ACCIDENT INVESTIGATION

1. ACCIDENT INVESTIGATION

2. What Is An Incident? Unplanned and unwanted event which disrupts the work process and has the potential of resulting in injury, harm, or damage to persons or property. An incident disrupts the work process, does not result in injury or damage, but should be looked as a “wake up call”. It can be thought of as the first of a series of events which could lead to a situation in which harm or damage occurs. Employers should investigate an incident to determine the root cause and use the information to stop process and behaviors that could just as easily have resulted in an accident. Example of an incident:: A 50 lb carton falls off the top shelf of a 12’ high rack and lands near a worker. This event is unplanned, unwanted, and has the potential for injury.

3. What Is An Accident? Unplanned, unwanted, but controllable event which disrupts the work process and causes injury to people. Most everyone would agree that an accident is unplanned and unwanted. The idea that an accident is controllable might be a new concept. An accident stops the normal course of events and causes property damage, or personal injury, minor or serious and occasionally results in a fatality.

4. What Is An Accident? • An accident is not “just one of those things”. • Accidents are predictable and preventable events. • They don’t have to happen. Most workplace injuries and illness are not due to “accidents”. The term accident is defined as an unexpected or unintentional event, that it was “just bad luck”. More often than not it is a predictable or foreseeable “eventuality”. By “accidents” we mean events where employees are killed, injured, or become ill from exposure to toxic chemicals or microorganisms (TB, Hepatitis, HIV, etc). A systematic plan and follow through of investigating incidents or disasters and altering behaviors can help stop a future accident. Let’s take the 50 lb carton falling 12’, for the 2nd time, only this time it hits a worker, causing injury. Predictable? Yes. Preventable? Yes. Investigating why the carton fell will usually lead to solution to prevent it from falling in the future.

5. “The Tip of the Iceberg” Accidents Accidents or injuries are the tip of the iceberg of hazards Investigate incidents since they are potential “accidents in progress” Incidents Don’t just investigate accidents. Incidents should also be reported and investigated. Criteria for investigating an incident: What is reasonably the worst outcome, equipment damage, or injury to the worker? What might the severity of the worst outcome have been? If it would have resulted in significant property loss or a serious injury, then the incident should be investigated with the same thoroughness as an actual accident investigation. The 50 pound carton falls off the top shelf of a 12’ high rack and lands near a worker. The outcome of an investigation might include correction of sloppy storage at several locations in the warehouse, unstable/heavy items will be stored at floor level if possible, refresher training of stockers on proper methods is done, supervisor begins doing daily checks.

6. What is an “Accident”? By dictionary definition: “an unforeseen event”, “.chance..”, “unexpected happening..”, • From experience and analysis: they are “caused occurrences” • Predictable - the logical outcome of hazards • Preventable and avoidable - hazards do not have to exist. They are caused by things people do -- or fail to do. Fatalities Severe Injuries Minor injuries Close calls Hazardous conditions

7. Why Investigate? • Prevent future incidents (leading to accidents). • Identify and eliminate hazards. • Expose deficiencies in process and/or equipment. • You lose money when regular work stops. • Maintain worker morale. • The rule requires you to investigate serious accidents.

8. How To Investigate • Develop a plan • The time to develop your company’s Accident Investigation Plan is before you have an • incident or an accident. The who, when, where, what and how should be developed • before the incident. • Accident Investigation Training, investigation tools and policies and procedures should be • developed before the incident or accident.

9. How To Investigate • Assemble an investigation kit • Investigate all incidents and accidents immediately • Collect facts It is important to begin your investigation immediately. Evidence disappears, the 50 lb carton of material was cleaned up and memory fades…the employee was not encouraged to report the near-miss incident and forgot about the whole thing. When investigating incidents or accidents be thorough in your capture of all available facts. You might discover that many other items were also improperly stored and that when employees were questioned there had been several other “near misses”

10. How To Investigate • Interview witnesses Interview witnesses and victims in a timely manner. LISTEN Don’t blame, don’t point out poor judgment, be sympathetic…LISTEN If you know for a fact that someone broke a rule it is not important to point that out to them at this time. Verify with them the training they have received and ask them if they know what happened to cause the accident. Again, it doesn’t do anyone any good at this stage to be told ”it was your fault” or “you knew better” As an investigator, you will often come to the conclusion that someone engaged in an unsafe act. It is most important to determine why they engaged in an unsafe act as well as verify that they did or did not know better.

