1.0 PURPOSE Incident Management Process (IMP) SaskPower has developed and implemented a process to investigate the facts and circumstances of incidents and dangerous occurrences to determine root causes and develop and communicate actions to prevent recurrence. The Incident Management Process (IMP) is designed to: Ensure Employees are capable of recognizing and acknowledging when an incident has occurred. Encourage notification of all incidents, and take remedial action to prevent further loss, with the understanding that investigations are completed to identify facts not place blame. Ensure a thorough, consistent investigation of all incidents, to identify root causes, which permit the development and implementation of appropriate corrective and preventative measures, eliminating the potential for recurrence and to prevent recurrence through the development of controls or actions that address the determined root causes. Develop and implement investigation processes and activities directed at identifying the facts and root causes. Meet Occupational Health and Safety legislative requirements. 2.0 DEFINITIONS 2.1 Dangerous Occurrence Any occurrence that does not, but could have resulted in, a condition or circumstance set out in clause 8(1) of the Occupational Health and Safety Regulations, and includes: a) the structural failure or collapse of i) a structure, scaffold, temporary false work or concrete formwork; or ii)all or any part of an excavated shaft, tunnel, caisson, coffer dam, trench or excavation; b) the failure of a crane or hoist or the overturning of a crane or unit of powered mobile equipment; c) an accidental contact with an energized electrical conductor; d) the bursting of a grinding wheel; e) an uncontrolled spill or escape of a toxic, corrosive or explosive substance; f) a premature detonation or accidental detonation of explosives; g) the failure of an elevated or suspended platform; and h) the failure of an atmosphere-supplying respirator. Refer to Appendix 1 IMP Reference Chart for list of conditions or circumstances. 2.2 Emergency A present or imminent event that requires prompt coordination of actions or special regulation of persons or property to protect the health, safety, or welfare of people, or to limit damage to property and the environment. 2.3 First Aid (FA) The initial and immediate assistance given for illness or injury with minimal or no medical equipment. The purpose of first-aid is to minimize injury and/or disability until definitive medical treatment can be accessed. 2.4 Incident An occurrence that did, or could have, resulted in injury, damage or loss as determined by the SaskPower Incident Reference Chart. 1 of 21
2.5 Investigation Is an analysis of all incidents with the intent of establishing root cause and corrective/preventive measures. 2.6 Lost Time Injury (LTI) An injury that required medical attention and day(s) are lost following the day of the injury. 2.7 Medical Treatment Case (MTC) An injury that requires medical attention in accordance with CEA Standards, but no day(s) is lost other than the day of the injury. NOTE: CEA defines medical treatment as the management and care of a patient to combat disease or disorder. Medical treatment does not include: Visits to a licensed health care professional solely for observation or counseling; Diagnostic procedures; or First aid. 2.8 Near Miss An incident that could have, but did not, result in unintended harm or damage. 2.9 Serious Injury An injury that causes or may cause the death of a worker or will require a worker to be admitted into a hospital as an in-patient for a period of 72 hours or more. 3.0 APPLICATION / EXCEPTIONS This Incident Management Process applies to all SaskPower facilities/operations, and employees, contractors and visitors. There are no exceptions to SaskPowers Incident Reporting Management Process. 4.0 ROLES AND RESPONSIBILITIES 4.1 Executive / Managers shall: Monitor the Incident Reporting and Investigation process for their respective areas of responsibility. Allocate technical resources to the investigation process where applicable. Cooperate, stay informed and provide resources from respective areas to increase effectiveness of investigation. Allocate resources to ensure the implementation of incident corrective/preventive actions 4.2 Out-of Scope Supervisors shall: Ensure medical assistance has been provided or initiated; Ensure medical assistance has been provided or initiated; 2 of 21
