Incident Management Program July 2011

Transcription

1 Incident Management Program July 2011 *This document is not controlled if printed*

2 Table of Contents 1.0 PURPOSE Description of Incident Cause of Incident (Why did it occur?) Recommendations SCOPE AND APPLICATION DEFINITIONS EXPECTATION ROLES AND RESPONSIBILITIES METHOD What Incidents should be investigated? Who Should Investigate? Investigation Kit Investigators Initial Actions Establishing Control Control Potential Secondary Incidents First Aid/Emergency Services Identify Sources of Evidence Preserve Evidence Determining Loss Potential Sketching The Scene Incident Photographs Equipment Examination Records Check Reenactment Medical Condition Other Outside Factors Interviewing Witnesses The Interviewing Process Analysis Incident Investigation Tree Immediate Causes & Basic Underlying Causes Root Cause Analysis Effective Solutions... 10

3 6.8. Corrective Actions Communication of Corrective Actions Incident Reporting & Notification Preliminary Incident Notification First Aid/ Medical Aid Injuries Reporting Equipment / Property Damage Near Hit Reporting Occupational Health and Safety (OHS) Reporting Requirements SAIT statistical reporting includes the following: Monthly Activity Report on Safety (MARS) Procedure for Determining a NH / FA / MA / MD / LT TRAINING REQUIREMENTS AND MATERIALS RESOURCES APPENDICIES SUPPORTING DOCUMENTS... 14

4 1.0 PURPOSE SAIT Polytechnic (SAIT) recognizes its legal obligation to provide a safe work environment and that Incident management in determining the cause, implementing suitable corrective measures and ensuring every effort is made to prevent the incident from recurring requires specific management and control. All faculty, staff and students and contractors of SAIT will be made aware and have available the tools related to incident reporting and investigating. Proper incident management will be made clear in order to put forward mitigative measures and prevent future loss Description of Incident The description identifies in detail how, when and where the incident occurred including all related factors (i.e., weights, heights, distances, time of day, weather conditions) Cause of Incident (Why did it occur?) What substandard actions, substandard conditions and personal factors contributed to the incident Recommendations After the cause of incident has been determined, every attempt needs to be made to identify truly effective solutions with recommendations to prevent recurrence. 2.0 SCOPE AND APPLICATION The SAIT Incident Management Program is designed to protect faculty, staff, students, contractors and visitors from harm and protect equipment or property from damage or loss. 3.0 DEFINITIONS Incidents (I): events which resulted in harm to people, damage to property, equipment or environment, loss of process. Or negative impact or perception with the public or stakeholder. As seen under Type of Incident in the Incident Report/Investigation Form as Safety, Environment, Production / Quality / Logistics or Security / Social. Near Hit (NH): events that under slightly different circumstances, could have resulted harm to people, damage to property or environment or loss to process. Hazard Identification: proactive report of a condition or practice that has the potential to cause harm to people, damage to property or environment or loss to process First Aid (FA): is a one-time treatment and subsequent observation of minor scratches, cuts, burns, splinters, and so forth, which do not ordinarily require care from a medical professional. Document Name: Incident Management Program Document No.: Page Reference: Page 1 of 17

