2010-11-10 Bolster Breaks Free Coast Region-Campbell River District-Eve River Main

WIncident Investigation Form
Site (Block, Operation):The Ridge, Eve River Mainline / Close Call Injury
Date of Investigation:November 10, 2010 / Investigation No. (Year-incident #): / 2010-11-10
Steps to an Effective Investigation:
1. Describe the incident or trend (i.e., back ground info, sequence of events, dates, consequence of incident, etc.)
2. Identify the contributing factors of the incident (e.g., Procedures in place [Training, Instructions]; Conditions [Weather, state equipment]; Actions done [Human Factors]
3. Determine the ‘Root Cause(s)’ (HINT: ask ‘why?’ five times) / 4. Describe the ‘Root Cause’
5. Make recommendations to prevent incident or trend from re-occurring
6. Assign Action Plan (Plan must mitigate the effects of the incident, remediate the consequences of incident, prevent the contributing factors and root cause of incident}
Location of Incident: 11.5 km on Eve River Main / Machine # : DY24
Names of those Involved in Incident: Luke Aitken
Names of Witnesses: no witnesses present at the time of the incident.
Date & Time of Incident: November 10, 2010 at 9:00 am
Type of Injury:
(select one, if applicable) / First Aid Medical Aid Medical Treatment Restricted Work Lost Time Fatality
Type of Event:
(select one) / Struck Against (running, bumping into) / Fall from elevation / Caught in (pinch, nip points)
Struck By (hit by moving object) / Fall from same level (slip/fall, trip) / Caught between/Under
Environmental Release / Overstress, overexertion, etc. / Contact with(electricity, toxics)
Investigation Team Members: Dennis Dystant , Chris Dystant
Summary of Incident
While travelling along the Eve River Mainline at 11 km a loaded truck came to an S Corner in the road. As the
driver proceded to follow the second curve in the road the bolster on the trailer which holds the bunk down
broke free throwing the truck and load onto its side. After further investigation it was discovered that one of the
bolts that held the bolster to the trailer had been broken for a period of time and the others were not tight. The
driver sustained a laceration to his right ear and scraped up his shoulder as well. First aid was on-site almost
immediately and treated the driver for his injuries. Proper procedures were followed to evacuate the vehicle
from the site and no damage was sustained to the area.
Attachments (relevant evidence, maps, notes, file references, diary entries, photos, sketch, etc.):
Pictures of accident and damage. First aid attendant treatment checklist for Luke.
Completed by:Chris Dystant
(Investigator Name) / Signature:
Management Representative:
(Owner Designate): Dennis Dystant / Date:
November 15, 2010 / Signature:

CMS – Forms & Checklists - Incident Investigation Form – April 2008Page ____ of ____

Root Cause Analysis
Use the listing below as an aid in identifying the factors that contributed to the accident, near miss or close call. Check those that apply.
The areas listed below are provided to help stimulate the discussion process. Add your own as needed.
Procedures: / In a Hurry:
None developed / Supervisor implied need
Developed but not followed / Employee perceived need
Developed but not trained / Friendly competition
Developed but not understood / Due to external factors
Developed but not accurate / Workload too heavy
Developed but not able to follow / Lack of teamwork
Communication: / Taking short cuts
Insufficient planning / Training:
Breakdown in communication between workers / Insufficient training
Breakdown in communication between workers and Supervisors / Circumstances not addressed in training
Confusion after communication / Tool / equipment used incorrectly
Hazard: / Facilities/Equipment:
Created by man / Faulty equipment
Created by external factors / Poor design
Documented but not addressed / Corrosion/wear
Unidentified / Ergonomic Factors
Identified but not accepted / Other Factors:
Addressed, but not sufficiently / Weather/Temperature
Conditions changed without proper communication / Working long hours
Lack of documentation / Physical overexertion
Personal protective equipment
Improper body position
Uneven ground
Root Cause Determination
Procedures / Communication / Hazard / In a Hurry
Training / Facilities/Equipment / Other:
Action Items (To prevent incident(s) from reoccurring)
Action to be Completed / By Who / By When
Better inspections of the truck and trailers and there load securement devices are to be done. / Drivers / immediately
Any loose objects in the cab of the trucks are to be properly stored or removed. / Drivers / immediately
Seatbelts are to be worn at all times, on the highway and off road. / Drivers / immediately

Instructions:1) Investigation team to complete for all incidents and significant close calls. File as indicated.

2) Copies to be forwarded to the Manager, WorkSafe BC (for fatalities, serious injuries, explosives/driving incidents), Licensee/Client, where applicable (front page only, within 24 hours), BC Forest Safety Council.

CMS – Forms & Checklists - Incident Investigation Form – April 2008Page ____ of ____