Ensure medical assistance has been provided or initiated; Ensure medical assistance has been provided or initiated; Ensure medical assistance has been provided or initiated; Ensure medical assistance has been provided or initiated; Ensure medical assistance has been provided or initiated; Ensure appropriate communications have taken place as per the Incident Reference Chart. Ensure Employee Family Assistance Program has been provided or intiated as required. Ensure the required information is entered into the incident reporting module of the Safety Software for employee and contractor incidents. Participate and fully cooperate in the Incident Investigation. Evaluate and cooperate in recommendations stemming from the incident investigation and initiate corrective or preventative actions are required. Ensure corrective and preventative actions have been followed in accordance with recommendations from the investigation and audit findings. 4.3 In-Scope Supervisors shall: Ensure medical assistance has been provided or initiated; Determine site control requirements and initiate them. Notify the management supervisor or designate of all incidents as soon as possible Ensure the incidents are documented in the incident reporting module of the Safety Software 4.4 Occupational Health Committees (OHC) shall: Be advised of all injuries and fatalities as required by OH&S legislation and participate in investigations when required Participate in other investigations at the request of the supervisor or as defined in the local OHC Terms of Reference; Have access to all incident reports and investigations for all incidents 4.5 Employee shall: Report all incidents are reported in accordance with the Incident Reference Chart. Assist with the completion of the incident report form. Cooperate and participate during the incident investigation as required. 4.6 Contractors shall: Report all incidents to their contract administrator Investigate all incidents as required and make results available to SaskPower contract administrators upon request Refer to the Contractor Health and Safety Management Program. 4.7 Corporate Safety shall: Provide centralized leadership to the incident response and investigation Maintain the Incident Reporting and Investigation Policy and support documentation of policy Provide administrative and technical support to the application of the incident investigation process as required Facilitate the development of Corporate corrective/preventive action plans as required. Demonstrate that the effectiveness of the corrective and preventative actions are monitored. Communicate information and findings through information bulletins Ensure that serious injuries, fatalities and dangerous occurrences are reported to the Ministry of Labour Relations and Workplace Safety 3 of 21
Conduct audits to ensure conformance. Provide centralized distribution of incident statistics and related key indicators, and conduct regular trending and analysis. 4.8 Communications and Public Affairs Responsible to lead media contacts as required. 5.0 METHOD / PRACTICE All incidents shall be communicated and investigated within the timelines specified in the Incident Management Process Reference Chart Appendix 1 and the Incident Management Process Flowchart Appendix 2. Incident investigation shall determine the facts of the incident, identify root cause(s) and make recommendations to prevent recurrence. Recommendations shall be tracked in the safety software. This shall include identifying responsible parties, resources required to complete and due dates. Incidents shall be reported to Corporate Safety, Management, and the Ministry of Labour Relations and Workplace Safety by the Safety Coordinator. Executive will be notified by the Chief Safety Officer. Incident reports and corrective/preventive actions shall be monitored through Safety Coordinators monthly reports. The Safety Coordinators will provide briefings at SMS/management meetings. Reports shall be available in the incident reporting module of the Safety Software. Incidents and corrective/preventive actions shall be communicated to applicable staff. Incident Management Process To be successful in preventing recurrences and reducing incidents, the following six step processes shall be followed: 4 of 21
