Accident Investigation/Root Cause Analysis

Complete This Report When Injured Employee Needs To Seek Medical Attention

County______Date of Injury______Time of Injury______AM/PM

Employee______WSI Claim Number______

Please indicate the location of the accident______

What task was being performed, how did the accident happen, and explain the nature of the injury______

Describe any tools, machinery, equipment, or PPE that was being used at the time of the accident______

Was the employee working alone?______Witness Name(s)______

How much experience did the employee have in performing this task?______

______

STEP 1—Obtain and review physical evidence, employee and witness information,

and paper evidence pertinent to the investigation.

Physical—Photographs, drawings, equipment manuals, etc… (Forward with report)

Employee/Witnesses—statements, interviews, WSI FROI

Paper—Policies, programs, training records, maintenance records, incident reports, etc.

STEP 2—Direct Cause, Contributing Cause, and Root Cause

Use the following listing as an aid for identifying the factors that led to the accident.

Don’t be limited by the categories listed—add items as needed. Check all that apply.

POLICIES/PROGRAMS / COMMUNICATION
A / Not Developed or Inadequate / A / Insufficient Planning For Tasks
A / Developed and Communicated / A / Lack of Worker Communication
A / Developed—Not Communicated / A / Lack of Supervisor Instruction
A / Developed-Not Followed/Enforced / A / Sufficient Supervisor Instruction
A / Developed—Not Understood / A / Confusion After Communication
A / Lack of Disciplinary Policy / A / Lack of Understanding of Task
A / Disciplinary Policy Not Enforced / A / Work Team Breakdown
HAZARDS / BLOODBORNE PATHOGEN
A / Unidentified or Not Labeled / A / Unaware/Aware of Air Borne Hazard
A / Known But Not Corrected / A / Stuck With Contaminated Needle
A / Known But Not Reported / A / Client Contact/Exposure
A / Created by External Factors / A / Inmate Contact/Exposure
A / Known But Not Reported / A / Sharps Container Not Available
A / Condition Changed Not Conveyed / A / Improper Cleanup
A / Equipment Repaired Deficiently / A / Contaminated Waste Not Labeled
A / PPE Not Adequate or Defective / A
PRODUCTIVITY FACTORS / WORK BEHAVIOR
A / Heavy Workload / A / Shortcuts Taken
A / Tight Schedule To Complete Task / A / Deviations-Common, Allowed etc…
A / Long/Unusual Working Hours / A / Special Infrequent Task
A / Falsely Perceived Need to Hurry / A / Tool/Equipment Used Improperly
A / Staff Assistance Unavailable / A / History of Accidents/Incidents
A / Staff Assistance Inadequate / A / Disregard/Refused to Follow Procedure
A / Changes in Process / A / Staff Assistance Required
A / Was Employee Ill? / A / Horseplay
A / Medication, Drugs, Alcohol Factors / A / Repetitive or Physically Demanding
A / Double Shift / A / Going On/Coming Off Vacation
TRAINING / ENVIRONMENT
A / Deficient Orientation Training / A / Weather/Temperature Factors
A / Deficient Job Specific Training / A / Poor Housekeeping
A / Insufficient Training for New Process or Task / A / Poor Lighting
A / Lack of Supervisor Follow-up or Reinforcement / A / Poor Visibility
A / Lack of Supervisor Training / A / Air Quality
A / Lack of Employee Training / A / Noise
A / Communication of Expectations / A / Visibility of Labels/Warning Signs
A / Communication of Rules/Policy / A / Visible and Audible Alarms
A / Hazards Overlooked in Training / A
Personal Protective Equip (PPE) / FACILITIES/EQUIPMENT
A / Available / A / Poor Facility Design
A / Required / A / Poor/Faulty Equipment or Design
A / Required PPE Not Used/Worn / A / Poor Workstation Design
A / Trained On How To Use / A / Equipment Not Guarded
A / Adequate Fit / A / Equipment Repair Deficient
A / PPE Not Used Adequately / A / Lack of Preventative Maintenance
A / Poor Condition / A / Employee Lack of Knowledge
A / Adequate for Job Performed / A / Equipment Failure
A / Lack of Supervisor Enforcment / A / Inadequate Inspection Timelines

STEP 3—CAUSES

From the categories identified above, circle the major cause or causes of the accident:

POLICIES/PROCEDURES PRODUCTIVITY FACTORS

TRAINING ENVIRONMENT

FACILITIES/EQUIPMENT HAZARDS

BLOODBORNE PATHOGEN WORK BEHAVIORS

COMMUNICATION PERSONAL PROTECTIVE EQUIP

Comments Related to Investigation______

______

STEP 4—ROOT CAUSE ANALYSIS

Why Did This Happen?
WHY…?
WHY…?
WHY…?
WHY…?
How Can This Be Prevented? (Develop Safety Policy, Enforce Safety Policies, Follow Safety Policies, Develop Training, Additional Training, etc…)
Steps For Corrective Action and Projected Completion Date:
Engineering Controls—Eliminate/ reduce hazards through equipment redesign, enclosure, replacement, substitution, etc. Administrative Controls—Eliminate/ reduce frequency and duration of exposure through (1) changes of work procedures and practices, and/or (2) scheduling, job rotation, breaks, etc. 3) Training 4) Additional Training
Personal Protective Equipment—for personal use that presents a barrier between worker and hazard.
1) Est. Completion Date______
2) Est. Completion Date______
3) Est. Completion Date______
4) Est. Completion Date______

The following persons have participated in the accident investigation and root cause analysis and are aware of the findings:

______

Risk Manager Date Witness Date

______

Supervisor Date Witness Date

______

Employee Date Witness Date

Pursuant to County Employer Group Policy, a WSI First Report of Injury (FROI) must be completed and filed with in 24-hours. This accident investigation report needs to be faxed to NDACo in four business days.

WITHIN 4 DAYS of the DATE of INJURY—FAX TO JENNIFER or MIKE AT 701-328-7308
Questions? Call Your Risk Manager or Jennifer 328-7329 or Mike 328-7330 at NDACo

CEG 4/2008