5 Medical Aid (MA): is any injury or illness that requires treatment by a physician or other medical professional (e.g., stitches, prescriptions). Diagnostic procedures such as X-rays or laboratory analysis are not considered medical aid cases unless they lead to further treatment. If a worker loses consciousness as the result of a work-related exposure or injury, the case is at a minimum a medical aid case regardless of what type of treatment was provided. Modified Duty (MD): injury or illness where the worker is unable to perform their assigned work tasks following the day of the injury or diagnosed illness but is able to perform modified duties as prescribed by a physician. For statistical purposes total modified duty days and total modified duty cases are tracked. Lost Time (LT): injury or illness where a physician recommends that the worker is not able to return to work on their next scheduled workday (e.g., if a worker was injured on a Friday and they are normally scheduled off Saturday and Sunday then the next scheduled day of work is Monday). Time away from work to recover from a worker-related injury or illness must be authorized by a physician. Supervisor: anyone who oversees the occupational health and safety of the workers employed by SAIT (e.g., Deans, Directors, Academic Chairs, Managers, Instructors, Supervisors). Below definition taken from Occupational Safety and Health Administration (OSHA) Duties of supervisor 27. (1) A supervisor shall ensure that a worker, (a) works in the manner and with the protective devices, measures and procedures required by this Act and the regulations; and (b) uses or wears the equipment, protective devices or clothing that the worker s employer requires to be used or worn. Additional duties of supervisor (2) Without limiting the duty imposed by subsection (1), a supervisor shall, (a) advise a worker of the existence of any potential or actual danger to the health or safety of the worker of which the supervisor is aware; (b) where so prescribed, provide a worker with written instructions as to the measures and procedures to be taken for protection of the worker; and (c) take every precaution reasonable in the circumstances for the protection of a worker. R.S.O. 1990, c. O.1, s. 27. Document Name: Incident Management Program Document No.: Page Reference: Page 2 of 17

6 Employer: (taken from Alberta Occupational Health and Safety Act) employer means (i) a person who is self-employed in an occupation, (ii) a person who employs one or more workers, (iii) a person designated by an employer as the employer s representative, or (iv) a director or officer of a corporation who oversees the occupational health and safety of the workers employed by the corporation; 4.0 EXPECTATION A successful Incident Management Program at SAIT involves every member of the SAIT community. It starts with management commitment and succeeds with active employee, contractor and student involvement and acceptance in order to achieve constructive change. The goal is to optimize the health, safety and environment of the workplace by correcting items from Near Hit and actual injury or damage incidents with the goal of preventing incidents of a similar nature from recurring. This will be achieved through proper training, and implementing an active health and safety program that features an incident investigation component. The expectation is that a successful Incident Management Program includes thorough timely incident reporting, investigation and analysis in order to proactively share incident learnings and promote education and awareness with the goal of eliminating recurrences and always putting forth truly effective solutions as corrective actions. Document Name: Incident Management Program Document No.: Page Reference: Page 3 of 17

7 5.0 ROLES AND RESPONSIBILITIES Staff, Students, Contractors and Visitors Depending on the nature of the incident, 911 may be your required first call, with immediate follow-up reporting to supervisor, Security and HSW Services. Supervisors (Instructors and Managers) Responsible for conducting timely investigations while involving affected parties and obtaining guidance or assistance as required (i.e., from an HSE Specialist). Management, Senior Management, Academic Chairs, Deans, Directors Are accountable for investigations being performed in a timely and constructive way. Provide support and resources as required. Ensure corrective actions are suitable and implemented. Health, Safety and Environment Committees Are responsible for reviewing incident investigations and ensuring ongoing controls are adequate to prevent harm or property damage. Health Safety and Wellness Services Department Provide training to all staff and faculty in incident reporting and investigation. Ensure that the SAIT community understands incident reporting and investigation concepts and the methods by which incidents are investigated. Ensure high level of quality, consistency and standardization within incident investigations. Be available to provide assistance with facilitating incident investigation. 6.0 METHOD The purpose of an investigation is to determine cause(s) and provide ways and means to prevent a recurrence. Supervisors are responsible for conducting incident investigations. The point is to find fact, not fault. Supervisors are reminded to focus on how and why the event occurred, rather than who should be blamed. The following information has been provided to assist with the investigation process. Document Name: Incident Management Program Document No.: Page Reference: Page 4 of 17

