ACCIDENT/INCIDENT INVESTIGATIONS

Transcription

1 ACCIDENT/INCIDENT INVESTIGATIONS PURPOSE OF THIS GUIDE The Workplace Health, Safety and Compensation Commission is developing resource materials to help workplace parties employers, workers including supervisors and managers, and occupational health and safety committees to carry out their responsibilities for health and safety in the workplace. This specific booklet, Accident/Incident Investigations, is designed to provide workplace parties with an understanding of their role in effective accident/incident investigations. It includes an outline for planning and the six steps involved in conducting accident/incident investigations. A sample accident/incident report form and a sample accident/incident investigation form are also included in this booklet. ACCIDENT/INCIDENT INVESTIGATIONS Sources of Information Workplace Health, Safety and Compensation Commission Prevention Services Phone: (709) Toll free or Department of Government Services Occupational Health and Safety Branch Phone: (709) Toll free or Human Resources and Social Development Labour Program, Newfoundland and Labrador office Phone: (709) (call collect outside St. John s) May 2006

2 Disclaimer The Workplace Health, Safety and Compensation Commission (the Commission) provides information and health and safety advisory services for most aspects of occupational health and safety programming. The information presented is subject to a disclaimer. It is intended to provide examples of general use and may not apply to every circumstance. While all reasonable efforts have been made to ensure the accuracy of the information presented, the Commission does not and cannot guarantee the accuracy thereof. The Commission does not warrant or assume any legal liability or responsibility for the accuracy, completeness, or usefulness of the information presented nor for any actions taken in reliance thereon. The Commission shall not be liable for any damage or loss arising out of the use of the information or the application of the concepts contained therein. All those using the information do so at their own risk and shall be deemed to indemnify the Commission from any loss or damage arising from the use of the information. The information presented is subject to jurisdictional variation and is always subject to change. Individuals or organizations responsible for working with the information presented are responsible for ensuring that all applicable standards and regulations are fulfilled. The information presented cannot and should not be considered a definitive guide to government regulations nor does it relieve individuals or organizations using the information from their responsibilities under any or all applicable legislation.

3 May, 2006 Legislative Requirements The legislation is a minimum guide for developing occupational health and safety (OH&S) policies and procedures in workplaces. However, best practices should be incorporated into all areas of businesses/organizations to increase the effectiveness of the OH&S program. The majority of employers in Newfoundland and Labrador must follow provincial legislation for occupational health and safety: Occupational Health and Safety Act Occupational Health and Safety Regulations For official copies of the Occupational Health and Safety Act and the Occupational Health and Safety Regulations please contact the following: Office of the Queen's Printer Ground Floor Confederation Building, East Block St. John's, Newfoundland and Labrador A1B 4J6 Telephone: (709) Unofficial copies are available on-line at: Some employers fall under federal jurisdiction and must follow the Canada Labour Code-Part II ( Code). The Code applies to the following inter-provincial and international industries: railways; highway transport; telephone and telegraph systems; pipelines; canals; ferries, tunnels and bridges; shipping and shipping services; radio and television broadcasting and cable systems; airports; banks; grain elevators licensed by the Canadian Grain Commission, and certain feed mills and feed warehouses, flour mills, and grain seed cleaning plants; the federal public service and persons employed by the public service and about 40 Crown corporations and agencies; employment in the operation of ships, trains and aircraft; and the exploration and development of petroleum on lands subject to federal jurisdiction. Note: Part II of the Canada Labour Code, Part II does not apply to certain undertakings regulated by the Nuclear Safety and Control Act. For an official copy of the Canada Labour Code please contact: Canadian Government Publishing, Communication Canada Ottawa, ON K1A 0S9 Telephone: (613) or FAX: (613) or Internet: Unofficial copies are available on-line at:

4 Introduction...1 More Information...2 Inside this Guide Accident/Incident Investigations...3 Requirements...3 Definitions...4 An Accident...4 An Incident...4 An Accident/Incident Investigation...4 Reporting and Investigating Accidents/Incidents...4 Benefits of an Effective Accident /Incident Investigation...5 Procedures...5 Roles in Accident/Incident Investigation...6 Employers...6 Investigation Team...7 Workers Including Managers and Supervisors...7 OH&S committees...7 Step 3 - Analyze the information to determine the root cause...14 Contributing Factors...14 Immediate/Direct Cause(s)...15 Root/Basic Cause(s)...16 Step 4 - Make recommendations...17 Step5-Write the accident/incident investigation report...18 Step 6 - Follow-up...19 Role of OH&S Committees...20 Accident/Incident Investigations and the OH&S Program...21 Planning Accident/Incident Investigations...8 Needs of the Investigation Team...8 Materials Needed for the Investigation...9 The Investigation Kit...9 Steps in Accident/Incident Investigations...9 Step 1 - Immediate response to the accident/incident...10 Step 2 - Gather information...11 Taking Notes...11 Conducting Interviews...11 Interviewing Tips...11 Sample Interview Questions...12 Tips for Taking Pictures for Evidence...12 Suggestions for Collecting Samples...12 Reviewing Documentation...13 Conclusion...22 Appendix A - Glossary...24 Appendix B - References to Legislation...28 Appendix C - Hazardous Occurrence Investigation Report...35 Appendix D - Sample Accident/Incident Report Form...36 Appendix E - Sample Accident/Incident Investigation Form...37

5 Introduction As part of the internal responsibility system, all workplace parties employers, workers, including managers and supervisors, and occupational health and safety (OH&S) committees have a shared responsibility for the OH&S program to the extent of each party s authority and ability to be involved. This means everyone works co-operatively, shows ownership for the program and is committed to preventing injury, illness and property damage in the workplace. Under provincial legislation, where 10 or more workers are employed in a workplace, the employer is required to establish and maintain an OH&S program in consultation with the OH&S committee. In workplaces where less than 10 workers are employed, the employer is required to ensure a worker health and safety (WH&S) representative is in place to monitor the health, safety and welfare of workers. And, in workplaces with less than six workers employed and where it is impractical to assign a WH&S representative, the employer may designate a workplace health and safety designate to monitor the health, safety and welfare of workers. For federally regulated workplaces, employers are responsible for developing, implementing and monitoring a prescribed program for the prevention of hazards in the workplace in consultation with the health and safety committee, policy committee or the health and safety representative. For the purpose of this booklet, the duties and responsibilities of the OH&S committee will also include those of WH&S representatives and workplace health and safety designates in provincially regulated workplaces and health and safety representatives in federally regulated workplaces. This booklet is designed to assist those responsible to carry out effective accident/incident investigations in the workplace. It provides basic information about accident/incident investigations including the role of workplace parties, planning the investigation, and the steps involved in conducting the investigation. Best practice is a standard that exceeds minimum legislative requirements and supports working in the safest possible way. Carrying out investigations on all accidents and incidents, finding root causes, and implementing corrective actions demonstrate best practices. For commonly used OH&S terms, please refer to Appendix A Glossary. 1