11. How To Investigate • Write a report • The report should include: • An accurate narrative of “what happened” • Clear description of unsafe ACT or CONDITION • Recommended immediate corrective action • Recommended long-term corrective action • Recommended follow up to assure fix is in place • Recommended review to assure correction is effective.

12. Tips for Developing A Plan • Develop your action plan ahead of time. • Your plan might include: • Who to notify in the workplace? • How to notify outside agencies? • Who will conduct the internal investigation? Preplanning will help you address situations timely, reducing the chance for evidence to be lost and witnesses to forget. All procedures, forms, notifications, etc. need to be listed out as step-by-step procedures. You might wish to develop a flow chart to quickly show the major components of program.

13. Develop a Plan Tips (continued) • What level of training is needed? • Who receives report? • Who decides what corrections will be taken and when? • Who writes report and performs follow up? • Some expansion questions on the above points are: • Who will be trained to investigate? • Who is responsible for the finished report and what is the time frame? • Who receives copies of the report? • Who determines which of the recommendations will be implemented? • Who is responsible for implementing the recommendations? • Who goes back and assures that fixes are in place? • Who assures that fixes are effective?

14. What Should Be In The “Investigation Kit” Camera equipment First aid kit Tape recorder Gloves Tape measure Large envelopes High visibility tape Report forms Scissors Graph paper Scotch tape Sample containers with labels Personal protective equipment These are some common items for a kit. What else might be useful? Anything for specific business or workplace that might be needed?

15. Investigate All Incidents/Accidents • Conduct and document an investigation that answers: • Who was present? • What activities were occurring? • What happened? • Where and what time? • Why did it happen? Root causes should be determined. Example: An employee gets cut. What is the cause? It is not just the saw or knife or the sharp nail. Was it a broken tool and no one reported? Did someone ignore a hazard because of lack of training, or a policy that discourages reporting? What are other examples of root causes? Enforcement failure, defective PPE, horseplay, no recognition plan, inadequate labeling.

16. Investigate All Incidents/Accidents • Also answer: • Is this a company or industry-recognized hazard? • Has the company taken previous action to control this hazard? • What are those actions? • Is this a training issue?

17. Begin Investigations Immediately • It’s important to collect evidence and interview witnesses as soon as possible because evidence will disappear and people will forget.

18. How Do You Investigate? • Notify individuals according to your “plan” • You must involve an employee representative, the immediate supervisor, and other people with knowledge • Grab your “investigation kit” • Approach the scene

19. Actions At The Accident Scene • Check for danger • Help the injured • Secure the scene • Identify and separate witnesses • Gather the facts • First, make sure you and others don’t become victims! Always check for still- • present dangerous situations. Then, help the injured as necessary. • Secure the scene and initiate chains of custody for physical evidence. • Identify witnesses and physical evidence. Separate witnesses from one another • If physical evidence is stabilized, then begin as quickly as possible with interviews. • REMEMBER, BE A GOOD LISTENER

20. Fact Finding • Witnesses and physical evidence • Employees/other witnesses • Position of tools and equipment • Equipment operation record, charts, • Equipment identification numbers

21. Fact Finding • Take notes on environmental conditions, air quality • Take samples • Note housekeeping and general working environment • Note floor or surface condition • Take many pictures • Draw the scene Some scenes are more delicate then others. If items of physical evidence are time sensitive address those first. If items of evidence are numerous then you may need additional assistance. Some scenes will return to normal very quickly. Are you prepared to be able to recreate the scene from your documentation? Consider creating a photo log. The plot should describe the date, time, give a description of what is captured in the photo and directionality. Link to sketch of accident scene.

