a i investigations 1

ACCIDENT/INCIDENT

INVESTIGATIONS

ACCID

EN

T/INCID

EN

TIN

VESTIG

ATIO

NS

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, 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,

PURPOSE OF THIS GUIDE

Sources of InformationWorkplace Health, Safety and

Compensation Commission

Prevention Services

Department of Government Services

Occupational Health and Safety Branch

Human Resources and Social

Development

Labour Program, Newfoundland and

Labrador office

Phone: (709) 778-1552

Toll free 1 800 563-9000

or

Phone: (709) 729-2706

Toll free 1-800-563-5471

or

Phone: (709) 772-5022

(call collect outside St. John’s)

www.safeworknl.com

May 2006

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.

©May, 2006

Legislative RequirementsThe 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 for occupational health

and safety:

Occupational Health and Safety Regulations

For official copies of the and the Occupational Health and Safety Regulations please

contact the following:

Unofficial copies are available on-line at: http://www.gs.gov.nl.ca/ohs/legislation.stm

Some employers fall under and must follow the ( The

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 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.

provincial legislation

Office of the Queen's Printer

Ground Floor

Confederation Building, East Block

St. John's, Newfoundland and Labrador

A1B 4J6

Telephone: (709) 729-3649

federal jurisdiction

persons employed by the public service

Occupational Health and Safety Act


Canada Labour Code-Part II Code). Code

Note: does not apply

Canadian Government Publishing, Communication Canada

Ottawa, ON K1A 0S9

Telephone: (613) 941-5995 or 1-800-635-7943

FAX: (613) 654-5779 or 1-800-565-7757

Internet:

Part II of the to certain undertakings regulated by the

.

For an official copy of the please contact:

Unofficial copies are available on-line at:

Canada Labour Code, Part II Nuclear Safety

and Control Act

Canada Labour Code

http://publications.gc.ca

http://laws.justice.gc.ca/en/l-2/17632.html

Inside this GuideIntroduction

More Information

Accident/Incident Investigations

Planning Accident/IncidentInvestigations

Steps in Accident/IncidentInvestigations

..........................................................1

.................................................2

......................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

.......................................................8

Needs of the Investigation Team ........................8

Materials Needed for the Investigation ..............9

The Investigation Kit ...........................................9

.......................................................9

............................................10

...........................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

Step 1 - Immediate response to theaccident/incident

Step 2 - Gather information

Step 3 - Analyze the information todetermine the root cause

Step 4 - Make recommendations

Step 5 - Write the accident/incidentinvestigation report

Step 6 - Follow-up

.............................14

Contributing Factors ...................................14

Immediate/Direct Cause(s) .........................15

Root/Basic Cause(s) ....................................16

...................17

........................................18

..........................................19

...............................20

............................................21

...........................................................22

.....................................24

........28

........................................35

.......................................................36

...........................................37

Role of OH&S Committees

Accident/Incident Investigations andthe OH&S Program

Conclusion

Appendix A - Glossary

Appendix B - References to Legislation

Appendix C - Hazardous OccurrenceInvestigation Report

Appendix D - Sample Accident/IncidentReport Form

Appendix E - Sample Accident/IncidentInvestigation Form

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 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

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 to monitor

the health, safety and welfare of workers.

For , 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 .

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 .

provincial legislation,

a worker

health and safety (WH&S) representative

a workplace health and safety designate

federally regulated workplaces

health and safety representative

Appendix A – Glossary

1


More Information

Fact Sheets:

For more information on building a health and safety program, there are

several booklets and information resources available in this series.

Look for these fact sheets in the near future:

Booklets:

Look for these booklets in the near future:

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

Communication

Emergency Preparedness

Guide to Writing an Occupational Health & Safety Policy

Occupational Health & Safety Committees

Introduction to an Occupational Health and Safety Program

Workplace Inspections


Communication

Emergency Preparedness

2



Requirements

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.

Specific OH&S requirements for employers who are can

be found in the and Regulations. Requirements

for employers can be found in the

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 “

.”

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;

and Regulations; Mines Safety of Workers Regulations; and

and Regulations. Employers should be aware of

legislation that relates to their industry and specific hazards in their workplaces.

contains details of the following

legislation.

provincially regulated

federally regulated

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.

Appendix B – References to Legislation


Canada Labour Code, Part II

.