5.1 Response Recognize that an incident has occurred. Complete an initial assessment of the incident to determine the following: What has occurred; Who was involved; and What is required to control the scene? Determine if emergency response is required If the incident is an emergency, follow the local Emergency Response Plan. If the incident does not meet the definition of an emergency continue following the Incident Management Process. Prevent further loss by determining and implementing immediate corrective action. Do not disturb the incident scene more than is necessary to safely remove injured personnel and shut down equipment still in operation. Secure the incident scene to: Prevent further incident(s); Locate and preserve evidence; and Meet legislative requirements. 5.2 Notification and Initial Reporting Verbally notify appropriate individuals of the incident occurrence based on incident type and severity. (Refer to Appendix 1 Incident Management Process Reference Chart for more information). Regardless of incident severity, employees must verbally notify their direct supervisor or designate immediately as practical. If the incident is critical, or may attract the attention of the media, notify Communications and Public Affairs, as per the local emergency response procedures. The supervisor shall refer to Appendix 1 Incident Management Process Reference Chart and notify support departments as applicable. Following verbal notification of the incident occurrence, an initial report will be entered into safety software by the employee, or designate. Electronic notifications will supplement the verbal notifications referenced in the Incident Management Process Reference Chart Appendix 1 and Incident Management Process Flow Chart - Appendix 2. 5.3 Investigation Investigation Tools & Equipment Investigation kits shall be assembled, maintained, located in a centralized area, and accessible to all supervisors, the Safety Coordinator and the Occupational Health Committee (OHC). Investigation kits shall contain the following, but not limited to: 5 of 21
Incident Classification And Notification Identification Tags (For Parts) Guide Incident Management Process Forms High-Visibility Tape Or Cord Local Emergency Management Plan High Visibility Traffic Vest Personal Protective Equipment Hazard Triangles Disposable 35 MM Camera Yellow Chalk Clipboard, Paper, Ruler And Pencils Large Plastic Bags For Gathering Evidence Graph Paper (For Diagrams) Flashlight Tape Measure (100' / 30 M) List of Drug and Alcohol Testing Locations and Contact Information Conduct Initial Assessment of Incident Gather evidence to assist in determining cause(s) of the incident such as the following: Diagrams; Maps; Photographs; Measurements; Videos, and Plot / site plans, etc. Note: All attachment information (i.e. photos, sketches, videos) shall be dated and referenced as an attachment. Note: Where reasonable grounds have been established to determine that drugs or alcohol may have been a contributing factor, and where the employee has denied use, the lead investigator will require a test, with approval from the appropriate supervisor, arrange for transportation for the employee to a testing location and inform the Return to Work department. Record details immediately as the incident site may be subject to rapid change or destruction. Include details such as: Potential witnesses (i.e. contact information); Law enforcement (if applicable); Position of injured (i.e. worker, public); Position of equipment (i.e. hoists, vehicles); Position of materials (i.e. chemicals, loads); Preventative devices in use (i.e. guards); Ergonomic conditions (i.e. lighting levels, position of machinery controls); Environmental conditions (i.e. weather conditions); and/or Housekeeping (i.e. debris). Physical evidence of drug or alcohol paraphernalia Document an initial sequence of events. The initial sequence of events should be compiled immediately so as to minimize confusion of the facts. Determine Investigation Resources and Establish Investigation Team (if required) Resources required for the investigation are assigned based on the incident category, event type and severity (Minor, Significant, Major, or Critical). Keep the investigation team led by Corporate Safety, to a manageable size and include those personnel who will add value to the process. 6 of 21
A member of the Occupational Health Committee shall sit as a member of the investigation team for all incidents classified as Critical, or as directed by local management. Incident summary reviews for all incidents shall reside as a standing agenda item for all OHC and local meetings. Assign roles / tasks to each person involved in the team (i.e. contact person, leader, etc.) The lead investigator will be a designate from Corporate Safety. Provide the investigation team with the appropriate tools as outlined above. Critical Incidents with a high potential for harm or highly technical contributing factors may require the Chief Safety Officer, in consultation with senior management, to appoint a Critical Incident Investigation Team (CIIT). The