6 More Information For more information on building a health and safety program, there are several booklets and information resources available in this series. Fact Sheets: Introduction to an OH&S Program Leadership and Administration OH&S Committees Education & Training Safe Work Practices and Procedures Hazard Recognition Evaluation and Control Workplace Inspections Accident and Incident Investigation Disability Management Ergonomics and the OH&S Elements Worker Health and Safety Representative/Workplace Health and Safety Designate Look for these fact sheets in the near future: Communication Emergency Preparedness Booklets: Guide to Writing an Occupational Health & Safety Policy Occupational Health & Safety Committees Introduction to an Occupational Health and Safety Program Workplace Inspections Accident/Incident Investigations Look for these booklets in the near future: Communication Emergency Preparedness 2

7 Accident/Incident Investigations Accident/incident investigations are an important part of the OH&S program. They include a process of fact finding to identify the root (basic) cause of accidents/incidents as a means of preventing further occurrences. Ergonomic considerations should always be part of accident/incident investigations. Including investigations in the OH&S program strengthens the internal responsibility system and is essential to building a positive health and safety culture in the workplace. Requirements Specific OH&S requirements for employers who are provincially regulated can be found in the Occupational Health and Safety Act and Regulations. Requirements for federally regulated employers can be found in the Canada Labour Code, Part II and the Canada Occupational Health and Safety Regulations. Contact information for obtaining provincial and federal OH&S legislation can be found at the beginning of this booklet and in Appendix B References to Legislation. The legislative references in Appendix B refer to the content in this booklet and may not be complete. Workplace parties must refer to the appropriate legislation to find complete information regarding legislative requirements for developing an OH&S program. Employers must also comply with industry-specific or hazard-specific legislation. Examples include: Asbestos Abatement Regulations; Asbestos Exposure Code Regulations; OH&S First Aid Regulations; Workplace Hazardous Materials Information System (WHMIS) Regulations; Radiation Health and Safety Act and Regulations; Mines Safety of Workers Regulations; and Workplace Health, Safety and Compensation Act and Regulations. Employers should be aware of legislation that relates to their industry and specific hazards in their workplaces. Appendix B References to Legislation contains details of the following legislation. OH&S Act OH&S Regulations Canada Labour Code Part II Canada OH&S Safety Regulations Workplace Health, Safety and Compensation Act Sections Sections Sections Sections Sections 4 41 (1) 42.1 (1) 54 4(1) (f) (iv) 4 (1) (j) 15.3, 15.4, 15.5, 15.6, 15.7, 15.8, (1) and (4) (d) 135 (1) and (7) (e) 136 (1) 136 (2) 3

8 Definitions An Accident An accident is an unplanned/undesired event that results in a personal injury or illness, or in damage to property, process or the environment. An Incident An incident is an unplanned/undesired event that has the potential to result in an injury, illness, or property damage. An Accident/Incident Investigation An accident/incident investigation is a well planned analysis of an event that identifies the root cause and recommends corrective action to prevent the event from happening again. Despite what many people think, workplace accidents/incidents don t just happen; they result from a series of events that usually stem from an ineffective OH&S program. The aim of an OH&S program is to prevent accidents and incidents; however, as part of the internal responsibility system, when accidents/incidents do happen, there should be a process in place to find the root cause of these events. Reporting and Investigating Accidents/Incidents Employers must immediately report accidents resulting in serious injury or death or the potential for serious injury or death to the assistant deputy minister and the OH&S committee ( OH&S Act, section 54). Employers must also report an injury to a worker for which the worker is disabled from earning full wages or the worker is entitled to medical aid ( Workplace Health, Safety and Compensation Act, section 56). Federally regulated workplaces have reporting and investigation requirements in cases of work-related injuries or illnesses. Please refer to Appendix B References to Legislation under the heading Canada Occupational Health and Safety Regulations for these requirements. Appendix C Hazardous Occurrence Investigation Report contains a copy of the form employers are required to complete. A copy of this form may be found on the Human Resources and Social Development web site: Go to Click Forms Click List of Forms Under the heading Occupational Health and Safety, find number LAB1070 Hazardous Occurrence Investigation Report. 4 When developing accident/incident investigation procedures for workplaces, best practices would include an internal process for reporting and investigating all accidents and incidents. Incidents are warnings that

9 something is wrong in the workplace. If incidents are investigated and the root cause found, accidents can be prevented. Please refer to Appendix D Sample Accident/Incident Report Form. Benefits of an Effective Accident/Incident Investigation employers demonstrate their commitment to health and safety to their workers and the public; workers on the investigation team are trained in investigation techniques; workers are trained in the importance of reporting accidents/incidents; accidents/incidents are promptly reported; accidents/incidents are immediately investigated; root causes are identified; corrective actions are implemented, monitored and evaluated; workers are trained in how to prevent similar accidents/incidents; pain and suffering are reduced; findings can be used to identify accident/incident trends; and associated costs of accidents and property damage are reduced. Procedures Accident/incident investigations are a mandatory part of an OH&S program and should have procedures to ensure their effectiveness. Accident/Incident investigation procedures are the step by step way for completing an accident/incident investigation. All workplaces are different; therefore, the procedures should be developed with the specific workplace in mind. For example, in some workplaces, the procedures may outline the duties of groups of workers in a specific department while another workplace may outline the duties of groups based on their job titles. Duties and responsibilities depend on what works best for the individual workplace. Accident/incident investigation procedures should include a process for planning and the six steps for conducting the investigation. They also identify those responsible for each step in the procedure and those responsible for communicating the results of the investigation. Ergonomic considerations should be included in accident/incident investigations procedures. 5