Radiation Health and Safety

Act Workplace Health,

Safety and Compensation Act

3


OH&S Act OH&SRegulations

Canada Labour CanadaOH&S SafetyRegulations

Code Part IIWorkplace Health,

Safety andCompensation

Act

Sections Sections Sections Sections Sections4

41 (1)42.1 (1)

54

4(1) (f) (iv)4 (1) (j)

134.1 (1) and (4)(d)

135 (1) and (7)(e)

136 (1)136 (2)

5615.3, 15.4,15.5, 15.6,15.7, 15.8,

15.9

4

Definitions

Reporting and Investigating Accidents/Incidents

An Accident…

An Incident…

An Accident/Incident Investigation…

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 is an unplanned/undesired event that has the to

result in an injury, illness, or property damage.

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.

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 ( , 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 (

, section 56).

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

potential

OH&S Act

Workplace Health,

Safety and Compensation Act

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Federally regulated workplaces


Appendix C – Hazardous Occurrence Investigation Report

have reporting and investigation

requirements in cases of work-related injuries or illnesses. Please refer to

under the heading “Canada

Occupational Health and Safety Regulations” for these requirements.

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.

www.sdc.gc.ca


something is wrong in the workplace. If incidents are investigated

and the root cause found, accidents can be prevented. Please refer to

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.

Appendix D – Sample Accident/Incident Report Form.

Benefits of an Effective Accident/Incident Investigation

Procedures

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.

5


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

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:

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.

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


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.

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.

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.

be trained in investigation techniques including

gathering information

interviewing skills�

Workers Including Managers and Supervisors

OH&S committees

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 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.

trained

The accident/incident investigation team should

Planning Accident/IncidentInvestigations

Needs of the Investigation Team

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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 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.

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.

rarely

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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

8


9

Accident/incident

investigation procedures

should outline a step-by-

step process for carrying

out each of the six steps in

the investigation:


inAccident/IncidentInvestigations

STEPS

The Investigation KitItems usually found in anaccident/Incident investigation kit

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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

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.

CAUTION:

Step 1

Step 2

Step 3

Step 4

Step 5

Step 6

Immediate response to the

accident/incident

Gather information

Analyze the information to

determine the root cause

Make recommendations

Write the accident/incident

investigation report

Follow-up

10

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.


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: .http://www.whscc.nf.ca/form.htm

Immediate responseto the accident/incident

STEP 1

The steps to be taken immediately in case of an accident/incident are:

When an injury occurs in the workplace and a worker requires medical

care, the employer is required to notify the Commission in writing within

three days.

The amount of information gathered and the resources needed depend on the

specific accident/incident.

Note:

1

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,

notify proper authorities – governmental agencies, Workplace Health,

Safety and Compensation Commission (the Commission), etc.

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remove nothing from the site without permission, and

maintain site until all information is collected;

11

Taking Notes

Conducting Interviews

Interview promptly and separately

Interviewing Tips

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.

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.

maintain privacy and put the person at ease;

explain why the interview is being conducted;

emphasize the investigation is for

ask people to explain what happened in their own words;

let people tell what happened – ;

try not to interrupt;

ask specific questions to clarify and fill in the gaps;

repeat what is reported to verify your understanding;

fact finding, not fault finding;

don’t lead the witness


STEP 2

Gather information

Notes should include:

sketches and diagrams; and

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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;

information about evidence gathered.

12

thank people for their co-operation; and

Was this the first time this task was done?

e collector’s name;

write-up a complete account as soon as possible after the interview to

ensure the details are accurate.

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 the work being supervised at the time?

Is there anything else you’d like to

add?

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

keep evidence in a secure place; and

keep a record if evidence is moved.

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the date and time evidence was

collected

the specific location evidence was

found

th

Sample Interview Questions

Suggestions for Collecting Samples


The following tips will

ensure pictures can be used

as evidence:

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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.�

for TakingPictures

forEvidence

13

Reviewing Documentation

Examples of documentation that mayneed to be reviewed

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.

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


14

Contributing Factors

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

Environment

� lighting� noise� air quality� housekeeping practices� weather conditions

STEP 3Analyze the informationto determine the root cause

15


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).

are events, conditions or acts that immediately

precede the accident/incident. Immediate/direct causes are usually the

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.

Immediate/Direct Cause(s)

symptoms

Immediate/Direct Cause(s)

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.

16

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.

17

Once the root cause of the accident/incident is identified, a set of well thought-

out 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.


STEP 4

Make 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.).

18

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.


Write theaccident/incidentinvestigation report

STEP 5

When writing an investigationreport, 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 investigationreport 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:

The report should be distributed to senior management, the OH&S

committee, and the management in the appropriate work areas.