CIIT will be selected for their technical abilities and knowledge of the system and apparatus. The CIIT investigation is intended to compliment any mandated OHC investigations. Obtain and Evaluate Data Put all those involved at ease. Evidence collected may include documents, interviews, written statements, photographic evidence, physical evidence, technical analysis and drug and alcohol records. Discuss with the individuals involved that the intent of the investigation is to prevent recurrence of similar incidents by determining cause(s) and that the investigation focuses on the facts to determine corrective and preventative actions. The assignment of blame and disciplinary action should not be associated with an incident investigation. These issues have to be dealt with, but should be done separately from the investigation process. The SaskPower Performance Management Process shall be used for disciplinary situations. Review the preliminary documentation and ensure the initial incident assessment details are recorded (i.e. positions of injured workers, where objects are in relation to each other, the angle something came from or the force behind an object). Interview witnesses Talk with everyone who was in the area at the time of the incident, or just before, or just after the incident occurred.. This includes eyewitnesses, individuals involved, or others such as individuals familiar with the work practices, procedures or work area. TIP: Questions to ask the witnesses will vary depending on the circumstances of the incident. However, there are six basic questions you should include in any interview: Who was injured? What were the materials, machines, equipment or conditions involved? When did it happen? Where did it happen? Why did it occur? How did the incident happen? TIP: Use the following techniques to help your interview be more effective: Conduct the interview at the scene; Interview individuals separately in a private area; 7 of 21
Keep the interview positive; Ask open-ended questions (do not lead the questions); Do not talk down to the person or rush them to answer quickly; Paraphrase what people tell you to make sure you understand; Watch for clues from the person s body language; Record a statement for each witness, have them sign it, and give them a copy as soon as possible; and Thank the person, and ask them to come back to you if they think of anything else. TIP: Separating fact from opinion and circumstantial evidence is a vital component of information gathering. To do this, divide the data into the following categories: Factual Evidence: Data that usually cannot be disputed. This includes information such as the time of day, the location of the incident, logs and printouts, and written reports or photographs illustrating the condition and position of physical evidence. This requires that the investigators can clearly establish that the evidence was neither moved nor tampered with. Witness Statements/Description of Events: Declarations from witnesses who actually saw the incident happen, or from people who came upon the scene. Circumstantial Evidence: A logical interpretation of facts that may lead to an unproved conclusion. Avoid the temptation to draw conclusions based on this type of evidence. Investigators must understand that the accuracy and thoroughness with which they obtain and record data and information will, to a great extent, determine the quality of the final report. It will also determine the effectiveness of the remedial actions. Evaluate historical data. Obtain relevant information from analysis of the conditions at the time of the incident, or from prior records such as technical data sheets, maintenance reports, past incident reports, training reports, work schedules, planning schedules, work practices and procedures, etc. Define sequence of events. Determine the chronological order of the events. Include relevant events that occurred 48 hours prior to the incident and following the incident. Complete Cause Analysis Where drugs or alcohol are a known or suspected cause, refer to the Drug and Alcohol Process and Testing Protocols for guidance. Identify the conditions that describe the circumstances relative to each event. Identify which of the conditions became a cause. Causes are often described as the substandard practices and conditions that precede the event. If there are too many conditions identified for a particular event, it needs to be broken down into several discrete events. One of the simplest and most effective methods of Multiple Cause Determination is to use the Effect/Cause Analysis process. Ask Why. Continue to ask Why. 8 of 21
