1. Trindel Insurance Fund Serious Incident Reporting, Investigation and Follow-up Presented by: Gene Herndon Director of Loss Prevention Programs Trindel Insurance Fund, JPA www.trindel.orgwww.trindel.org, tifso@trindel.orgtifso@trindel.org Office: (530) 894-2027, Cell: (530) 521-8291

2. Now What?

3. Potential Consequences of a Serious Incident: Serious Injury or Loss of life!

4. Other less important consequences:  Property & Liability Loss  Cal/OSHA Citation(s)  Serious and Willful Penalties  Criminal Liability  Civil Liability

5. Serious Incident Response  Reporting  Investigation  Follow-up The purpose: Prevent a re-occurrence!

6. What is a serious incident What is a serious incident?  Any occurrence resulting in, or having the potential for …  “… injury or illness, occurring in a place of employment or in connection with any employment, which requires inpatient hospitalization for a period in excess of 24 hours for other than medical observation or in which an employee suffers a loss of any member of the body or suffers any serious degree of permanent disfigurement…”

7. Cal/OSHA Reportable “Serious Injury”  Hospitalization for more than 24 hours for other than observation.  Amputation  Disfigurement  Dismemberment  Death Must report to Cal/OSHA within 8 hours from knowledge!!

8. Serious Incident Reporting Do it Now!!

9. Reporting:  Remove themselves from immediate danger.  Call 911 for medical assistance if needed.  Provide first aid for injured.

10. Reporting:  Immediately notify:  immediate supervisor.  designated county safety officer.  department safety representative.  Remain at the scene (unless injured) until released by S.I.I.T. leader.  Do not disturb incident scene (except to prevent further injury or damage or if ordered to do so by law enforcement authorities).

11. (S.I.I.T.) - Serious Incident Investigation Team  Designated County Safety Officer – Team Leader.  The immediate supervisor of the employee(s) involved.  The designated department safety representative (DSR) from the department involved.  Any other individuals necessary for a thorough and objective investigation.

12. Serious Incident Investigation Facts that lead to cause not blame!!

13. The investigation:  Don’t pre-judge.  Gather facts.  Look for cause not fault.  Don’t draw conclusions before gathering all the facts.

14. The investigation – Arriving at the scene.  The S.I.I.T. leader usually in charge.  Check on welfare of all involved including witnesses.  Let all know that your purpose is not to place blame but gather facts to prevent a re-occurance.

15. The investigation – The interview  Have involved employees and witnesses make a written description of events.  Include events leading to incident, the incident itself and events following the event.

16. The investigation – The interview  Tell them not to worry about penmanship, grammer or spelling.  Encourage drawings.  This a good way to separate all involved.

17. The investigation – The face to face interview.  Find a comfortable quiet place.  Once again inquire about their welfare.  Ask them to describe what happened.  Listen and take notes.  Don’t interrupt with questions.  Note you questions for later.

18. The investigation – The face to face interview  When they are finished tell them what you heard.  When you are in agreement ask your questions.  Always ask open-ended questions. Ones that don’t have a yes or no answer.  Always ask, “How could this have been prevented?”.

19. The investigation – Face to face interview  Conclude by asking if there is anything else they want to add  Depending on the situation be sure to offer up the EAP program for follow-up  Thank them and tell them they can call you if they think of anything else.

20. The investigation – The face to face Final thoughts:  You will hear a few facts and a lot of opinion.  You are looking for facts but opinion has value too.  Don’t rush the interview.  Give time to vent.  Don’t ask leading questions.

21. The investigation - At the Scene  Do not disturb the scene.  Take time to walk around and observe. conditions and environment.  Note day and time of incident.  Note weather conditions.

22. The investigation - Pictures of the Incident Scene  Take photos from front, sides, above, and rear.  Capture details: data plate, serial number, model number, manufacturer.  Use digital still camera.  Keep photo log.

23. The investigation - Drawings and diagrams  Draw picture of accident scene.  Label all key parts.  Show distances.  Keep details.  Use notes.

24. The investigation – Policy, procedures, training & supervision All of the following reviews are done after all personnel interviews and incident site investigations are completed.  Review Dept. Code of Safe Practices relative to incident.  Review employee safety training records relative to incident.  Review past safety meetings relative to incident.

25. The investigation – Policy, procedures, training & supervision  Review CWIIPP for relative to incident.  Review County Policy relative to incident.  Review Cal OSHA regulations relative to incident.

26. The Investigation – Writing serious incident report  Use facts to write the narrative.  Make findings that are definite, suspected, and found but not contributing.  Make recommendations for all findings.

27. The Serious Incident Investigation Report Has 3 Parts: 1. The Narrative 2. The Findings 3. The Recommendation

28. The “Narrative ”  Is a word picture that tells the reader exactly what happen.  Includes all facts taken from witness statements.  Includes technical information obtained from the accident investigation.  Does not speculate.

29. The “Findings”  Identifies the cause(s) of the accident.  Can be grouped in 3 categories: Man, Machine, and Environment.  Can be definite, suspected, and/or found but not contributing based on the fact pattern.

30. The “Recommendations”  Are linked to each finding.  Indicate the corrective action needed to prevent future accidents.  Makes top management aware of the problems and solutions.  Creates a “paper trail”.

31. Serious Incident Follow - up If you don’t like what happened… Change what you’re doing!

32. Serious Incident Follow - up  Communicate to all employees  Conduct employee safety meetings related to incident  Assemble suggestions for remediating cause of incident

33. Serious Incident Follow - up  Modify the department code of safe practices.  Train all employees on the changes.  Ensure supervisors implement changes.