8 6.1. What Incidents should be investigated? Competent supervisors recognize that minor injuries and incidents including near hits serve as a warning of a condition or practice that needs to be modified before it develops into a serious situation. The investigation of an incident should be proportionate to the loss potential. As the degree of loss potential increases, so will the degree of investigation. Cause(s) must be determined and preventive action taken. In some cases minor incidents or near hits are not reported because of a fear of ridicule from their fellow workers, reprisal from a supervisor, and or fear of loss of wages due to lost time. Unreported incidents signify: Nothing is learned from the experience. Incident causes are not corrected and are allowed to potentially recur. Infractions and injury aggravations can result. A culture of not reporting incidents could spread Who Should Investigate? Supervisors are responsible for conducting investigations and including all affected parties. Health, Safety and Wellness Services department is available to facilitate the incident investigation process as specialists Investigation Kit Responding to the requirements of an incident investigation where time is of the essence can be a challenging experience. To assist this endeavour, an investigation kit should be available at each general location for proper ease of availability and use. Ideally, this kit should contain the following items including: A plastic, see through tote or carrying case A copy of the incident investigation procedures, Incident Report / Investigation Form and Witness Statement forms An investigation check list A ruler, tape measure, pencil, pen, eraser, writing pad and sketch paper A camera A flashlight c/w batteries A reflective safety vest A roll of plastic fluorescent or yellow ribbon (for cordoning off incident scene) Document Name: Incident Management Program Document No.: Page Reference: Page 5 of 17

9 6.4. Investigators Initial Actions The success of an investigation is generally the result of prompt and efficient response. Many things can happen in a short period of time which can distort information and not allow a proper investigation. The investigator must be prepared so that the investigation process can be adequately planned, initiated and completed successfully. An investigation check list is a tool that is made available for use through this program to assist with investigations. Here are some initial steps to assist and support this process Establishing Control Incidents are stressful and make people act differently. People are also curious and want to help. The investigator needs to take charge by directing and approving everything that is done at the scene of the incident Control Potential Secondary Incidents Before entering an incident scene, assess the situation. Secondary incidents can sometimes be more serious because normal controls can be weakened or modified as a result of the incident. Positive temporary actions need to be taken after timely but careful consideration of the consequences First Aid/Emergency Services People's lives and their well being come first. Depending on the nature of the incident, 911 may be your required first call, with immediate follow-up reporting to supervisor, Security and HSW Services. Coordinate first aid to be administered as required Identify Sources of Evidence The scene of an incident can change rapidly. Emergency rescue work involving equipment, machinery, lights, ventilation and people can alter the incident scene and destroy valuable evidence. The investigator needs to know and recognize these things while taking other initial actions. This is when photographs can be very useful. If photographs are taken, note the locations at which photographs were taken on the sketch plan Preserve Evidence Incident scenes involving significant injury, loss or damage should be cordoned off, work stopped in that area immediately, and people restricted from entering the area until the investigation has been completed. Review all actions with your supervisor, manager, security & HSW Services. Document Name: Incident Management Program Document No.: Page Reference: Page 6 of 17

10 Determining Loss Potential It is vital to future loss control and prevention that the investigator complete the investigation form to make an appraisal of how bad the incident could have been, and how likely it is to occur again by filling out the severity section within the Incident Report/Investigation Form which addresses the actual severity, potential severity, frequency and potential for recurrence Sketching The Scene Is a sketch useful for the investigation or will a photo suffice? In most cases a plan view is sufficient however, elevation views may be necessary to identify certain items. Sketches should include directional orientation (i.e. north, south, east, west) so that recorded information adequately describes the incident site. Measurements should be included to identify and determine who and what was where. Witness locations at time of incident should be noted on the sketch as well as photograph locations. Some incident scenes may require a grid which in turn should be included in the sketch Incident Photographs Photographs save time and energy. If properly done, they can save hours of note taking, drawing and writing. Photographs can also be used for training purposes. Photographs are suggested to be taken as follows: Use a long range, medium range and close up sequence. Take a general scene photograph. Take a photograph of work station(s). Take a close up shot of deficiency items or damaged area(s). Photograph the scene from all sides. Number each photograph and document the location of each shot on the sketch of the incident scene Equipment Examination An investigation should include the tools, equipment and materials that people were using at the time of the incident. In many cases this does not require the services of an expert. Guards, warning labels, condition of tools, application of tools, equipment and materials as well as wear and tear can reveal evidence of what may have happened Records Check Training records, maintenance logs/records, schedule of work practices causing congestion in work areas and job procedures should also be reviewed to see if they may have contributed to the incident. Document Name: Incident Management Program Document No.: Page Reference: Page 7 of 17