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.

All confidential worker information should be removed

before distribution of the investigation report and before

communicating the investigation findings.

Accident/incident investigation procedures should identify those responsible

for:

All confidential worker information should be removed

before distribution of the investigation report and before

communicating the investigation findings.

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.

19


STEP 6

Follow-up

Role of OH&S CommitteesThe 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:

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.

accident/incident investigations are an effective part of the OH&S

program.

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

20


Accident/Incident Investigations andthe OH&S ProgramAccident/incident investigations are an important part of and are closely linked

to other elements of an OH&S program; for example, they:

21


�

�

�

�

�

�

�

�

demonstrate the employer’s to

preventing injury, illness and property damage by providing

necessary resources to complete accident/incident investigations;

are an important means of

identify

involve the ;

identify items that may need to be added to the

checklist;

improve about OH&S in the workplace;

will need a program in place if the

accident results in an injury or illness; and

may identify a need for review of

equipment and procedures.

leadership and commitment

hazard recognition, evaluation and

control;

OH&S committee

workplace

inspections

communication

good disability management

emergency

preparedness/response

�

�

�

needs,

that need to be

reviewed, revised or developed, and

injury, illness and property damage trends;

education and training

safe work practices and procedures

22


ConclusionUsing 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.

Appendix A

Appendix B

Appendix C

Appendix D

Appendix E

Glossary....................................................24

References to Legislation ..........................28

Hazardous Occurrence InvestigationReport.....................................................35

Sample Accident/IncidentReport Form............................................36

Sample Accident/IncidentInvestigation Form...................................37

Appendices

24

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Appendix A - Glossary

Accident

Basic/root cause

Best practice

Controls

Direct

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

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 [

].

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.

(immediate)

cause

which occur immediately before an accident/

incident; for example, inadequate guards and

barriers, defective tools, and improper lifting. These

are not the “root” cause.

section 2 (f)

OH&S

Act,


25

Formal

Hazard

Informal

Internal

Occupation

OH&S committee

regularly scheduled examinations carried out as a

dangerous object, event, behaviour or condition which

has the potential to cause injury, illness or property

damage.

daily routines used as a means of preventing injury,

a philosophy guiding OH&S legislation in all

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, ].

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 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.

workplace

inspections

Incident (near

miss; potential

accident)

workplace

inspections

responsibility

system

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.

an undesired event that could have resulted in injury,

illness or damage to property, process or environment.

illness and property damage and of ensuring a safe and

healthy workplace; for example, a supervisor’s walk-

through or a worker’s routine equipment check. Informal

inspections are usually not scheduled or documented and

do not require a checklist.

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.

section 2 (f)

OH&S Act

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Procedures (in

Risk

Root/basic cause

Serious accident

Serious injury

Supervisor

step by step way for completing of the OH&S

program components.

section 2 (j)

relation to the

OH&S program)

chance of loss based on:

(a) the of an injury, illness, damage or

loss of property, process or environment; and

(b) the 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

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 [ 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, ].

probability

possible severity

OH&S Act,

OH&S Act,

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Unsafe act

Unsafe condition

Worker

Workplace Health,

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 [

].

an employer-funded no-fault insurance system that

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.

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

[ section 2 (n)]

promotes safe and healthy workplaces, provides return-

to-work programs and offers compensation to injured

workers and their dependants.

Workplace

Safety and

Compensation

Commission

OH&S Act, .


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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.

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Provincial legislation contactinformation:For official copies of the Occupational

Health and Safety Act and the Occupational

Health and Safety Regulations please

contact:

Office of the Queen’s PrinterGround FloorConfederation Building, East BlockSt. John’s, Newfoundland and LabradorA1B 4J6Telephone: (709) 729-3649Unofficial copies are available on-line at:http://www.gs.gov.nl.ca/ohs/legislation.stm

OH&S Act

4. Employers’ general duty

41. Worker representative

An employer shall ensure, where it is reasonably practicable, the health,

safety and welfare of his or her workers.

(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.

Federal legislation contactinformation:For an official copy of the Canada Labour

Code please contact:

Canadian Government Publishing,Communication CanadaOttawa, Ontario K1A 0S9Telephone: (709) 772-5571Bookstores: (613) 954-5779or 1-800-667-2868Fax: (613) 654-5779 or 1-800-565-7757Internet:Unofficial copies are available on-line at:

http://publications.gc.ca

http://laws.justice.gc.ca/en/l-2/17632.html

29

42.1 Workplace designate

54. Reporting accidents

(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.