10 Roles in Accident/Incident Investigation In keeping with the internal responsibility system and with best practice, workplace parties have a role in accident/incident investigations. To meet their legislative requirements for establishing and maintaining an OH&S program and conducting accident/incident investigations, employers should ensure accident/incident investigation procedures outline the responsibilities of all workplace parties. Following are examples of roles and responsibilities based on legislative requirements and best practice. Employers must immediately report accidents resulting in serious injury or death or the potential for serious injury or death to the assistant deputy minister and the OH&S committee; must report an injury to a worker for which the worker is disabled from earning full wages or the worker is entitled to medical aid; provide the resources human and financial to carry out accident/incident investigations; ensure accident/incident investigation procedures are developed and followed; ensure all workers are provided with the education and training needed to understand their responsibility to report accidents/incidents and to cooperate with those conducting investigations; review accident/incident investigation reports; ensure corrective action is implemented, monitored, evaluated and communicated; and review accident/incident investigation procedures at least every three years. Investigation Team Managers and supervisors are often the ones that carry out accident/incident investigations. However, it is a good practice, when possible, to include other workers and members of the OH&S committee on investigation teams. This practice would promote the internal responsibility system in the workplace. Those conducting the investigation are to: conduct the investigation as soon as possible after the accident/incident; follow accident/incident investigation procedures; put emphasis on finding the root cause not on finding fault or placing blame; 6

11 consider multiple causes to find all factors contributing to the event; do not jump to the obvious answer keep looking; and ensure the results of the investigation are communicated to workplace parties. Workers Including Managers and Supervisors report accidents/incidents to their supervisors immediately; co-operate with the accident/incident investigation team; participate as members of the investigation team when requested; make suggestions for corrective actions to the investigation team; and take part in training required as the result of the investigation. OH&S committees are a resource to the accident/incident investigation team; may participate as members of the investigation team; review all accident/incident investigation reports to identify trends in injury, illness and property damage; monitor implementation, follow-up, and evaluation of corrective actions; review training required as the result of the accident/incident investigation; and regularly evaluate this element of the OH&S program. Planning Accident/Incident Investigations Accident/incident investigation procedures should identify the members of the investigation team, their training requirements, and their responsibilities. It is beneficial to have a core team of trained individuals to carry out an investigation. Depending on the accident/incident and the potential for it recurring, the team may differ in size. Having more than one person investigating means there is less of a chance to overlook something. Needs of the Investigation Team The accident/incident investigation team should be trained in investigation techniques including gathering information interviewing skills 7

12 collecting samples analysing information contributing factors of accidents/incidents identifying immediate/direct causes identifying root/basic causes writing recommendations writing reports; know what is expected of them in the investigation process; keep an open mind about the cause; never jump to a conclusion before all the information has been analyzed; be impartial; understand that there is rarely only one cause of an accident/incident; be familiar with work processes, the people that work in the workplace, and practices and procedures; have knowledge of OH&S legislation, standards, codes of practice, manufacturers specification, etc.; know the layout of the workplace; be objective and honest; and possess interviewing, analytical, organizational and report-writing skills. Materials Needed for the Investigation The accident/incident investigation procedure should include a list of the materials needed for an investigation plus the materials in the investigation kit. The accident/incident investigation procedure should identify required materials, equipment, and personal protective equipment (PPE); names and phone numbers of personnel such as the investigation team, first aid responders, members of the OH&S committee, management personnel, maintenance staff, security staff, etc.; and items to be included in an investigation kit. 8

13 STEPS in Accident/Incident Investigations Accident/incident investigation procedures should outline a step-bystep process for carrying out each of the six steps in the investigation: Step 1 Immediate response to the accident/incident Step 2 Gather information Step 3 Analyze the information to determine the root cause Step 4 Make recommendations Step 5 Write the accident/incident investigation report Step 6 Follow-up The Investigation Kit Items usually found in an accident/incident investigation kit accident/incident investigation forms 'Do Not Enter' tape clip board tape measure and ruler camera, batteries, film (or video camera) flashlight and batteries plastic bags and containers for samples labels and permanent marker for labelling samples pens/pencils eraser notebook and graph paper CAUTION: Some workplaces may not permit the use of devices such as cameras, flashlights, etc. because, depending on the workplace and the accident, they may pose a hazard to the investigation team. Therefore, the above items should be evaluated to ensure they do not create additional hazards. 9

14 STEP 1 Immediate response to the accident/incident CAUTION: The investigation team members must ensure that: the equipment they bring to the accident site does not endanger themselves or others; and they take particular care and follow safe work procedures so as not to be exposed to workplace hazards such as confined space, invisible gases, electrocution, engulfment, etc. as the result of helping injured workers or conducting the investigation. The steps to be taken immediately in case of an accident/incident are: eliminate immediate hazards to ensure no one else is injured; provide emergency care to the injured; secure the accident site: use ropes, barrier tape and/or cones or human guards if required, remove nothing from the site without permission, and maintain site until all information is collected; notify proper authorities governmental agencies, Workplace Health, Safety and Compensation Commission (the Commission), etc. Note: When an injury occurs in the workplace and a worker requires medical care, the employer is required to notify the Commission in writing within 1 three days. The amount of information gathered and the resources needed depend on the specific accident/incident. 1 If a worker is injured and requires medical care, the worker must complete a Form 6 Worker's Report of Injury, and the employer must complete a Form 7 Employer's Report of Injury. These forms are available at: 10

15 STEP 2 Gather information Taking Notes Keeping notes in a notebook throughout an investigation process keeps information together and organized. Notes should be neat and detailed, yet concise; and they should answer who, what, when, where, why and how. Good notes help to recall facts and are useful when analyzing information to determine the root cause. Notes should include: dates and times; names and addresses; information from interviews; observations; action taken by you and others; description of site and environmental conditions; reference to pictures, if taken; measurements; sketches and diagrams; and information about evidence gathered. Conducting Interviews Interview promptly and separately injured workers; witnesses to the event; immediate supervisor; staff from departments such as maintenance, purchasing or supplies (if necessary); and anyone else who can provide information; for example, a representative of the manufacturer or a company trainer. Interviewing Tips maintain privacy and put the person at ease; explain why the interview is being conducted; emphasize the investigation is for fact finding, not fault finding; ask people to explain what happened in their own words; let people tell what happened don t lead the witness; try not to interrupt; ask specific questions to clarify and fill in the gaps; repeat what is reported to verify your understanding; 11

16 thank people for their co-operation; and write-up a complete account as soon as possible after the interview to ensure the details are accurate. Sample Interview Questions Where were you when the accident (incident) happened? What were you doing at that time? What did you see? What did you hear? Who else was around at the time? Is there a standard procedure for the task? Are workers trained in the standard procedure? Was this the first time this task was done? Was the work being supervised at the time? Is there anything else you d like to add? Suggestions for Collecting Samples use a diagram of the area to note where samples were found; keep people away from area; ensure evidence is not damaged; place samples in a bag or container, seal it, and label with a permanent marker; label the evidence with a reference number the date and time evidence was collected the specific location evidence was found the collector s name; keep evidence in a secure place; and keep a record if evidence is moved. for Taking Pictures for Evidence The following tips will ensure pictures can be used as evidence: use adequate lighting; ensure unobstructed view of the area or object; date the photograph; reference the measurement (i.e. place a ruler, measuring tape, another object or person, etc. next to the area or object); and keep the negatives. 12