11 Reenactment In very rare occasions, a re-enactment of the incident may become necessary to see what happened and how it occurred. Incident re-enactment should be used only when: The information cannot be gained in another way. It is vital to the development of remedial or corrective actions. It is absolutely necessary to verify critical facts Medical Condition One area which should not be overlooked during an investigation is the possibility of a medical condition (acute/chronic) which may have contributed to the incident (i.e. blurred vision or dizziness caused by diabetes or other condition) Other Outside Factors Thorough incident investigation means you evaluate all factors that may or may not be relevant. Other items to consider could include substance abuse, mental health, physical disabilities, and possible fraudulent behaviour Interviewing Witnesses Immediately after the site has been secured, witnesses are to be interviewed. A witness is anyone who knows something related to what happened and can contribute to the investigation. Eyewitnesses and the people involved in the incident should be interviewed first. The first details from these witnesses give the investigator symptoms of the problem(s) and/or causes of the incident. The investigators will obtain more objective information when they demonstrate a calm, supportive, non-judgmental attitude The Interviewing Process Interviews should be conducted as follows: Interview promptly and near incident scene (if possible). Mark the locations where witnesses were when incident happened on the sketch plan. Interview witnesses separately and privately. Put the witness at ease. Ask open ended questions. Ask witness to complete a Witness/Injured Person Statement Form. Repeat information to witness for verification. Give the witnesses a copy of their statements. Document Name: Incident Management Program Document No.: Page Reference: Page 8 of 17

12 Thank the witnesses for their time and effort. Keep communication open by advising them if they remember anything else to call you Analysis Once all information and evidence has been collected, the analysis of what happened can begin. This process should include but not be limited to: Writing down all facts. Listing the facts that contradict one another. Comparing facts with physical evidence to establish the most likely answer. Listing the sequence of events. Identifying incident causes. Writing the report Incident Investigation Tree The Incident Investigation Tree allows the investigator to analyse the cause of the incident. The Incident Investigation Tree is a toll made available for use through this program Immediate Causes & Basic Underlying Causes Immediate causes usually consist of substandard actions and substandard conditions. On average 90% of immediate causes are found to be substandard actions with the remaining 10% are substandard conditions. Basic or underlying causes consist of personal factors and job factors. Please refer to the section within the Incident Report/Investigation Form for further detail Root Cause Analysis The purpose of a Root Cause Analysis (RCA) is to discover weaknesses in the HSE Management System that allowed for an incident to happen. A Root Cause Analysis is a tool made available though this program which identifies surface and root causes. Surface Causes are the hazard and the behavior that occurred to cause the incident and Root Causes are usually inadequate procedures or training. To get to the root cause, ask why until you cannot ask why anymore. In addition a timeline toll is used in combination with the RCA. Document Name: Incident Management Program Document No.: Page Reference: Page 9 of 17