22. Interview Witnesses • LISTEN • Don’t blame, just get facts • Talk to witnesses as equals • Keep conversations informal

23. Interview Witnesses • Choose a private place to talk • Ask open ended questions • Interview promptly after the incident • Ask some questions you know the answers to Your method and outcome of interview should include: who is to be interviewed first; who is credible; who can corroborate information you know is accurate; how to determine the truth bases on a limitation of numbers of witnesses. Be respectful, are you the best person to conduct the interview? If the issue is highly technical consider a specialist, this may be an internal resource or it may be an outside resource.

24. Write The Report • How and why did the accident happen? • A list of suspected causes and human actions • Use information gathered from sketches, photographs, physical evidence, witness statements Remember that your report needs to be based on facts. All recommendations should be based on accurate documented findings of facts and all findings and recommendations should be from verifiable sources.

25. Write The Report Answer the following in the report: • When and where did the accident happen? • What was the sequence of events? • Who was involved? • What injuries occurred or what equipment was damaged? • How were the employees injured?

26. Report Conclusions • What should happen to prevent future accidents? • What resources are needed? • Who is responsible for making changes? • Who will follow up and insure implementation of corrections? • What will be future long-term procedures? Conclusions must always be based upon facts found during your investigation. If additional resources are needed during the implementation of recommendations then provide options. Having a comprehensive plan in place will allow for the success of your investigation. Success of an investigation is the implementation of viable corrections and their ongoing use.

27. Report A Death or Hospitalization (Catastrophe) • Report the death, probable death, or the in-patient hospitalization of 2 or more employees within 8 hours. The required information that must be provided 1- Name of the work place 2- Location of the incident 3- Time and date of the incident 4- Number of fatalities or hospitalized employees 5- Contact person 6- Phone number 7- Brief description of the incident

28. The ultimate purpose of incident investigation and analysis activities is to prevent future incidents. As such, the investigation or analysis must produce factual information leading to corrective actions that prevent or reduce the number of incidents. • The more complete the information, the easier it will be for management to take effective corrective actions. All incidents should be investigated, regardless of severity of injury or amount of property damage.

29. The minimum data set that investigators should record includes the following: • If data will be used to compare one company with another, record data about employer characteristics. This includes the type of industry and the size of the company (number of full-time equivalent employees). • Record employee characteristics. The victim's age and sex, the department and occupation in which he or she worked, and whether a full-time, part-time, or seasonal employee. Questions about the victim's experience are also asked. • How long has the victim been with the company? • How long in current occupation? • How often had the employee repeated the activity engaged in when the incident occurred? Employee training records may be examined and assessed during this part of the investigation. • Record the characteristics of the injury. Describe exactly the injury or injuries and the part or parts of the body affected by the incident.

30. Prepare a narrative description and accident sequence that provides the exact location of the incident (attach any maps or diagrams to the report); • a complete, specific breakdown of the sequence of events leading to the injury or near-miss; • what objects or substances were involved in the incident; • conditions such as temperature, light, noise, and weather pertaining to the incident; • whether any preventive measures had been in place; and • The investigators should include only the facts obtained during the investigation; they should not record opinions or place blame. • Record the characteristics of the equipment associated with the incident. These data should be incorporated into the narrative description on the report form. Include the type, brand, size, and any distinguishing features of the equipment, its condition, and the specific part involved. • Record the characteristics of the task being performed when the incident happened: the general task (such as repairing a conveyor) and the specific activity (such as using a wrench).

31. Record the time factors. The investigation should record the time of day and whether it was the victim's first hour of the shift, second hour, or later. • Record the task and activity factors. First, describe the general type of task the employee was performing at the time the injury occurred. Second, record the specific activity in which the employee was engaged. • Record supervision information. Indicate in the appropriate place on the form whether the employee was being supervised directly, indirectly, or not at all at the time of the incident. • Record the causal factors. Record the events and conditions that contributed to the incident. Be as specific and complete as possible. • Describe the corrective actions taken immediately after the incident to prevent a recurrence, including temporary actions.

