Trindel Insurance FundTrindel Insurance Fund

Serious Incident Serious Incident Reporting, Investigation and Reporting, Investigation and

Follow-upFollow-up

Presented by: Gene HerndonDirector of Loss Prevention Programs

Trindel Insurance Fund, JPAwww.trindel.org , tifso@trindel.org

Office: (530) 894-2027, Cell: (530) 521-8291

Now What?Now What?

Potential Consequences Potential Consequences of a Serious Incident:of a Serious Incident:

Serious InjurySerious Injury

or or

Loss of life!Loss of life!

Other less important Other less important consequences:consequences:

Property & Liability LossProperty & Liability Loss Cal/OSHA Citation(s)Cal/OSHA Citation(s) Serious and Willful PenaltiesSerious and Willful Penalties Criminal LiabilityCriminal Liability Civil LiabilityCivil Liability

Serious Incident Serious Incident ResponseResponse

ReportingReportingInvestigationInvestigationFollow-upFollow-up

The purpose:The purpose:

Prevent a re-Prevent a re-occurrence!occurrence!

What is a serious What is a serious incidentincident? Any occurrence resulting in, Any occurrence resulting in, or having the or having the

potentialpotential for for … … “ “… … injury or illness, occurring in a place of injury or illness, occurring in a place of

employment or in connection with any employment or in connection with any employment, which requires inpatient employment, which requires inpatient hospitalization for a period in excess of 24 hours hospitalization for a period in excess of 24 hours for other than medical observation or in which for other than medical observation or in which an employee suffers a loss of any member of the an employee suffers a loss of any member of the body or suffers any serious degree of permanent body or suffers any serious degree of permanent disfigurement…”disfigurement…”

Cal/OSHA Cal/OSHA ReportableReportable“Serious Injury”“Serious Injury”

HHospitalization for more than 24 ospitalization for more than 24 hours for other than hours for other than observation.observation.

AAmputationmputation DDisfigurementisfigurement DDismembermentismemberment DDeatheath

Must reportMust report to Cal/OSHA to Cal/OSHA within 8 hourswithin 8 hours from from knowledge!!knowledge!!

Serious Incident Serious Incident ReportingReporting

Do it Now!!Do it Now!!

Reporting:Reporting:

Remove themselves from Remove themselves from immediate danger.immediate danger.

Call 911 for medical assistance Call 911 for medical assistance if needed.if needed.

Provide first aid for injured.Provide first aid for injured.

Reporting:Reporting: Immediately notify:Immediately notify:

immediate supervisor.immediate supervisor. designated county safety officer .designated county safety officer . department safety department safety

representative.representative. Remain at the scene (unless injured) Remain at the scene (unless injured)

until released by S.I.I.T. leader.until released by S.I.I.T. leader. Do not disturb incident scene Do not disturb incident scene (except (except

to prevent further injury or damage or if to prevent further injury or damage or if ordered to do so by law enforcement ordered to do so by law enforcement authorities).authorities).

(S.I.I.T.) -(S.I.I.T.) - Serious Incident Serious Incident Investigation TeamInvestigation Team

Designated County Safety Officer – Designated County Safety Officer – Team Leader.Team Leader.

The immediate supervisor of the The immediate supervisor of the employee(s) involved.employee(s) involved.

The designated department safety The designated department safety representative (DSR) from the representative (DSR) from the department involved.department involved.

Any other individuals necessary for Any other individuals necessary for a thorough and objective a thorough and objective investigation.investigation.

Serious Incident Serious Incident InvestigationInvestigation

Facts that lead to cause Facts that lead to cause not blamenot blame!!!!

The investigation:The investigation:

Don’t pre-judge.Don’t pre-judge. Gather facts.Gather facts. Look for cause not fault.Look for cause not fault. Don’t draw conclusions Don’t draw conclusions

before gathering before gathering allall the the facts.facts.

The investigation – The investigation – Arriving at the scene.Arriving at the scene.

The S.I.I.T. leader usually in The S.I.I.T. leader usually in charge.charge.

Check on welfare of all Check on welfare of all involved including witnesses.involved including witnesses.

Let all know that your purpose Let all know that your purpose is not to place blame but is not to place blame but gather facts to prevent a re-gather facts to prevent a re-occuranceoccurance..

The investigation – The investigation – The interviewThe interview

Have involved employees and Have involved employees and witnesses make a written witnesses make a written description of events.description of events.

Include events leading to Include events leading to incident, the incident itself and incident, the incident itself and events following the event.events following the event.

The investigation – The investigation – The interviewThe interview

Tell them not to worry about Tell them not to worry about penmanship, grammer or penmanship, grammer or spelling. spelling.

Encourage drawings. Encourage drawings. This a good way to separate all This a good way to separate all

involved.involved.

The investigation – The investigation – The face to face The face to face

interview.interview. Find a comfortable quiet place.Find a comfortable quiet place. Once again inquire about their Once again inquire about their

welfare.welfare. Ask them to describe what Ask them to describe what

happened.happened. Listen and take notes.Listen and take notes.

Don’t interrupt with questions.Don’t interrupt with questions. Note you questions for later.Note you questions for later.