(1) Where an accident takes place at a workplace

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 fracture of the skull, spine, pelvis, femur, humerus, fibula or tibia, or

radius or ulna;

an amputation of a major part of a hand or foot;

the loss of sight of an 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

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.

(a)

(b)

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

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30

OH&S Regulations

Canada Labour Code, Part II

4. Occupational health and safety program

(1) An occupational health and safety program required under section

36.1 of 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

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,

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

(f)

(j)

the Act

134.1 Policy Health and Safety Committees

Establishment mandatory

Duties of policy committee

135. Work Place Health and Safety Committees

Establishment mandatory

(1)

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)

A policy committee

( ) shall participate to the extent that it considers necessary in

inquiries, investigations, studies and inspections pertaining to

occupational health and safety;

(1)

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.

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31

Duties of committee

136. Health and Safety Representatives

Appointment of health and safety representative

Selection of person to be appointed

(7)

A work place committee, in respect of the work place for which it is

established…

( ) 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…

(1)

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)

The health and safety representative for a work place shall be selected as

follows:

( ) the employees at the work place who do not exercise managerial

functions shall select from among those employees the person to be

appointed; or

( ) 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

e

a

b

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. 1.

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Investigations

Telephone or Telex Reports

15.4

15.5

(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,

( ) appoint a qualified person to carry out an investigation of the

hazardous occurrence;

( ) 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

( ) 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)( ) 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/2002-208, s. 31.

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,

( ) the death of an employee;

( ) a disabling injury to two or more employees;

( ) 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;

( ) the permanent impairment of a body function of an employee;

( ) an explosion;

( ) damage to a boiler or pressure vessel that results in fire or the

rupture of the boiler or pressure vessel; or

( ) 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/2002-208, s. 38.

a

b

c

a

a

b

c

d

e

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Records

Minor Injury Records

Written Reports

15.6

15.7

15.8

(1) The employer shall, within 72 hours after a hazardous occurrence

referred to in paragraph 15.5( ) or ( ), record in writing

( ) a description of the hazardous occurrence and the date, time and

location of the occurrence;

( ) the causes of the occurrence; and

( ) 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/2002-208, s. 32.

(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

( ) the date, time and location of the occurrence that resulted in the

minor injury;

( ) the name of the employee affected;

( ) a brief description of the minor injury; and

( ) the causes of the minor injury. SOR/89-479, s. 1.

(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)( ), where that investigation discloses that the hazardous occurrence

resulted in any one of the following circumstances:

( ) a disabling injury to an employee;

( ) an electric shock, toxic atmosphere or oxygen deficient

atmosphere that caused an employee to lose consciousness;

( ) the implementation of rescue, revival or other similar emergency

procedures; or

( ) a fire or an explosion

f g

a

b

c

a

b

c

d

a

a

b

c

d

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(2) The employer shall submit a copy of the report referred to in

subsection (1)

( ) without delay, to the work place committee or the health and

safety representative; and

( ) 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/2002-208, s. 33.

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/2002-208, s. 38.

(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

the occurrence of the injury and nature of it;

the time when the injury occurred;

the name and address of the worker;

the place where the injury occurred;

the name and address of the doctor who looks after the injury; and

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.

a

b

(a)

(b)

(c)

(d)

(e)

(f)

15.9

56. Duties of employer

Workplace Health, Safety and Compensation Act

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Appendix C – Hazardous Occurrence Investigation Report

Ap

pend

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azard

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Occurr

ence

Inve

stig

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Rep

or t

Human Resources Développement des

Age / Âge

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?

Telephone Number / Numéro de téléphone

Telephone Number / Numéro de téléphone

1. TYPE OF OCCURRENCE / GENRE DE SITUATION

Date

Date

Telephone number / Numéro de téléphone

Postal code / Code postal

2. Department file no.N° de dossier du ministère

( ) -

() -

() -

Direct cause of injury / Cause directe de la blessure

SCHEDULE 1 / ANNEXE 1(section 15.8 / article 15.8)

HAZARDOUS OCCURRENCEINVESTIGATION REPORT

RAPPORT D'ENQUÊTE DESITUATION COMPORTANT DES RISQUES

Explosion

LAB 1070 (02-01) B

Disabling InjuryBlessure invalidante

OtherAutre

Specify / Préciser

Loss of ConsciousnessÉvanouissement

Emergency ProcedureMesures d'urgence

Title / Titre

Signature

9. Work place committee's or health and safety representative's comments / Observations du comité local ou du représentant