Determine causes until you reach the point where if specific action is taken the incident will not recur. EFFECT WHY? CAUSE Injury Fall Fall Slick Surface Slick Surface Water Inadequate Drainage EFFECT WHY? CAUSE Inadequate Drainage Plugged Drain Barrel Over Drain Constricted Work Space Plugged Drain Barrel Over Drain Constricted Work Space 3.2 Inadequate Design Specification EFFECT WHY? CAUSE Water Leaky Valve Inadequate Maintenance Leaky Valve Inadequate Maintenance 4.1 Inadequate Work Planning There are a number of other tools and techniques available to assist in identifying root cause (i.e. Fault Tree Analysis, etc.). Contact your Safety Coordinator for further assistance. Develop Recommendations for Corrective Action Plans Once cause(s) have been determined, appropriate corrective and preventative actions can be identified and implemented so similar incidents do not recur. Recommendations should address each cause and can be of two types: Interim Actions are ones that should be taken immediately to reduce the hazards. These stop gap measures are usually ones that have been recommended by the Investigation team or steps implemented at the time the incident occurred. They are extremely important because they reduce the hazard potential immediately. Corrective / Preventative Actions are permanent solutions and may require more time to accomplish. Corrective and preventative actions must address each cause. Implementation and follow up of these permanent measures are essential and may require input and consultation from other groups such as senior management, Legal, etc. Ensure each recommendation specifically describes the action to be taken, and is defined in clear and measurable terms. Recommendations should be practical and achievable and eliminate or decrease risk or consequences. 9 of 21
Recommendations must be assigned to a person, by name not position, for completion by an identified date. Recommendations can only be assigned to Investigation Team Members. Prior to assigning accountability outside the investigation team, a team member must review the Corrective Action Plan (CAP) with the identified personnel. In some situations, recommendations will require further analysis to determine their potential effectiveness. Refer to the Hazard & Risk Assessment Standard to address the risk in terms of the probability of the incident recurring and its potential severity. Recommendations for control generally fall into the following four categories: Substitution; Engineering controls; Administrative controls, and / or Personal protective equipment. To complete further analysis, consult with the appropriate technical experts (i.e. Safety Coordinator and/or SMS Specialist). 5.4 Reporting Once all the initial information has been collected and interpreted, it must be documented on the Initial Incident Report Form in the safety software. Detailed investigation reports and support documents will be attached to the initial incident report. Corrective Action Plans will be tracked to completion in accordance with the Corrective Action Plan (CAP) section of the report form, which is designed to: Identify and notify individuals accountable for CAP implementation; Assign responsibility to individuals to action specific items; Track implementation progress by providing status updates on targeted completion dates; and Confirm the incident has been managed until all actions are completed. Communication and reporting to the Saskatchewan Occupational Health and Safety Division and / or to the Workers Compensation Board via W1 forms may be necessary. Refer to Appendix 1 Incident Management Process Reference Chart for information on reporting requirements by incident type. 5.5 Information Distribution Information identified and documented throughout the management of the incident may assist others (internal or external) in preventing similar incidents from recurring. SaskPower employees, contractors and external parties may learn from incidents and prevent recurrence in the future. Corporate Safety personnel are accountable for communicating appropriate incident findings and corrective action. 6.0 TRAINING REQUIREMENTS AND MATERIAL Those staff responsible for the implementation and maintenance of the Incident Management Process shall be trained in the requirements outlined in this Process. Reference SaskPower Safety Training Management Process for full details. 10 of 21