32. ESTIMATING INCIDENT COSTS • Although most executives want to make their company a safe place to work, they also have a responsibility to run their business profitably. Definition of Work Incidents for Cost Analysis • Work incidents, for the purpose of cost analysis, are unintended occurrences arising in the work environment. These incidents fall into two general categories: (1) incidents resulting in work injuries or illnesses (2) incidents causing property damage or interfering with production. Method for Estimating • To be of maximum usefulness, cost figures should represent as accurately as possible the specific experience of the company. • Estimated costs of incidents in general do not take into account differences in hazards from one industry to another. • Because of the differences between direct and indirect costs are difficult to maintain, instead they use more precise terms "insured" and "uninsured" costs. Using these data, a company can estimate its incident cost with reasonable accuracy.

33. Insured Costs • Every organization paying compensation insurance premiums recognizes such expense as part of the cost of incidents. In some cases, medical expenses too, may be covered by insurance. These costs are definite and known. They include the insured element of the total incident cost. • In addition to these costs, many other costs arise in connection with incidents. • Although the expense of damaged equipment is easily identified, others, such as wages paid to the injured employee for downtime on the day of the injury, are hidden. These items include the uninsured element of the total incident cost. Uninsured Costs • While insured costs can be determined easily from accounting records, uninsured (also called "indirect") costs are more difficult to assess. The method described here is one way to calculate these added expenses associated with many incidents.

34. The first step is to conduct a pilot study • Determine approximate averages of uninsured costs for each of the following four classes of incidents: 1. Class 1-Cases involving lost workdays • days away from work or days of restricted work activity 2.Class 2-Medical treatment cases • requiring the attention of a physician outside the facility 3.Class 3-Medical treatment cases requiring only first aid • local dispensary treatment and resulting in property damage of less than $100 or loss of less than eight hours in work time 4.Class 4-Incidents that either cause no injury or cause minor injury, not • requiring the attention of a physician, and that result in property damage of $100 or more, or loss of eight or more employee-hours. • Once average costs have been established for each incident class, they can be used as multipliers to obtain total uninsured costs in subsequent periods. These costs are then added to known insurance premium costs to determine the total cost of incidents.

35. Example of a Cost Estimate • An estimate of costs made by one company is given in the following example. First, a pilot study was conducted to obtain the average cost of each class of incident. • Included in the study were 20 Class 1 incidents, 30 Class 2 incidents,50 Class 3 incidents, and 20 Class 4 incidents. Costs were determined and averages developed in Table 7-A. • During the entire year, the company had 34 Class 1 incidents, 148 Class 2 incidents, and 4,000 Class 3 incidents. No record was kept of the Class 4 incidents after the pilot study was completed. Instead, the ratio of the number of Class 4 to Class 1 incidents found in the pilot study was used. • This ratio was shown to be about 1 to 1, and since there were 34 Class 1 incidents during the year, it was assumed there were about 34 Class 4 incidents. (A separate record could be kept of the number of Class 4 incidents.)

36. TABLE 7-A Average Cost Determined by Pilot Study ___________________________________________________ Class of Number of Average of Accidents Accident Reported Uninsured cost ______________________________________________ Class 1 20 $251.10 Class 2 30 80.80 Class 3 50 15.70 Class 4 20 507.10 • The average cost for each incident class was applied to these totals to secure the results shown in Table 7-B. • The estimate should be rounded to three significant digits-in this case, to the nearest thousand dollars. As a result, in this instance, the analyst reported to the plant manager, "During the past year, incidents cost this company about $155,000 in compensation, medical expense, lost time, and property damage." • The average costs determined in this pilot study represent the actual experience of this particular organization.