17 Reviewing Documentation Examples of documentation that may need to be reviewed log books work schedules files policy and procedure manuals specific legislation manufacturer s specification check lists training records formal workplace inspection reports previous records of this kind of event previous accident/incident investigation reports Once all information about the accident/incident is gathered, it must be reviewed to determine the root cause. The information should be organized into a logical sequence of events, working back from when the accident/incident occurred. All possible causes should be listed at each step and checked to see if they are supported by the evidence. If gaps in the evidence are discovered, there may be a need to re-interview witnesses, review the documentation again, or gather further information. 13

18 STEP 3 Contributing Factors Analyze the information to determine the root cause There are many factors that contribute to accidents/incidents; however they can usually be broken down into four major categories: people, equipment, materials and the environment. The following are some areas that may be explored when investigating accidents/incidents to determine the root cause(s). People (management, non-management workers, contract workers, visitors) knowledge, experience, skill, understanding, orientation,training job site analyses communication safe work practices and procedures documentation of hazards equipment preventative maintenance physical capability analysis workload workplace inspections Equipment design manufacturers specifications use preventative maintenance ergonomics job safety analysis safe work practices and procedures hazard recognition, evaluation and control documentation personal protective equipment (PPE) Materials manufacturers specifications use preventative maintenance ergonomics job safety analysis safe work practices and procedures hazards recognized, evaluated and controlled documentation 14 Environment lighting noise air quality housekeeping practices weather conditions

19 It is widely accepted that accidents/incidents occur as a result of a chain of events. There is rarely one cause. Causes of accidents/incidents are usually grouped into two main categories: immediate/direct cause(s) and root/basic cause(s). Immediate/Direct Cause(s) Immediate/Direct Cause(s) are events, conditions or acts that immediately precede the accident/incident. Immediate/direct causes are usually the symptoms of the root/basic cause, not the root cause itself. Immediate/direct causes are usually related to uncontrolled hazards arising from substandard conditions and/or substandard actions. Examples of conditions: machine guards in good working order; noise at acceptable levels; planning documented; good housekeeping practiced; and personal protective equipment maintained. Examples of actions: safe work procedures followed; equipment appropriately maintained and used; hazards communicated; rules followed; and personal protective equipment properly used and maintained. 15

20 Root/Basic Cause(s) Root/Basic Cause(s) are real or underlying cause(s) of accidents/incidents. They are not always immediately evident. Examples of job factors: design of equipment; knowledge of workplace parties; communication practices; workplace inspections scheduled and conducted; and appropriate equipment available and used. Examples of personal factors: orientation; communication and understanding of safe work practices and procedures; pace of work; education and training; and performance feedback. Analyzing all information contributing factors and the immediate/direct causes increases the likelihood of finding the root cause(s). Finding the root cause(s) and implementing corrective actions will in turn prevent similar accidents/incidents in the future. 16

21 STEP 4 Make recommendations Once the root cause of the accident/incident is identified, a set of well thoughtout recommendations should be developed as a means of preventing a similar event in the future. The accident/incident investigation procedures should outline the criteria for writing recommendations. Recommendations should: be clearly written; be as specific as possible what, when and where; identify target dates for implementation and follow-up; and list the resources required for implementation (i.e. human, financial, equipment, materials, etc.). 17

22 STEP 5 Write the accident/incident investigation report The purpose of the accident/incident investigation report is to communicate the investigation information and document recommendations for corrective action. Accident/incident investigation reports may be used as evidence during legal proceedings; therefore, it is important that it is fully completed. The accident/incident investigation procedures should identify who is responsible for distributing the written report and who is responsible for communicating its findings to the appropriate workers. Please refer to Appendix E Sample Accident/Incident Investigation Form. When writing an investigation report, remember to: keep the report well organized, clear and to the point; describe what happened including the sequence of events and timelines; write a short description of the investigation methods used; and describe the analysis of the cause including the immediate/direct causes and the root cause(s). The accident/incident investigation report should include: supporting documentation and other evidence; for example, summaries of interviews, pictures and analysis of evidence; recommendations for corrective actions; outline of the follow-up procedure; signatures of the investigation team; and date the report is submitted to the employer. The accident/incident investigation procedures should identify: those responsible for distributing the investigation report; those who should receive the report or the findings of the investigation; and a mechanism for communicating the findings to appropriate staff. The report should be distributed to senior management, the OH&S committee, and the management in the appropriate work areas. All confidential worker information should be removed before distribution of the investigation report and before communicating the investigation findings. 18

23 STEP 6 Follow-up Accident/incident investigation procedures should identify those responsible for: implementing corrective actions within the assigned time frame; meeting time-lines for implementing the corrective actions; adding the corrective actions to the workplace inspection checklist as a means of evaluating them; evaluating corrective actions to ensure they are effective; sharing the investigation findings with workers; and communicating the effectiveness of the corrective actions to senior management, the OH&S committee, and the staff in the affected work area. All confidential worker information should be removed before distribution of the investigation report and before communicating the investigation findings. 19

24 Role of OH&S Committees The OH&S committee should receive all accident/incident investigation reports. The accident/incident investigation procedures should outline those responsible for distributing the report to the OH&S committee and those responsible for updating the OH&S committee on implementation, follow-up and evaluation of corrective actions. As part of the internal responsibility system, the OH&S committee reviews all accident/incident investigation reports to ensure: accident/incident investigation procedures are followed; root causes are identified; recommendations for corrective actions are appropriate; additional recommendations are developed and forwarded to the employer if appropriate; implementation time-lines are met; corrective actions are monitored and evaluated; communication procedures for accident/incident investigations are followed; trends in injury, illness and property damage are identified; and accident/incident investigations are an effective part of the OH&S program. In addition to the above, the employer may ask the OH&S committee to accept other duties such as being part of the investigation team. Just as with other team members, these OH&S committee members should be trained in accident/incident investigations and in hazard recognition, evaluation and control. 20

25 Accident/Incident Investigations and the OH&S Program Accident/incident investigations are an important part of and are closely linked to other elements of an OH&S program; for example, they: demonstrate the employer s leadership and commitment to preventing injury, illness and property damage by providing necessary resources to complete accident/incident investigations; are an important means of hazard recognition, evaluation and control; identify education and training needs, safe work practices and procedures that need to be reviewed, revised or developed, and injury, illness and property damage trends; involve the OH&S committee; identify items that may need to be added to the workplace inspections checklist; improve communication about OH&S in the workplace; will need a good disability management program in place if the accident results in an injury or illness; and may identify a need for review of emergency preparedness/response equipment and procedures. 21