7.0 RESOURCES For more information regarding the Incident Management Process, you should contact your local Safety Coordinator. 8.0 ATTACHMENTS Appendix 1 - IMP Reference Chart Appendix 2 - IMP Flow Chart Appendix 3 - IMP Forms Appendix 4 - IMP Communication Guide 9.0 REFERENCES The legal requirements for incident management are outlined in the statutes / regulations of the jurisdiction having authority: Saskatchewan Occupational Health and Safety Regulations, 1996. SaskPower (located on SafetyNet) o Incident Reporting and Investigation Policy o Incident Reporting and Investigation Standard 11 of 21
SaskPower Appendix 1 IMP Reference Chart 12 of 21
Appendix 2 IMP Flow Chart Recognize That An Incident Has Occurred. Incident Occurs Complete an initial assessment of the incident to determine the following: What has occurred; Who was involved; and What is required to control the scene? Determine If Emergency Response Is Required. If the incident is an emergency, follow local Emergency Response Plans. Incident Response Prevent Further Loss By Determining And Implementing Immediate Corrective Action. Do not disturb the incident scene more than is necessary to safely remove injured personnel and shut down equipment still in operation. Incident Communication Incident Investigation Verbally Notify Appropriate Individuals Of The Incident Occurrence Based On Incident Type And Severity. Regardless of incident severity, employees must verbally notify their Direct Supervisor immediately. If the incident is Critical, or may attract the attention of the media, notify Communications and Public Affairs. Following verbal notification of the incident occurrence, an initial report will be entered into SafetyNet Incident Reporting by the employee, or designate. Conduct Initial Assessment Of Incident. Gather evidence to assist in determining cause(s) of the incident. All attachment information (i.e. photos, sketches, videos) shall be dated and referenced as an attachment. Record details immediately as the incident site may be subject to rapid change or destruction. Document an initial sequence of events. Determine Investigation Resources And Establish Investigation Team The supervisor accountable for incident selects resources required for the investigation based on incident category, event type and severity. A member of the Occupational Health Committee shall sit as a member of the investigation team for all incidents of Critical or as determined by local management. Assign roles / tasks to each person involved in the team (i.e. contact person, leader, etc.) Designate a lead investigator to co-ordinate the investigation. 13 of 21
Appendix 2 IMP Flow Chart Obtain And Evaluate Data. Put all those involved at ease. Discuss with the individuals involved that the intent of the investigation is to prevent recurrence of similar incidents by determining cause(s) and that the investigation focuses on the facts to determine corrective and preventative actions. Review the preliminary documentation. Ensure the initial incident assessment details are recorded (i.e. positions of injured workers, where objects are in relation to each other, the angle something came from or the force behind an object). Interview witnesses. Talk with everyone who was in the area at the time of the incident, or just before, or just after it happened. This includes eyewitnesses, individuals involved, or others such as individuals familiar with the work practices, procedures or work area. Evaluate historical data. Obtain relevant information from analysis of the conditions at the time of the incident, or from prior records such as technical data sheets, maintenance reports, past incident reports, training reports, work schedules, planning schedules, work practices and procedures, etc. Define Sequence Of Events. Determine the chronological order of the events. Include relevant events that occurred 48 hours prior to the incident and following the incident. Complete Cause Analysis. Identify the basic cause(s) that lead to the incident. One of the simplest and most effective methods of Multiple Cause Determination is to use the Effect/Cause Analysis process. Ask Why. Continue to ask Why. Determine causes until you reach the point where if specific action is taken the incident will not recur Develop Recommendations For Corrective Action Plans. Once cause(s) have been determined, appropriate corrective and preventative actions can be identified and implemented. Recommendations must address each cause and can be of two types: Interim Actions are ones that are being taken immediately to reduce the hazards. Corrective / Preventative Actions are permanent solutions and may require more time to accomplish. Ensure each recommendation specifically describes the action to be taken, and is defined in clear and measurable terms. Recommendations must be assigned to a person, by name not 14 of 21