10. COPIES 1 and 2 to Health and Safety Officer, COPY 3 to the Work Place Committee or Health and Safety Representative 4 to the Employer

COPIES 1 et 2 pour 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 occurrenceDate et heure de la situation comportant des risques

4. Description of what happened / Description des circonstances

Site of hazardous occurrenceLieu de la situation comportant des risques

Witnesses / Témoins

3. Employer's name and mailing address / Nom et adresse postale de l'employeur

Brief description and estimated cost of property damage / Description sommaire et coût estimatif des dommages matériels

Occupation / Profession

Years of experience in occupation /Nombre d'années d'expérience dans la profession

SexSexe

Yes / Oui No / Non Specify /Préciser

7. Corrective measures and date employer will implement / Mesures correctives qui seront appliquées par l'employeur et date de leur mise en oeuvre

Reasons for not taking corrective measures / Raisons pour lesquelles aucune mesure corrective n'a été prise

Supplementary preventive measures / Autres mesures de prévention

Work place committee member's or health and safety representative's nameNom du membre du comité local ou du représentant

Signature

Title / Titre

6. Direct causes of hazardous occurrence / Causes directes de la situation comportant des risques

8. Name of person investigating / Nom de la personne faisant l'enquête

Weather / Conditions météorologiques

Employer ID No.Numéro d'identification de l'employeur

Regional or District OfficeBureau régional ou de district

Supervisor's name / Nom du surveillant

:

5. Injured employee's name (if applicable) / Nom de l'employé blessé (s'il y a lieu)

Description of Injury / Description de la blessure

Development Canada ressources humaines Canada

sam

ple

35

sam

ple

Appendix D – Sample Accident/Incident Report Form

36

Ap

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–Sam

ple

Accid

ent/

Incid

ent

Rep

ort

Form


Category/Status (Internal Use Only)

Near Miss (No injury) Medical Care Lost Time

Recurrence Original Injury Date

This report must be completed for all work-related incidents/accidents. Please immediatelynotify your manager/supervisor. Complete theemployee section and distribute as noted below.Accurate information is required so appropriatefollow-up can occur to prevent future incidents.PLEASE NOTE, all serious injuries must also beimmediately reported to the Dept. of GovernmentServices (OH&S Branch).

Confidentiality: The information contained in thisreport is considered confidential & will only be usedfor analyzing trends, injury prevention initiatives andWHSCC claims management.

PermanentTemp

Part TimeFull TimeCasual/On call

Your last name: Your first name: Your employee number:

The date and time of incident/accident

D______ M______ Y ______ _______ am/pm

The date/timestopped work:(ifapplicable)

What was your jobclassification attime of accident/incident?

Wh

oan

dW

hen

?

The incident/accident was reported to: Title:

Which site did the incident/accident occur? (kitchen, office, etc)

Wh

ere?

Where did it actually occur?(Be as specific as possible: room, corridor, workstation, facility)

Describe what happened (mention events leading up to how it occurred and if machinery/equipment/tool wereinvolved)

This incident/accident resulted in (more thanone may need to be checked):

Near miss Loss of materials

Damage to equipment/ Injury requiringproperty

Damage to environment Injury leadingto lost time

If you have been injured, please check which mostaccurately describe the type of injury.

Abrasion(s)Burn(s)B/BF ExposureContusionFracture(s)Infectious ContactIrritation (respiratory)Needle PunctureLaceration(s) No InjuryStrains(s) & Sprain(s)Other ____________

Wh

atH

app

ened

?

If you were injured, was there any immediatetreatment required?If so, please describe briefly.

Part of Body Injured (if applicable):

Left Right

medical aid only

Mark with (?) if item isapplicable

Allergic ReactionAssisting Patient for X-rayAssisting Patient from floor/chairBathing Pt. (bed/tub)B/BF ExposureBed MakingCatching Falling ObjectCatching PatientChanging PatientWalking PatientChemical Exposure Type _____Crushed/Pinched b/w Objects

Patient Aggression/Non Cooperation

Infectious Disease Exposure

cific Task

Dressing PatientFt/Bk slide with transfer boardHot Object/Surface

Lifting Equipment/SuppliesLifting/Lowering BedrailsMoving/Pushing/PullingEquipment/SuppliesNo SpeNeedle Stick Puncture

Repositioning Patient in BedRepositioning Patient in Chair

Respond to an EmergencyCode (specific)

Sharpe Object Type:__________________Struck by ObjectSlipped/Fell on ______________________Transferring Patient – Bed – StretcherTransferring Patient – OtherTransporting Patient______ Wheelchair______ Bed______ StretcherWorking at computer workstationOther:____________________________Recurrence of previous injury

Employee Signature:_____________________________ Home Phone:_______________ Date:

HR

use

on

ly Date first lost shift: D____ M ______ Y _____ Anticipated RTW Date: D ____ M _____ Y _____

____ M _____ Y _____

RTW Date D____ M______ Y_____

Name of Attending Physician:_______________________________ Date Seen: D

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: StaffAccident/Incident Investigation Policy X -05).