26 Conclusion Using the information in this booklet will help workplace parties to plan accident/incident investigations, choose the investigation team, document the findings, identify the root cause(s), recommend corrective action, complete the report, and follow-up on corrective action. Accident/incident investigations are an important part of an OH&S program. The involvement of all workplace parties strengthens the internal responsibility system, is important to preventing similar occurrences in the future, and is essential to building a positive health and safety culture in workplaces. 22

27 Appendix A Glossary...24 Appendix B References to Legislation...28 Appendix C Hazardous Occurrence Investigation Report...35 Appendix D Sample Accident/Incident Report Form...36 Appendix E Sample Accident/Incident Investigation Form...37 Appendices

28 Appendix A - Glossary Appendix A Glossary 24 Accident Basic/root cause Best practice Controls Direct (immediate) cause Due Diligence Employer Ergonomics an unplanned event that results in a personal injury or illness, damage or loss of property, process or environment. see root/basic cause performance standards developed by employers, workers and OH&S professionals which exceed basic OH&S legislative requirements and which strive toward doing work in the safest possible way. measures that are implemented to eliminate or minimize hazards in the workplace. These controls are established as either engineering (first line of defence), administrative, or personal protective equipment (used as a last resort). those unsafe objects, conditions or behaviours which occur immediately before an accident/ incident; for example, inadequate guards and barriers, defective tools, and improper lifting. These are not the root cause. occurs when actions normally considered reasonable in a particular circumstance are taken. In cases where a serious workplace injury occurs and legal action is taken, a due diligence defence can be mounted if the person charged did everything a reasonable person would do in the same situation to prevent the injury. a person who employs one or more workers [ OH&S Act, section 2 (f)]. a science that seeks to adapt work or working conditions to suit the worker. The aim is the evaluation and design of facilities, environments, jobs, training methods and equipment to match the capabilities and limitations of workers and reduce the potential for fatigue, error or unsafe acts.

29 Formal workplace inspections regularly scheduled examinations carried out as a means of preventing injury, illness and property damage and of ensuring a safe and healthy workplace. They are formally documented with the use of a checklist and a report that includes recommendations for corrective actions. Hazard dangerous object, event, behaviour or condition which has the potential to cause injury, illness or property damage. Incident (near miss; potential accident) an undesired event that could have resulted in injury, illness or damage to property, process or environment. Informal workplace inspections daily routines used as a means of preventing injury, illness and property damage and of ensuring a safe and healthy workplace; for example, a supervisor s walkthrough or a worker s routine equipment check. Informal inspections are usually not scheduled or documented and do not require a checklist. Internal responsibility system a philosophy guiding OH&S legislation in all Canadian jurisdictions. It is a system where all workplace parties employers, workers including supervisors and managers, and OH&S committees share in the responsibility for workplace health and safety to the degree of each party s authority and ability to do so. Occupation OH&S committee employment, business, calling or pursuit but does not include an endeavour that is not included in one of the classes of occupations in the current Canadian Classification and Dictionary of Occupations [OH&S Regulations, section 2 (f)]. a committee required to be established by the employer in workplaces with 10 or more workers. The OH&S committee must consist of representatives of the employer and the workers at the workplace. Sections 37, 38, 38.1, 39, 40 and 45 of the OH&S Act describe the composition and duties of the committee, and the training and meeting requirements. Further requirements for OH&S committees can be found in section 21 of the OH&S Regulations. 25 Appendix A Glossary

30 Appendix A Glossary 26 Procedures (in relation to the OH&S program) Risk Root/basic cause Serious accident Serious injury Supervisor step by step way for completing of the OH&S program components. chance of loss based on: (a) the probability of an injury, illness, damage or loss of property, process or environment; and (b) the possible severity of the injury, illness, damage or loss of property, process or environment. the real cause of an accident/incident and the reason why it occurred; for example, inadequate design, lack of knowledge or skill, physical and physiological stress, etc. The root cause is usually not immediately evident and requires investigation. an accident resulting in death, permanent or temporary disability, excessive property damage, or accidental release of pollutants with significant effects. More specifically, serious accidents are those accidents meriting in-depth investigation and are defined in the OH&S Act, section 54(3). a fracture of the skull, spine, pelvis, femur, humerus, fibula, tibia, radius or ulna; an amputation of a major part of a hand or foot; the loss of sight of a eye; a serious internal hemorrhage; a burn that requires medical attention; an injury caused directly or indirectly by explosives; an asphyxiation or poisoning by gas resulting in a partial or total loss of physical control; or any other injury likely to endanger life or cause permanent injury. A serious injury does not include injures to a worker of a nature that may be treated through first aid or medical treatment and the worker is able to return to his or her work either immediately after the treatment or at his or her next scheduled shift [ OH&S Act, section 54(3)]. includes a superintendent, foreman or other worker authorized or delegated to exercise direction and control over workers of an employer [OH&S Regulations, section 2 (j)].

31 Unsafe act Unsafe condition Worker Workplace Workplace Health, Safety and Compensation Commission Workplace parties departure from an accepted, normal or correct procedure or practice which has actually produced injury or property damage or which has the potential for producing such loss. departure from a standardized, accepted or normal physical state to create circumstances which increase the likelihood of an accident. a person engaged in an occupation [ OH&S Act, section 2 (m)]. a place where a worker or self-employed person is engaged in an occupation and includes a vehicle or mobile equipment used by a worker in an occupation [ OH&S Act, section 2 (n)]. an employer-funded no-fault insurance system that promotes safe and healthy workplaces, provides returnto-work programs and offers compensation to injured workers and their dependants. those who perform work or are responsible for the performance of work in a workplace. They include employers, workers including managers and supervisors, and the OH&S committee. 27 Appendix A Glossary

32 Appendix B References to Legislation Important Note: The legislative references included in this section are not official versions. For official versions of the legislation, please see below. The legislative references in Appendix B refer to the content in this booklet and may not be complete. Workplace parties must refer to the appropriate legislation to find complete information regarding legislative requirements for developing an OH&S program. Provincial legislation contact information: For official copies of the Occupational Health and Safety Act and the Occupational Health and Safety Regulations please contact: Office of the Queen s Printer Ground Floor Confederation Building, East Block St. John s, Newfoundland and Labrador A1B 4J6 Telephone: (709) Unofficial copies are available on-line at: Federal legislation contact information: For an official copy of the Canada Labour Code please contact: Canadian Government Publishing, Communication Canada Ottawa, Ontario K1A 0S9 Telephone: (709) Bookstores: (613) or Fax: (613) or Internet: Unofficial copies are available on-line at: OH&S Act Appendix B - References to Legislation Employers general duty An employer shall ensure, where it is reasonably practicable, the health, safety and welfare of his or her workers. 41. Worker representative (1) Where less than 10 workers are employed at a workplace, the employer shall ensure that a worker not connected with the management of the workplace is designated as the worker health and safety representative to monitor the health, safety and welfare of workers employed at the workplace.

