vehicle License Number; the license plate number of other vehicle(s) involved or the rental companies assigned unit number State; State the other vehicle(s) are registered in or the state the equipment was rented from Rental Company; name of the vendor, company or entity that the equipment was rented from. E. Employee s Involved Employees or others involved in the incident Name; Name of each person involved matching company documents Age; age of each individual involved Classification and Employee Number; classification or job title along with the employee number of individual involved Elkhorn Experience; amount of time as an Elkhorn employee Years Experience; amount of time in the industry in their particular trade F. Incident Witness(es) Personnel or others that may have witnessed the incident or has information that is critical to the investigation. A dated and signed statement from each witness is required to be added to the report. G. Give a complete discription of how the incident happened Document No: Revision 2 Page 5 of 7

6 Describe from the facts gathered what each employee involved were assigned to performed, what was taking place before, how the incident happen and what happened following the incident. Explain what each individual was doing, their location, or involvement. H. List the unsafe behaviors or conditions that led to the incident From the facts gather the investigation team needs to recognize the unsafe behaviors of conditions that led to the incident happening. I. List the corrective actions that will be taken to prevent similar incidents Corrective actions shall be taken to ensure that similar incidents don t re-occur on the project. Document who was assigned the corrective action, and the time frame it s required to be completed within. Lessons learned shall be reviewed and communicated. Changes to processes must be placed into effect to prevent reoccurrence or similar events. J. Who is responsible for the incident Individuals or entity(s) that the investigation team finds are responsible for the incident happening from the facts gathered, whether it is an unsafe behavior or condition. K. Will additional investigation need to be performed If a Root Cause Analysis or management review is required or other investigation teams are requested. L. Date of Report, Prepared by, Title Date the report was completed, who it was prepared by or the investigation team, and the titles of those participating on the investigation team. M. Analysis of Factors Contributing to the Cause of the Incident The table is designed to cover the items that may be associated with the contributing factors of an incident such as weather, attitude, conditions, etc. Check mark all that apply to the incident your team is investigating. N. Employee Statement When not providing a separate signed and dated statement, have the employee involved statement added. If the employee does not write a statement but dictates it to you, have the employee sign the statement. O. Witness Statement When not providing a separate signed and dated statement, have the witness place statement added. P. Supervisor or Investigators Remarks; Place all other remarks from the investigation team in regards to the incident, such as behaviors during the interview process, facts not covered in other portions of Document No: Revision 2 Page 6 of 7

7 the report. Supervisor statement placed here if not providing a separate signed and dated statement. Q. Incident Diagram Area provided to draw map of incident, location of equipment or vehicles in correspondence with other objects, etc. V. Incident Scene Photography Before taking any pictures of an incident scene make sure the scene is safe, that you have the proper permission of our client, and you follow hot work policies. In some cases pictures will not be allowed or are not possible. The more pictures you can take the better. No one is expected to be a professional photographer. The use of a camera following any incident resulting in actual or potential damage to vehicles, equipment, property or persons helps to ensure that the facts are properly and accurately documented. Taking pictures at the scene of a vehicle incident may have an indirect benefit by sending a message to the other parties involved that your company takes incidents seriously and the facts are clearly recorded, reducing the possibility of their word against ours. A. Incident Scenes other than Vehicle/Equipment Take pictures from all possible angles showing the area where the incident occurred, tools used access to the work area, point of view of persons involved, along with a general overall picture for a map of the sequence of events. Close up of damage caused, tools involved, and general condition of work area. Remember that some facilities have rules or policies covering the use of photography equipment. Follow all client policies before taking any pictures. B. Vehicle and/or Equipment Incidents Take a few pictures of the overall area of the incident. Start outside and work in towards the final resting place of all vehicles or equipment in relation to the rest of the scene. If incident happened at an intersection take pictures from all four directions that approach the intersection. Photos of all four sides of your vehicle and the other vehicles involved. Close up of damage, or lack of damage to each unit involved. Skid marks created by the vehicles involved or track marks of the equipment involved. Any contributing factors such as construction areas, road conditions, etc. Any evidence that could be moved later. VI. Supplemental Reports All JSA s, required permits, copies of citations, signed and dated statements need to be attached to reports when they are sent to the managers for review. Other information may be requested, and should be supplied upon request. Document No: Revision 2 Page 7 of 7

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