37. Table 7-B. Estimate of Yearly Accident Costs ________________________________________________________ Average Cost Total Class of Number of per Accident Uninsured Accident Accidents (from pilot study) Cost ________________________________________________________ Class 1 34 $251.10 $ 8,537.40 Class 2 148 80.80 11,958.40 Class 3 4,000 15.70 62,800.00 Class 4 34 507.10 17,241.40 Total Uninsured Cost $100,537.20 Insurance Premiums 54,400.00 Total Accident Cost for the Period $154,937.20

38. Items of Uninsured Cost • Important to a pilot study is a careful investigation of each incident to determine all the costs arising out of it. • The following items of uninsured or indirect costs are clearly the result of work incidents and are subject to reasonably reliable measurement. 1. Cost of Wages Paid for Time Lost by Workers Who were not Injured. • These are employees who stopped work to watch or assist after the incident or who lost time because they needed the equipment damaged in the incident or because they needed the output or the aid of the injured worker. 2.Nature and Cost of Damage to Material or Equipment. • The validity of property damage as a cost can hardly be questioned. Occasionally, there is no property damage, but a substantial cost is incurred in reorganizing material or equipment. 3.Cost of Wages Paid for Time Lost by the Injured Worker, other than Workers' Compensation Payments. • Payments made under workers' compensation laws for time lost after the waiting period are not included in this element of cost. 4.Extra Cost of Overtime Work Necessitated by the Incident. • The charge against an incident for overtime work is the difference between normal wages and overtime wages for the time needed to make up lost production, and the cost of extra supervision, and other extra services.

39. 5.Cost of Wages Paid to Supervisors for Time Spent on Activities Concerning the Incident. The most satisfactory way of estimating this cost is to charge the wages paid to the supervisor for the time spent away from normal activities as a result of the incident. 6.Wage Cost Caused by Decreased Output of Injured Worker after Return toWork. If the injured worker's previous wage payments are continued despite a 40% reduction in output, the incident should be charged with 40% of the worker's wages during the period of low output. 7. Cost of Learning Period of New Worker. If a replacement worker produces only half as much in the first two weeks as the injured worker would have produced in the same time for the same pay, then half of the new worker's wages for the two weeks' period should be considered part of the cost of the incident. 8.Uninsured Medical Cost Borne by the Company. This cost is usually that of medical services provided at the plant dispensary. There is no great difficulty in estimating an average cost per visit for this medical attention. 9.Cost of Time Spent by Management and Clerical Workers on Investigations or in the Processing of Compensation Application Forms. Time spent by management or supervision and by clerical employees in investigating an incident, or settling claims arising from it, is chargeable to the incident. 10.Miscellaneous Costs. Among such possible costs are public liability claims, equipment rental, losses due to cancelled contracts or lost orders if the incident causes an overall reduction in total sales, loss of company bonuses, cost of hiring new employees if this expense is significant, cost of above-normal spoilage by new employees.

40. Conducting a Pilot Study • The purpose of the pilot study is to develop average uninsured costs for different classes of incidents that can be applied to future incident totals. • Therefore, it is desirable not to include the costs of deaths and permanent total disabilities. Such incidents occur so seldom that the costs should be calculated individually and not estimated on the basis of averages. OFF - THE - JOB DISABLING INJURY COST • When incidents take place off the job, a major portion of the costs are borne by employers. Some of the costs are obvious, such as insurance premiums and wages paid to absent employees. • Some of the costs are hidden, such as training for new or transferred workers and medical staff time demanded for workers returning to work after an incident. • For example, a new worker does not produce at the same level as an experienced worker; thus, the decreased productivity of the new worker indirectly increases the manufacturing overhead.

41. Categorizing OTJ Disabling Injury Cost • The cost of off the job disabling injuries (O T J DI) to an organization falls into the following two categories: insured and uninsured. • Most uninsured costs are hidden. Aside from wage costs, most organizations do not keep records of uninsured costs. However, these costs are associated with all O T J D I incidents and, therefore, affect profit margins. • InsuredCosts – worker productivity cost, product loss, and equipment damage. –directly associated with the employee who sustained the O T J D I injury are included in this expense subcategory. • UninsuredCosts – worker productivity cost, product loss, equipment damage, and administrative cost. – incurred by personnel other than the employee who sustained the OTJ DI injury are included in this sub­category. • Miscellaneous costs –This subcategory includes loss of profit for cancelled contracts or orders and the costs of demurrage (compensation), telephone calls, transportation, or other miscellaneous expenses.