33 42.1 Workplace designate (1) Notwithstanding section 41, where less than six persons are engaged at a workplace and the designation of a worker health and safety representative is impracticable, the employer may designate a workplace health and safety designate to monitor the health, safety and welfare of workers employed at the workplace. 54. Reporting accidents (1) Where an accident takes place at a workplace (a) (b) that results in serious injury to a person or results in the death of a person; or that had, or continues to have, the reasonable potential of causing serious injury to or the death of a person the employer, or principal contractor shall immediately notify the assistant deputy minister of the accident. (2) Where an accident is reported under subsection (1), notification shall immediately be given to the committee, the worker health and safety representative or the workplace health and safety designate. (3) In this section and section 55 "serious injury" means (a) a fracture of the skull, spine, pelvis, femur, humerus, fibula or tibia, or radius or ulna; (b) an amputation of a major part of a hand or foot; (c) the loss of sight of an eye; (d) a serious internal hemorrhage; (e) a burn that requires medical attention; (f) an injury caused directly or indirectly by explosives; (g) an asphyxiation or poisoning by gas resulting in a partial or total loss of physical control; or (h) another injury likely to endanger life or cause permanent injury, but does not include injuries to a worker of a nature that may be treated through first aid or medical treatment and the worker is able to return to his or her work either immediately after the treatment or at his or her next scheduled shift. 29 Appendix B - References to Legislation

34 OH&S Regulations 4. Occupational health and safety program (1) An occupational health and safety program required under section 36.1 of the Act shall be signed by the employer and by the person or persons responsible for the management of the employer s operations in the province and shall include (f) a system for the recognition, evaluation and control of hazards that includes: (iv)procedures for the prompt investigation of hazardous occurrences to determine the cause of the occurrence and the actions necessary to prevent a recurrence, (j) maintenance of records and statistics, including occupational health and safety committee minutes, reports of occupational health and safety inspections and investigations, with procedures to allow access to them by persons entitled to receive them under the Act. Canada Labour Code, Part II Policy Health and Safety Committees (1) Establishment mandatory Appendix B - References to Legislation 30 For the purposes of addressing health and safety matters that apply to the work, undertaking or business of an employer, every employer who normally employs directly three hundred or more employees shall establish a policy health and safety committee and, subject to section 135.1, select and appoint its members. (4) Duties of policy committee A policy committee ( d) shall participate to the extent that it considers necessary in inquiries, investigations, studies and inspections pertaining to occupational health and safety; 135. Work Place Health and Safety Committees (1) Establishment mandatory For the purposes of addressing health and safety matters that apply to individual work places, and subject to this section, every employer shall, for each work place controlled by the employer at which twenty or more employees are normally employed, establish a work place health and safety committee and, subject to section 135.1, select and appoint its members.

35 (7) Duties of committee A work place committee, in respect of the work place for which it is established ( e) shall participate in all of the inquiries, investigations, studies and inspections pertaining to the health and safety of employees, including any consultations that may be necessary with persons who are professionally or technically qualified to advise the committee on those matters 136. Health and Safety Representatives (1) Appointment of health and safety representative Every employer shall, for each work place controlled by the employer at which fewer than twenty employees are normally employed or for which an employer is not required to establish a work place committee, appoint the person selected in accordance with subsection (2) as the health and safety representative for that work place (2) Selection of person to be appointed The health and safety representative for a work place shall be selected as follows: ( a) the employees at the work place who do not exercise managerial functions shall select from among those employees the person to be appointed; or ( b) if those employees are represented by a trade union, the trade union shall select the person to be appointed, in consultation with any employees who are not so represented, and subject to any regulations made under subsection (11). The employees or the trade union shall advise the employer in writing of the name of the person so selected Canada Occupational Health and Safety Regulations Reports by Employee 15.3 Where an employee becomes aware of an accident or other occurrence arising in the course of or in connection with the employee s work that has caused or is likely to cause injury to that employee or to any other person, the employee shall, without delay, report the accident or other occurrence to his employer, orally or in writing. SOR/89-479, s Appendix B - References to Legislation

36 Investigations 15.4 (1) Where an employer becomes aware of an accident, occupational disease or other hazardous occurrence affecting any of his employees in the course of employment, the employer shall, without delay, ( a) appoint a qualified person to carry out an investigation of the hazardous occurrence; ( b) notify the work place committee or the health and safety representative of the hazardous occurrence and of the name of the person appointed to investigate it; and ( c) take necessary measures to prevent a recurrence of the hazardous occurrence. (2) Where the hazardous occurrence referred to in subsection (1) is an accident involving a motor vehicle on a public road that is investigated by a police authority, the investigation referred to in paragraph (1)( a) shall be carried out by obtaining from the appropriate police authority a copy of its report respecting the accident. (3) As soon as possible after receipt of the report referred to in subsection (2), the employer shall provide a copy thereof to the work place committee or the health and safety representative. SOR/89-479, s. 1; SOR/94-263, s. 56; SOR/ , s. 31. Telephone or Telex Reports Appendix B - References to Legislation The employer shall report to a health and safety officer, by telephone or telex, the date, time, location and nature of any accident, occupational disease or other hazardous occurrence referred to in section 15.4 that had one of the following results, as soon as possible but not later than 24 hours after becoming aware of that result, namely, ( a) the death of an employee; ( b) a disabling injury to two or more employees; ( c) the loss by an employee of a body member or a part thereof or the complete loss of the usefulness of a body member or a part thereof; ( d) the permanent impairment of a body function of an employee; ( e) an explosion; ( f) damage to a boiler or pressure vessel that results in fire or the rupture of the boiler or pressure vessel; or ( g) any damage to an elevating device that renders it unserviceable, or a free fall of an elevating device. SOR/89-479, s. 1; SOR/94-263, s. 57; SOR/ , s. 38.