Appendix 2 IMP Flow Chart position, for completion by an identified date. Recommendations can only be assigned to Investigation Team Members. Incident Report Once All The Information Has Been Collected And Interpreted, It Must Be Documented On The Incident Report Form In Intelex. Corrective Action Plans will be tracked to completion in accordance with the Corrective Action Plan (CAP) section of the report form, which is designed to: Identify and notify individuals accountable for CAP implementation; Assign responsibility to individuals to action specific items; Track implementation progress by providing status updates on targeted completion dates; and Confirm the incident has been managed until all actions are completed. Incident Information Information Identified And Documented Throughout The Management Of The Incident That May Assist Others (Internal Or External) In Preventing Similar Incidents From Recurring Shall Be Shared As Appropriate. SaskPower employees, contractors and external parties may learn from incidents and prevent recurrence in the future. Corporate Safety personnel are accountable for communicating appropriate incident findings and corrective action. Notification and reporting to the Saskatchewan Occupational Health and Safety Division and / or to the Workers Compensation Board via WI forms maybe necessary dependent on incident type and severity. 15 of 21
Appendix 3 IMP Forms SaskPower Incident Initial Reporting Form Reporting Information: Date of Incident: Time of Incident: Record #: SaskPower Incident Type: (Reference Incident Guide - Check all that apply) Personal Incident Motor Vehicle Incident Property / Equipment Damage Regulatory Public Incident Classification: Near Miss: Yes No Incident Severity: Minor Significant Major Critical SaskPower Incident Affiliation: Company Incident Immediate Supervisor Name: Employee Name: Contractor Incident Contractor Company: Location Information: Business Unit: Incident Site / Location Description: Contract Employee Name: Incident Sequence Summary: (Brief factual description of incident. (Relevant events, in chronological order, that happened prior to the incident, during the incident, and immediate actions that followed the incident. Identify who (function, not name), what, when, where, why.) 16 of 21
Appendix 3 IMP Forms SaskPower Incident Supervisor Reporting Form Reporting Information: Date of Incident: Time of Incident: Record #: SaskPower Incident Type: (Reference Incident Guide - Check all that apply) Personal Incident Motor Vehicle Incident Property / Equipment Damage Regulatory Public Incident Classification: Near Miss: Yes No Incident Severity: Minor Significant Major Critical SaskPower Incident Affiliation: Company Incident Immediate Supervisor Name: Employee Name: Contractor Incident Contractor Company: Location Information: Business Unit: Incident Site / Location Description: Contract Employee Name: Incident Report Status: Initial Incident Report Date Reported: Date Completed: Detailed Report Required: Yes No Date Completed and Attached: SaskPower Investigation Team: Team Members /Role: Witness Information if required: Witness Name: Witness Name: Telephone: Telephone: Incident Sequence Summary: (Brief factual description of incident. (Relevant events, in chronological order, that happened prior to the incident, during the incident, and immediate actions that followed the incident. Identify who (function, not name), what, when, where, why.) 17 of 21
Appendix 3 IMP Forms Injury / Illness Summary: (Complete this section only if this incident involved injury or illness) Severity: First Aid Medical Treatment Case Restricted Work Case Lost Time Injury Fatality Onsite First Aid Provider Name: First Aid Provider Qualifications: Description of First Aid Treatment Provided: Injured Party(s) Information: Name Affiliation Current Condition Employee Contractor Public Employee Contractor Public Employee Contractor Public Body Location of Injury / Illness Head Neck Torso Arm Hand Back Leg Foot Other: Type of Injury: Burn Cut Sprain Broken Bone Soft Tissue Damage Exposure Twist Dislocation Other: SaskPower Motor Vehicle Incident Summary: (Complete this section only if a SaskPower or Contractor Vehicle is Involved) Location: Police File # Service Order# Roadbed Surface Type: Asphalt Gravel Concrete Dirt Light Conditions: Darkness Daylight Dusk Dawn Road Conditions: Dry Wet Covered w/ snow Covered w/ ice Weather Conditions: Clear Sunny Raining Cloudy Foggy Snowing Vehicle & Driver Information Vehicle #1 SaskPower Vehicle Driver Name: Occupation: Drivers License # & Province: Years of Driving Experience: Drivers License Class: Unit No: Serial No: License Plate #: Year: Make/Model: SaskPower Contractor Vehicle Last Defensive Driving Course: (yyyy/mm/dd) Speed: (kms/hr) Speed Limit: (kms/hr) Direction of Travel: Seat Belts Worn: Yes No Charges Laid: Yes No Charge Description: Description of Damage: (Attach photo to file) Repair Estimate: Vehicle & Driver Information Vehicle #2 - Public Utility Contractor Driver Name & Company: License Plate #, Drivers License # & Province: Vehicle Make, Model and Year: Description of Damage &Estimate: 18 of 21