42. Estimating O T J D Costs • Some experts say the ratio of insured cost to uninsured cost is 3:2. In order to estimate a company's losses from employee OTJ D I s, management must first determine the insured cost. • Next, using the 3:2 factor, it must rise the insured cost to determine the total (insured and uninsured) employee costs. The insured cost for injuries to dependents of employees is then added to the total employee cost to determine total losses. The following examples illustrate calculation procedures.

43. Example 1 • Company A is insured by an outside carrier. Twenty percent or $225,000 of its annual premium charge was required to pay for its previous calendar year OTJ DI incident experience. Of that total, $75,000 was required for 11 employee injuries and the remaining $150,000 was required for 22 employee-dependent injuries. These figures include the administrative fee paid by the company to the carrier. • The total cost for employee-dependent injuries is a conservative figure, since it does not include the administrative cost incurred by the company's insurance office staff to process claims. If this cost is known, it should be added to the employee – dependent injury expense category. • When the $75,000 insured cost category is escalated to include the uninsured cost category, the total expense for employee injuries becomes $125,000. Company A Estimated OTJ DI Costs Insured cost for employee injuries = $75,000 Uninsured cost for employee injuries = 50,000 Insured cost for Employee – dependent injuries = 150,000 Total annual estimated OTJ DI cost = $275,000

44. Example 2 • Company B is insured by an outside carrier. Its carrier stated that $850,000 was paid for 138 employee injuries and $1,800,000 was paid for 279 employee-dependent injuries for its previous calendar year OTJ DI incident experience. • Their administrative fee to the carrier was 6% of the total cost, resulting in a cost of approximately $900,000 for employee injuries and $1,900,000 for employee – dependent injuries. If the cost for insurance office staff claim-processing is known, it should be added to the total employee-dependent cost. • Escalation of the insured cost category for employee injuries include the uninsured cost category indicated a total of $1,500,000. Company B Estimated OTJ DI Costs Insured cost for employee injuries = $900,000 Uninsured cost for employee injuries = 600,000 Insured cost for employee-dependent injuries = 1,900,000 Total annual estimated OTJ DI cost = $ 3,400,000

45. Example 3 • Company C is self-insured. Insurance office records indicated that for the previous calendar year, OTJ DI incident experience for the amount of medical and health claims paid for 350 employee injuries was $2,280,000, and $4,700,000 was paid for 690 employee-dependent injuries. • Insurance office staff administrative costs for claim processing should be added to the employee – dependent cost category if that cost is known. • Thus, $2,280,000 escalated to include the uninsured cost category for employee injuries resulted in a total cost of approximately $3,800,000. Company C Estimated OTJ DI Costs Insured cost for employee injuries = $2,280,000 Uninsured cost for employee injuries = 1,520,000 Insured cost for employee-dependent injuries = 4,700,000 Total annual estimated OTJ DI cost = $ 8,500,000

46. Measuring the Effects of OTJ Safety Programs • Calculations of average costs are useful tools to support initiating or accelerating off the job safety awareness programs. The calculations also can be used to measure the effects of safety programs. • For example, 350 employees of Company C experienced OTJ injuries during the previous year for a total of approximately $3,800,000 and an average cost per incident of approximately $10,860. • Based upon the OTJ DI loss experience, top management allocated $50,000 from the budget to initiate a safety awareness program. • At the end of the year, the $10,860 average cost figure will be escalated to adjust for inflation and, in turn, the new figure will be used to calculate losses. • For illustration purposes, it is assumed that the new average cost per incident figure is $11,500 and that employee injuries were reduced from 350 to 300. • Calculations (300 x $11,500) indicate losses of $3,450,000, a savings of approximately $350,000 from last year's total. The estimated net return is $300,000, which is a 600% return on investment. • To further support justification for operating funds, safety personnel can add savings realized from reduced employee-dependent injuries to the employee savings total. • This type of analysis provides a management tool to evaluate the impact of off-the-job disabling injuries on profit margins; thus, it can be used to gain management commitment to support operating budgets for safety awareness programs.