37 Records 15.6 (1) The employer shall, within 72 hours after a hazardous occurrence referred to in paragraph 15.5( f) or ( g), record in writing ( a) a description of the hazardous occurrence and the date, time and location of the occurrence; ( b) the causes of the occurrence; and ( c) the corrective measures taken or the reason for not taking corrective measures. (2) The employer shall, without delay, submit a copy of the record referred to in subsection (1) to the work place committee or the health and safety representative. SOR/89-479, s. 1; SOR/94-263, s. 58; SOR/ , s. 32. Minor Injury Records 15.7 (1) Every employer shall keep a record of each minor injury of which the employer is aware that affects any employee in the course of employment. (2) A record kept pursuant to subsection (1) shall contain ( a) the date, time and location of the occurrence that resulted in the minor injury; ( b) the name of the employee affected; ( c) a brief description of the minor injury; and ( d) the causes of the minor injury. SOR/89-479, s. 1. Written Reports 15.8 (1) The employer shall make a report in writing, without delay, in the form set out in Schedule I to this Part setting out the information required by that form, including the results of the investigation referred to in paragraph 15.4(1)( a), where that investigation discloses that the hazardous occurrence resulted in any one of the following circumstances: ( a) a disabling injury to an employee; ( b) an electric shock, toxic atmosphere or oxygen deficient atmosphere that caused an employee to lose consciousness; ( c) the implementation of rescue, revival or other similar emergency procedures; or ( d) a fire or an explosion 33 Appendix B - References to Legislation

38 (2) The employer shall submit a copy of the report referred to in subsection (1) ( a) without delay, to the work place committee or the health and safety representative; and ( b) within 14 days after the hazardous occurrence, to a health and safety officer at the regional office or district office. SOR/89-479, s. 1; SOR/94-263, s. 59; SOR/ , s Where an accident referred to in subsection 15.4(2) results in a circumstance referred to in subsection 15.8(1), the employer shall, within 14 days after the receipt of the police report of the accident, submit a copy of that report to a health and safety officer at the regional office or district office. SOR/89-479, s. 1; SOR/ , s. 38. Workplace Health, Safety and Compensation Act 56. Duties of employer Appendix B - References to Legislation 34 (1) An employer shall, within 3 days after the occurrence of an injury to a worker in his or her employment as a result of which the worker is disabled from earning full wages or the worker is entitled to medical aid, notify the commission in writing of (a) the occurrence of the injury and nature of it; (b) the time when the injury occurred; (c) the name and address of the worker; (d) the place where the injury occurred; (e) the name and address of the doctor who looks after the injury; and (f) other particulars required by the commission. (2) An employer shall make further and other reports respecting the injury and workers that may be required by the commission. (3) Where an employer fails to notify the commission of the occurrence of an injury the commission may in relation to compensation paid in respect of that injury charge the cost of the claim against the experience record of that employer.

39 Appendix C Hazardous Occurrence Investigation Report Human Resources Développement des Development Canada ressources humaines Canada SCHEDULE 1 / ANNEXE 1 (section 15.8 / article 15.8) Explosion HAZARDOUS OCCURRENCE INVESTIGATION REPORT RAPPORT D'ENQUÊTE DE SITUATION COMPORTANT DES RISQUES 1. TYPE OF OCCURRENCE / GENRE DE SITUATION Disabling Injury Blessure invalidante Other Autre 3. Employer's name and mailing address / Nom et adresse postale de l'employeur Loss of Consciousness Évanouissement Emergency Procedure Mesures d'urgence Specify / Préciser 2. Department file no. N de dossier du ministère Regional or District Office Bureau régional ou de district Employer ID No. Numéro d'identification de l'employeur Postal code / Code postal Site of hazardous occurrence Lieu de la situation comportant des risques Witnesses / Témoins 4. Description of what happened / Description des circonstances Age / Âge Occupation / Profession Was training in accident prevention given to injured employee in relation to duties performed at the time of the hazardous occurrence? L'employé blessé a-t-il reçu une formation en prévention des accidents relativement aux fonctions qu'il exerçait au moment de la situation comportant des risques? Title / Titre LAB 1070 (02-01) B Signature Telephone Number / Numéro de téléphone ( ) - 9. Work place committee's or health and safety representative's comments / Observations du comité local ou du représentant Telephone Number / Numéro de téléphone () - Telephone number / Numéro de téléphone () - Years of experience in occupation / Nombre d'années d'expérience dans la profession Direct cause of injury / Cause directe de la blessure 10. COPIES 1 and 2to Health and Safety Officer, COPY 3 to the Work Place Committee or Health and Safety Representative 4to the Employer COPIES 1 et 2pour l'agent de santé et de sécurité 3 pour le comité local ou pour le représentant, COPIE 4 pour l'employeur See reverse for INSTRUCTIONS au verso Date and time of hazardous occurrence Date et heure de la situation comportant des risques: Weather / Conditions météorologiques Brief description and estimated cost of property damage / Description sommaire et coût estimatif des dommages matériels 5. Injured employee's name (if applicable) / Nom de l'employé blessé (s'il y a lieu) Description of Injury / Description de la blessure Yes / Oui No / Non Specify / Préciser 6. Direct causes of hazardous occurrence / Causes directes de la situation comportant des risques 7. Corrective measures and date employer will implement / Mesures correctives qui seront appliquées par l'employeur et date deleur mise en oeuvre Sex Sexe Reasons for not taking corrective measures / Raisons pour lesquelles aucune mesure corrective n'a été prise Supplementary preventive measures / Autres mesures de prévention 8. Name of person investigating / Nom de la personne faisant l'enquête Work place committee member's or health and safety representative's name Nom du membre du comité local ou du représentant Title / Titre Supervisor's name / Nom du surveillant sample Signature Date Date 35 Appendix C Hazardous Occurrence Investigation Report