The investigation – The investigation – The face to face interviewThe face to face interview

When they are finished tell them what When they are finished tell them what you heard.you heard.

When you are in agreement ask your When you are in agreement ask your questions. questions.

Always ask open-ended questions. Ones Always ask open-ended questions. Ones that don’t have a yes or no answer.that don’t have a yes or no answer.

Always ask, “How could this have been Always ask, “How could this have been prevented?”.prevented?”.

The investigation – The investigation – Face to face interviewFace to face interview

Conclude by asking if there is Conclude by asking if there is anything else they want to addanything else they want to add

Depending on the situation be Depending on the situation be sure to offer up the EAP sure to offer up the EAP program for follow-upprogram for follow-up

Thank them and tell them they Thank them and tell them they can call you if they think of can call you if they think of anything else.anything else.

The investigation – The investigation – The face to faceThe face to face

Final thoughts:Final thoughts: You will hear a few facts and You will hear a few facts and

a lot of opinion.a lot of opinion. You are looking for facts but You are looking for facts but

opinion has value too.opinion has value too. Don’t rush the interview.Don’t rush the interview. Give time to vent .Give time to vent . Don’t ask leading questions.Don’t ask leading questions.

The investigation - The investigation - At the SceneAt the Scene

Do not disturb the scene.Do not disturb the scene. Take time to walk around and Take time to walk around and

observe. conditions and observe. conditions and environment.environment.

Note day and time of incident.Note day and time of incident. Note weather conditions.Note weather conditions.

The investigation - The investigation - Pictures of the Incident Pictures of the Incident

SceneScene Take photos from front, sides, Take photos from front, sides,

above, and rear.above, and rear. Capture details: data plate, Capture details: data plate,

serial number, model number, serial number, model number, manufacturer.manufacturer.

Use digital still camera.Use digital still camera. Keep photo log.Keep photo log.

The investigation - The investigation - Drawings and diagramsDrawings and diagrams

Draw picture of accident scene.Draw picture of accident scene. Label all key parts.Label all key parts. Show distances.Show distances. Keep details.Keep details. Use notes.Use notes.

The investigation – The investigation – Policy, procedures, training Policy, procedures, training

& supervision& supervision

All of the following reviews are done All of the following reviews are done after allafter all personnel interviews and personnel interviews and incident site investigations are incident site investigations are completed.completed. Review Dept. Code of Safe Review Dept. Code of Safe

Practices relative to incident .Practices relative to incident . Review employee safety training Review employee safety training

records relative to incident.records relative to incident. Review past safety meetings Review past safety meetings

relative to incident.relative to incident.

The investigation – The investigation – Policy, procedures, training Policy, procedures, training

& supervision& supervision

Review CWIIPP for relative to Review CWIIPP for relative to incident.incident.

Review County Policy Review County Policy relative to incident.relative to incident.

Review Cal OSHA regulations Review Cal OSHA regulations relative to incident.relative to incident.

The Investigation –The Investigation –Writing serious incident Writing serious incident

reportreport

Use facts to write the narrative.Use facts to write the narrative. Make findings that are Make findings that are definitedefinite, ,

suspectedsuspected, and , and found but not found but not contributingcontributing..

Make recommendations for all Make recommendations for all findings.findings.

The Serious Incident The Serious Incident Investigation Report Has Investigation Report Has 3 3

Parts:Parts:

1. The Narrative1. The Narrative

2. The Findings2. The Findings

3. The Recommendation3. The Recommendation

The “Narrative”

Is a word picture that tells the Is a word picture that tells the reader exactly what happen.reader exactly what happen.

Includes all facts taken from Includes all facts taken from witness statements.witness statements.

Includes technical information Includes technical information obtained from the accident obtained from the accident investigation.investigation.

Does Does notnot speculate. speculate.

The “Findings”

Identifies the cause(s) of the Identifies the cause(s) of the accident.accident.

Can be grouped in 3 categories: Can be grouped in 3 categories: Man, Machine, and Environment.Man, Machine, and Environment.

Can be Can be definitedefinite, , suspectedsuspected, , and/or and/or found but not contributingfound but not contributing based on the fact pattern.based on the fact pattern.

The “Recommendations”

Are linked to each finding.Are linked to each finding. Indicate the corrective action Indicate the corrective action

needed to prevent future needed to prevent future accidents.accidents.

Makes top management aware Makes top management aware of the problems and solutions.of the problems and solutions.

Creates a “paper trail”.Creates a “paper trail”.

Serious Incident Follow - Serious Incident Follow - upup

If you don’t like what If you don’t like what happened…happened…

Change what you’re doing!Change what you’re doing!

Serious Incident Serious Incident Follow - upFollow - up

Communicate to all employeesCommunicate to all employees Conduct employee safety Conduct employee safety

meetings related to incidentmeetings related to incident Assemble suggestions for Assemble suggestions for

remediating cause of incidentremediating cause of incident

Serious Incident Serious Incident Follow - upFollow - up

Modify the department code of Modify the department code of safe practices.safe practices.

Train all employees on the Train all employees on the changes.changes.

Ensure supervisors implement Ensure supervisors implement changes.changes.