Employee is responsible for completing the Incident/Accident Report portion and forwarding the white copy tothe appropriate Human Resources.Report must be completed and forwarded to Human Resources within 24 hours of the incident/accident.

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Appendix E – Sample Accident/Incident Investigation Form

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Instruction: This form must be completed by the store manager and a member of OH&S committeewhenever an accident/incident occurs. The assistant manager or authorized designate for the store willbe responsible for completing this form in the absence of the store manager. The store manager mustensure a copy of the completed report is forwarded to the Human Resources Manager, and the OH&Scommittee.

Accident/incident resulted in: ___ injury ___ illness ___ property damage ____ near miss

____ first aid ___ medical aid ___ recurrence ____ other (check all that apply)

Store Location Department

Location of Incident(Be specific – eg. aisle 10)

Date of incidentam

Time_________ 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 ofinjury:______________________________________________________

Object/equipment/substance inflicting damage/injury:________________________________________

Nature of injury:_______________________________ a ffBody part(s) ected:_____________________

EMPLOYEE INFORMATION

___________________________________________ Home phone number:___________________

Home Address:_______________________________ Age: ____________ Sex: M / F

________________________________

________________________________

Date of employment:___________________________ Occupation/Position: __________________________________

Experience (time) in job:________________________

Name (last name first – please print)

Evaluation of loss Loss severity potential Probability of occurrencePotential if not corrected

Describe how the event occurred.

Immediate causes: What substandard acts/practices and conditions caused or could cause the event?See end of form.

Major HighSerious ModerateMinor Low

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? Seeend of form.

Remedial actions: What has and/or should be done to control the causes listed?


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Attach all supporting documentation and evidence, ie. summaries of interviews, pictures, andanalysis of evidence.

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Prevention of Accident/Incident RecurrenceDescribe what action is planned or has been taken to prevent a recurrence of the accident, based on thekey contributing factors

(immediate)

(long term)

Signed by Supervisor________________________ Supervisor’s Name ______________________________

Signed by Person Involved:___________________ Signed by HR: _________________________

Signed by Store Manager:_ Date: ________________________________

REPORT FORM DEFINITIONS

INJURY – physical harm or damage to a person.

ILLNESS – unhealthy condition in mind or body.

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.

BASIC CAUSES – check all as appropriatePersonal Factors

□Inadequate capability

□Lack of knowledge/training

□Lack of skill

□Stress

□Improper motivation

Job Factors

□Inadequate leadership/supervision

□Inadequate engineering

□Inadequate purchasing

□Inadequate maintenance

□Inadequate tools/equipment

□Inadequate work standards

□Wear and Tear

□Abuse and/or misuse

IMMEDIATE CAUSES – check all as appropriateActions

□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

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

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St. John's

Grand Falls-Windsor

Corner Brook

Department of Government Services

OH&S Branch

Human Resources and Social Development

Newfoundland & Labrador Employers’ Council

Newfoundland and Labrador Federation of Labour

146-148 Forest Road

P.O. Box 9000

St. John's, NL A1A 3B8

Prevention Services Inquiries (709) 778-1552

Prevention Services Fax (709) 778-1564

Toll Free 1 800 563-9000

26 High Street

P.O. Box 850

Grand Falls Windsor, NL A2A 2P7

Telephone: (709) 489-1600

Fax (709) 489-1616

Toll Free 1 800 563-3448

Suite 201, Fortis Towers

4 Herald Avenue

P.O. Box 474

Corner Brook, NL A2H 6E6

Telephone: (709) 637-2700

Fax (709) 639-1018

Toll Free 1 800 563-2772

(709) 729-2706

Toll Free: 1-800-563-5471

Labour Program, Newfoundland and Labrador Office

Phone: (709) 772-5022 (call collect outside St. John’s)

(709) 368-6532

Toll Free: 1-888-738-5900

(709) 754-1660

www.whscc.nl.ca

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