13 6.7. Effective Solutions What are Effective Solutions? This is a tool made available for use through this program. Effective solutions are developed considering the hierarchy of controls. The goal is to use the controls in the order shown below. Hierarchy of Controls 1. Elimination Substitute hazardous equipment, process or material with a less hazardous one 2. Engineering Redesign the equipment or work processes Separate or isolating the hazard by guarding or enclosure 3. Administrative Providing controls such as training, procedures etc. 4. Personal Protective Equipment (PPE) Using properly fitted PPE Use appropriate pollution control equipment where other controls are not practicable 6.8. Corrective Actions Corrective actions are usually comprised of two types including temporary and permanent. Temporary Action includes those items which can be implemented immediately to prevent recurrence of the incident. Permanent Action includes those items which take substantial time to implement such as training and/or developing or modifying a particular practice, standard or procedure. Monitor corrective actions until fully implemented Communication of Corrective Actions Learning From Incident (LFI) is a tool which takes an incident and breaks down the information into easy to understand segments to share with potentially affected parties. The Learning from Incident is generally created in a PowerPoint with pictures to illustrate what went wrong, the causes and the effective solutions. A decision to perform a LFI is usually taken by the HSW Manager or by a senior staff member that deems it required. A Hazard Alert is a one or two page communication that can be used to share the incident learning s at toolbox, tailgate or workplace safety meetings. Document Name: Incident Management Program Document No.: Page Reference: Page 10 of 17

14 6.9. Incident Reporting & Notification All serious incidents including near hits with a significant potential for harm to people, damage to property or environment or loss to process must be reported and documented immediately. Review with your supervisor to determine if the incident requires reporting. Senior Executive and in some cases, government authorities will require a detailed and accurate explanation of the incident. Although review any planned actions with Supervisor, Security and HSW Services. The incident reporting procedures are intended to assist workers with legitimate claims for compensation as quickly and fairly as possible. Thorough and punctual reporting of incidents provides required information and learning s on the workers nature of injuries, types of incidents, frequency and severity of incidents, as well as compensation claim costs and can allow actions to be taken to prevent a similar incident from recurring. The effectiveness of the incident reporting, investigation and loss control program depends entirely on the cooperation and commitment of all employees to all components of the program Preliminary Incident Notification In order to be as proactive as possible, prompt notification to supervisor, security and HSW Services is required. In order to take proactive actions involving as many support groups as possible (e.g., notifying Facilities, Counselling Services, which many be able to provide immediate assistance) First Aid/ Medical Aid Injuries If 911 assistance is deemed required, contact 911 and then advise supervisor, security and HSW Services immediately after. This process will allow for all major and minor injuries to be reported for documentation and reporting purposes. If further medical assistance is required Security and the Health Services Clinic will facilitate transportation and required documentation Reporting Equipment / Property Damage It is important to investigate significant equipment or property damage in order to ensure loss control Near Hit Reporting Near Hits with a significant potential are to be reported immediately. Review with your supervisor to determine if a Near Hit requires reporting. Near Hits must be treated seriously and serve as a warning that an incident or significant loss or damage could have occurred. Near Hits are to be recorded using the Near Hit Form. Document Name: Incident Management Program Document No.: Page Reference: Page 11 of 17

15 Occupational Health and Safety (OHS) Reporting Requirements Local health and safety government authorities must be notified in the event of certain incidents. In the event of any of the following, ensure timely reporting and investigating as per Alberta Occupational, Health and Safety Act, Regulations and Code (Section 18 and 19). NB: For consistency of documentation the word accident has been replaced with incident in the below excerpt from the Alberta OHS Legislation. Please see definition for incident. Serious Injuries and incidents 18 (1) If an injury or incident described in subsection (2) occurs at a work site, the prime contractor or, if there is no prime contractor, the contractor or employer responsible for that work site shall notify a Director of Inspection of the time, place and nature of the injury or incident as soon as possible. (2) The injuries and incidents to be reported under subsection (1) are (a) an injury or incident that results in death, (b) an injury or incident that results in a worker s being admitted to a hospital for more than 2 days, (c) an unplanned or uncontrolled explosion, fire or flood that causes a serious injury or that has the potential of causing a serious injury, (d) the collapse or upset of a crane, derrick or hoist, or (e) the collapse or failure of any component of a building or structure necessary for the structural integrity of the building or structure. (3) If an injury or incident referred to in subsection (2) occurs at a work site or if any other serious injury or any other incident that has the potential of causing serious injury to a person occurs at a work site, the prime contractor or, if there is no prime contractor, the contractor or employer responsible for that work site shall (a) carry out an investigation into the circumstances surrounding the serious injury or incident, (b) prepare a report outlining the circumstances of the serious injury or incident and the corrective action, if any, undertaken to prevent a recurrence of the serious injury or incident, and (c) ensure that a copy of the report is readily available for inspection by an officer. (4) The prime contractor, contractor or employer who prepared the report referred to in subsection (3) shall retain the report for 2 years after the serious injury or incident. (5) A report prepared under this section is not admissible as evidence for any purpose in a trial arising out of the serious injury or incident, an investigation or public inquiry under the Fatality Inquiries Act or any other action as defined in the Alberta Evidence Act except in a prosecution for perjury or for the giving of contradictory evidence. (6) Except as otherwise directed by a Director of Inspection, an occupational health and safety officer or a peace officer, a person shall not disturb the scene of an incident reported under subsection (1) except insofar as is necessary in (a) attending to persons injured or killed, (b) preventing further injuries, and (c) protecting property that is endangered as a result of the incident. Document Name: Incident Management Program Document No.: Page Reference: Page 12 of 17