40 Appendix D Sample Accident/Incident Report Form This report must be completed for all workrelated incidents/accidents. Please immediately notify your manager/supervisor. Complete the employee section and distribute as noted below. Accurate information is required so appropriate follow-up can occur to prevent future incidents. PLEASE NOTE, all serious injuries must also be immediately reported to the Dept. of Government Services (OH&S Branch). Category/Status (Internal Use Only) Near Miss (No injury) Medical Care Lost Time Recurrence Original Injury Date Who and When? Confidentiality: The information contained in this report is considered confidential & will only be used for analyzing trends, injury prevention initiatives and WHSCC claims management. Permanent Temp Part Time Full Time Casual/On call Your last name: Your first name: Your employee number: Appendix D Sample Accident/Incident Report Form 36 Where? What Happened? Special Instructions HR use only What were you doing at the time? The date and time of incident/accident D M Y The incident/accident was reported to: am/pm Title: Which site did the incident/accident occur? (kitchen, office, etc) The date/time stopped work:(if applicable) Where did it actually occur?(be as specific as possible: room, corridor, workstation, facility) sample What was your job classification at time of accident/incident? Describe what happened (mention events leading up to how it occurred and if machinery/equipment/tool were involved) This incident/accident resulted in (more than one may need to be checked): Near miss Damage to equipment/ property Damage to environment Loss of materials Injury requiring medical aid only Injury leading to lost time If you were injured, was there any immediate treatment required? If so, please describe briefly. Mark with (?) if item is applicable Allergic Reaction Assisting Patient for X-ray Assisting Patient from floor/chair Bathing Pt. (bed/tub) B/BF Exposure Bed Making Catching Falling Object Catching Patient Changing Patient Walking Patient Chemical Exposure Type Crushed/Pinched b/w Objects If you have been injured, please check which most accurately describe the type of injury. Abrasion(s) Burn(s) B/BF Exposure Contusion Fracture(s) Infectious Contact Irritation (respiratory) Needle Puncture Laceration(s) No Injury Strains(s) & Sprain(s) Other Part of Body Injured (if applicable): Left Right Dressing Patient Respond to an Emergency Code (specific) Ft/Bk slide with transfer board Hot Object/Surface Sharpe Object Type: Infectious Disease Exposure Struck by Object Lifting Equipment/Supplies Slipped/Fell on Lifting/Lowering Bedrails Transferring Patient Bed Stretcher Moving/Pushing/Pulling Transferring Patient Other Equipment/Supplies Transporting Patient No Specific Task Wheelchair Needle Stick Puncture Bed Patient Aggression/ Stretcher Non Cooperation Working at computer workstation Repositioning Patient in Bed Other: Repositioning Patient in Chair Recurrence of previous injury Employee Signature: Home Phone: Date: Date first lost shift: D M Y Anticipated RTW Date: D M Y RTW Date D M Y Name of Attending Physician: Date Seen: D M Y Address of Physician: Manager (or designate) is responsible for completing the Incident/Accident Investigation portion of the form. Please complete the section located on the lower portion of the yellow and pink copies. (Reference: Staff Accident/Incident Investigation Policy X05). - Employee is responsible for completing the Incident/Accident Report portion and forwarding the white copy to the appropriate Human Resources. Report must be completed and forwarded to Human Resources within 24 hours of the incident/accident.

41 Appendix E Sample Accident/Incident Investigation Form Attach all supporting documentation and evidence, ie. summaries of interviews, pictures, and analysis of evidence. Instruction: This form must be completed by the store manager and a member of OH&S committee whenever an accident/incident occurs. The assistant manager or authorized designate for the store will be responsible for completing this form in the absence of the store manager. The store manager must ensure a copy of the completed report is forwarded to the Human Resources Manager, and the OH&S committee. Accident/incident resulted in: injury illness property damage near miss first aid medical aid recurrence other (check all that apply) Accident/Incident Investigations Store Location Department Location of Incident (Be specific eg. aisle 10) Date of incident Time am pm Date reported accident/incident ACCIDENT/INCIDENT INFORMATION Supervisor: Date of first missed shift: No. of days lost Approximate date of onset, if no specific date of injury: Object/equipment/substance inflicting damage/injury: Nature of injury: Body part(s) af f ected: Name (last name first please print) EMPLOYEE INFORMATION Home phone number: Home Address: Age: Sex: M / F sample Date of employment: Experience (time) in job: Occupation/Position: Evaluation of loss Loss severity potential Probability of occurrence Potential if not corrected Major Serious Minor High Moderate Low Describe how the event occurred. Immediate causes: What substandard acts/practices and conditions cause d or could cause the event? See end of form. Basic causes: What specific personal or job/system factors led to the immediate causes? Basic causes: What specific personal or job/system factors caused or could cause this event? See end of form. Remedial actions: What has and/or should be done to control the causes listed? 37 Appendix E Sample Accidence/Incident Investigation Form

42 Prevention of Accident/Incident Recurrence Describe what action is planned or has been taken to prevent a recurrence of the accident, based on the key contributing factors (immediate) (long term) Signed by Supervisor Supervisor s Name Signed by Person Involved: Signed by HR: Signed by Store Manager:_ Date: Appendix E Sample Accidence/Incident Investigation Form 38 INJURY physical harm or damage to a person. ILLNESS unhealthy condition in mind or body. REPORT FORM DEFINITIONS FIRST AID INJURY a minor injury requiring only first aid treatment. MEDICAL AID INJURY an injury requiring treatment by a health care professional. LOST TIME INJURY a disabling injury where the injured person is unable to report for the next regular shift. RECURRENCE an accident or incident which has occurred more than once. PROPERTY DAMAGE ACCIDENT accidental loss to equipment, material, and/or the environment. INCIDENT (NEAR-MISS) an undesired event that could have resulted in personal injury, property damage or loss. IMMEDIATE CAUSES check all as appropriate Actions Operating equipment without authority Failure to warn Failure to secure Operating at improper speed Making safety devices inoperable Removing safety devices Using defective equipment Failure to use PPE Improper loading Improper placement Improper lifting Improper position for task Servicing equipment in operation Horseplay Under influence of alcohol and/or other substances sample BASIC CAUSES check all as appropriate Personal Factors Inadequate capability Lack of knowledge/training Lack of skill Stress Improper motivation Conditions Inadequate guards or barriers Inadequate or improper protective equipment Defective tools, equipment or materials Congestion or restricted action Inadequate warning system Fire and explosion hazard Poor housekeeping, disorder Hazardous environmental conditions, gases, smoke, dusts, fumes Noise exposure Radiation exposure High or low temperature exposure Inadequate or excess illumination Inadequate ventilation Job Factors Inadequate leadership/supervision Inadequate engineering Inadequate purchasing Inadequate maintenance Inadequate tools/equipment Inadequate work standards Wear and Tear Abuse and/or misuse

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44 HOW TO REACH US St. John's Forest Road P.O. Box 9000 St. John's, NL A1A 3B8 Prevention Services Inquiries (709) Prevention Services Fax (709) Toll Free Grand Falls-Windsor 26 High Street P.O. Box 850 Grand Falls Windsor, NL A2A 2P7 Telephone: (709) Fax (709) Toll Free Corner Brook Suite 201, Fortis Towers 4 Herald Avenue P.O. Box 474 Corner Brook, NL A2H 6E6 Telephone: (709) Fax (709) Toll Free Department of Government Services OH&S Branch (709) Toll Free: Human Resources and Social Development Labour Program, Newfoundland and Labrador Office Phone: (709) (call collect outside St. John s) Newfoundland & Labrador Employers Council (709) Toll Free: Newfoundland and Labrador Federation of Labour (709)