Appendix 3 IMP Forms Property Damage Summary: (Complete this section only if this incident involved damage to SaskPower Property) Description of Property Damage: Repair Estimate: Public Property Damage Summary: (Complete this section only if this incident involved Public Property Damage by SaskPower) Description of Public Party Damage: Repair Estimate: Name: Address: Telephone #: Insurance Company: Insurance Policy #: Insurance Company Address: Insurance Company Telephone #: Cause Analysis Table: (Check all that apply) 1. Codes/Practices/Procedures 1.1 Not developed 1.2 Inadequate code, practice or procedure 1.3 Code, practice or procedure not followed 1.4 Inadequate communication of code, practice or procedure 1.5 Inadequate assessment of risk 1.6 Not implemented Job Factors 2. Tools and Equipment 2.1 Inadequate availability 2.2 Defective 2.3 Inadequate maintenance 2.4 Inadequate inspection 2.5 Tool used incorrectly 2.6 Inadequate assessment of tools for task 3. Design 3.1 Inadequate hazard assessment 3.2 Inadequate design specification 3.3 Design process not followed 3.4 Inadequate assessment of ergonomic impact 3.5 Inadequate assessment of operational capabilities 3.6 Inadequate programming 4. Planning 4.1 Inadequate work planning 4.2 Inadequate management of change 4.3 Conflicting planning 4.4 Inadequate assessment of needs & risks 4.5 Inadequate documentation 7. Capabilities 7.1 Limited physical capabilities (height, strength, size, weight, reach, etc.) 7.2 Sensitivity to sensory extremes (sight, sound, sense of smell, balance, touch) 7.3 Substance sensitivities / allergies Personal Factors Systemic / Management Factors 5. Communication 5.1 Unclear roles, responsibilities, and accountabilities 5. 2 Lack of communications 5.3 Inadequate direction/information 5.4 Misunderstood communications 8. Judgment 8.1 Preoccupied and unable to address recognized hazard 8.2 Conflicting demands/priorities 8.3 Emotional stress 8.4 Fatigue 8.5 Criminal intent 8.6 Extreme judgment demands 8.7 Substance abuse 6. Knowledge/Skill 6.1 Inadequate training/orientation 6.2 Training need not identified 6.3 Lack of coaching 6.4 Failure to recognize hazard 6.5 Inadequate assessment of needs & risks Natural Factors 9. Natural Factors 9.1 Fires 9.2 Flood 9.3 Extreme weather 9.4 Other Cause Analysis: Cause (i.e. 2.2) Cause Explanation (i.e. Steering axle had metallurgical flaw) 19 of 21
Appendix 3 IMP Forms Interim Action Plan: (Immediate action taken to control the incident scene) Action Taken Accountability Corrective Action Plan: (Long term action taken to control the incident scene) Action Planned or Taken Accountability Target Date (yyyy/mm/dd) Complete Date (yyyy/mm/dd) Incident Sign Off: (Report must se signed off by all listed personnel prior to closure in accordance with the Incident Classification & Notification Guide) OS Supervisor: Print: Date: Manager: Print: Date: Safety Coordinator: Print: Date: Incident Review: (Report must be reviewed as per OHS Regulations) Local OHC Member: Print: Date: For Critical Incidents Only: Executive: Print: Date: President: Print: Date: Chief Safety Officer: Print: Date: Attachments: (Identify and explain attachments) Detailed Report Description: Photos Description: Diagrams Description: Other Explain: 20 of 21
Appendix 4 IMP Communication Guide Means of Communication Minor Incident Significant Incident Major Incident Critical Incident Verbal Notification X X X X Formal Report (SafetyNet Incident Reporting) X X X X Data Reporting / Trending (SafetyNet) X X X X Incident Bulletins As Necessary As Necessary X X Postings to Safety Bulletin Boards (Sanitized Versions) X X X Local Safety Meetings X X X Safety Committee Reviews (Safety Council, Safety Network, Safety Summit) X X Executive Meetings X X NOTE: It is critical that incidents and investigation results be effectively communicated. This flowchart is a guide to communication methods for each incident type. Additional communication may be required. 21 of 21