16 Investigation of Incident 19 (1) If an incident occurs at a work site, an officer may attend at the scene of the incident and may make any inquiries that the officer considers necessary to determine the cause of the incident and the circumstances relating to the incident. (2) Every person present at an incident when it occurred or who has information relating to the incident shall, on the request of an officer, provide to the officer any information respecting the incident that the officer requests. (3) An officer may, for the purposes of determining the cause of the incident, seize or take samples of any substance, material, product, tool, appliance or equipment that was present at, involved in or related to the incident. (4) If an officer seizes or takes samples of any substance, material, product, tool, appliance or equipment under subsection (3), the officer shall (a) give to the person from whom those items were seized or taken a receipt for those items, and (b) on that person s request, return those items to that person when those items have served the purposes for which they were seized or taken. (5) Any statement given under this section is not admissible in evidence for any purpose in a trial, public inquiry under the Fatality Inquiries Act or other proceeding except to prove (a) non-compliance with this section, or (b) a contravention of section 41(3) in an action or proceeding under this Act. (6) a peace officer may assist an officer in carrying out the officer s duties under this section if the officer so requests. As a result of any of the above the requirement is to prepare a report containing corrective actions available to an officer and keep for 2 years. As per the OHS Act employers are expected to make themselves available to OHS Officers SAIT statistical reporting includes the following: Near Hits First Aids Medical Aids Modified Duty Cases Lost Time Incidents; and Fatalities Monthly Activity Report on Safety (MARS) This report consists of data compiled from the Health Clinic, Workers Compensation Board data and SAIT Incident Reporting Procedure for Determining a NH / FA / MA / MD / LT Please refer to definitions as outline in Section 3.0. Document Name: Incident Management Program Document No.: Page Reference: Page 13 of 17

17 7.0 TRAINING REQUIREMENTS AND MATERIALS Incident management program is the foundation for incident reporting, management, investigation and follow-up. Staff are required to make themselves familiar and review the program as made available on SAITNOW. HSW Services Department can facilitate training related to this program. 8.0 RESOURCES Alberta Occupational Health and Safety Act, Regulations and Code 2009 Occupational Safety and Health Administration (OSHA) 9.0 APPENDICIES None 10.0 SUPPORTING DOCUMENTS The following forms and tools can be found on SAITNOW. Forms SAIT Incident Report / Investigation Form SAIT Near Hit Form Tools SAIT Witness / Injured Person Statement Form SAIT Incident Report / Investigation Flow Chart SAIT Incident Investigation Checklist SAIT Incident Investigation Tree SAIT Root Cause Analysis SAIT What is an Effective Solution Document Name: Incident Management Program Document No.: Page Reference: Page 14 of 17