ACCIDENT INVESTIGATION FOR ACCIDENT INVESTIGATION FOR SUPERVISORSSUPERVISORS

Kelley IrelandKelley Ireland

Worker’s Compensation Worker’s Compensation

Program ManagerProgram Manager

Tucson, AZTucson, AZ

520-792-1450 ext 6082520-792-1450 ext 6082Kelley.ireland@va.gov

PurposePurpose

Broaden and develop knowledge Broaden and develop knowledge of proper accident investigationof proper accident investigation

Work together as a team with Work together as a team with Safety during accident Safety during accident investigations and the investigations and the development of accident development of accident prevention countermeasuresprevention countermeasures

PurposePurpose

Identify/analyze accident trendsIdentify/analyze accident trends POWER Initiative – Target POWER Initiative – Target

reductions in accidents/injuriesreductions in accidents/injuries

ObjectivesObjectives

How accident investigations relate to WC How accident investigations relate to WC case managementcase management

VAVA Form 2162 - Incident ReportForm 2162 - Incident Report CA 1 & 2CA 1 & 2

Preserve critical information at accident Preserve critical information at accident scenescene

What supervisors need to know What supervisors need to know Information collection techniques & tipsInformation collection techniques & tips Determine root causesDetermine root causes

Reduce potential for similar employee Reduce potential for similar employee injuriesinjuries

Hazard recognition - mitigate subsequent Hazard recognition - mitigate subsequent injuries injuries

Foster alliance with Safety/Workers’ Foster alliance with Safety/Workers’ Comp/TORTComp/TORT

Create safer work environmentCreate safer work environment

Reduce operational costsReduce operational costs Direct costs versus indirect costs Direct costs versus indirect costs (Medical bills are not the end of the story)(Medical bills are not the end of the story)

Observe and analyze trendsObserve and analyze trends Countermeasures and observations are Countermeasures and observations are

key to preventionkey to prevention Near miss today could mean accident Near miss today could mean accident

tomorrowtomorrow

Compare accident reports to CA formsCompare accident reports to CA forms WC writes better/more timely challenges WC writes better/more timely challenges

based on information gained from good based on information gained from good supervisory investigationssupervisory investigations

Why VA Form 2162 and CA-forms must Why VA Form 2162 and CA-forms must matchmatch

……and finallyand finally

Save VA moneySave VA money Claims pay outs on questionable Claims pay outs on questionable

WC claimsWC claims TORT Claims and associated legal TORT Claims and associated legal

costscosts Provide accurate information that Provide accurate information that

can be used in litigationcan be used in litigation

POWER InitiativePOWER Initiative

On July 19, 2010, President Obama On July 19, 2010, President Obama established a 4-year “Protecting Our established a 4-year “Protecting Our Workers and Ensuring Reemployment” Workers and Ensuring Reemployment” (POWER) Initiative(POWER) Initiative

The scope of POWER is to extend prior The scope of POWER is to extend prior workplace safety and health efforts of the workplace safety and health efforts of the Federal Government by setting more Federal Government by setting more aggressive performance targetsaggressive performance targets

Each Federal agency is to improve Each Federal agency is to improve performance in seven areasperformance in seven areas

What are the initiatives and What are the initiatives and what do they really mean?what do they really mean?

1.1. Reduce total injury and illness case ratesReduce total injury and illness case rates (Less claims = safer employees and (Less claims = safer employees and

workplaces)workplaces)

2. Reduce lost time injury and illness case 2. Reduce lost time injury and illness case ratesrates

(Lost time injuries and illnesses are the most (Lost time injuries and illnesses are the most severe so we want to reduce them)severe so we want to reduce them)

3. Analyze lost time injury and illness data3. Analyze lost time injury and illness data (Identify trends - what injuries are happening (Identify trends - what injuries are happening

where, why and by whom to enlist where, why and by whom to enlist improvements)improvements)

4. Increase timely filing of 4. Increase timely filing of workers’ comp claimsworkers’ comp claims(Claims processed immediately aid (Claims processed immediately aid injured worker in getting benefits and injured worker in getting benefits and in healing)in healing)

5. Increase timely filing of wage 5. Increase timely filing of wage loss claimsloss claims(Injured employee gets paid on time – (Injured employee gets paid on time – no loss of income)no loss of income)

6. Reduce lost production day 6. Reduce lost production day ratesrates(Less injury time more production to (Less injury time more production to unit)unit)

7. Speed employee’s return to 7. Speed employee’s return to work in cases of serious injury or work in cases of serious injury or

illnessillness

(Reduces financial and emotional (Reduces financial and emotional impact of injury when employee is impact of injury when employee is

back at work. Employee is “back in back at work. Employee is “back in the saddle again”) the saddle again”)

Form 2162 Incident ReportForm 2162 Incident Report Must be completed for all accidents regardless Must be completed for all accidents regardless

of extent of injury or amount of damageof extent of injury or amount of damage Should not differ from information on CA formsShould not differ from information on CA forms Data mined from Incident Report ensures Data mined from Incident Report ensures

correct data is captured for Bureau of Labor correct data is captured for Bureau of Labor Statistics & OSHA LogStatistics & OSHA Log

Stats can be used to monitor, create and alter Stats can be used to monitor, create and alter current workplace safety programscurrent workplace safety programs

Data can be used to identify trends and Data can be used to identify trends and generate accident countermeasuresgenerate accident countermeasures

What is the definition of an What is the definition of an accident?accident?

The National Safety Council The National Safety Council defines an accident as:defines an accident as:

““An undesired event that An undesired event that results in personal injury results in personal injury or property damage.” or property damage.”

Definition of “Near Definition of “Near Miss”Miss”

Near miss describes events Near miss describes events where no property was where no property was damaged and no personal damaged and no personal injury sustained, but given a injury sustained, but given a slight shift in time or position, slight shift in time or position, damage and/or injury could damage and/or injury could easily have occurred. easily have occurred.

OSHA Regs - Accident OSHA Regs - Accident InvestigationInvestigation

1960.29(d)1960.29(d) The investigative report of the The investigative report of the accident shall include appropriate documentation accident shall include appropriate documentation on date, time, location, description of operations, on date, time, location, description of operations, description of accident, photographs, interviews of description of accident, photographs, interviews of employees and witnesses, measurements, and employees and witnesses, measurements, and other pertinent information. A copy of the other pertinent information. A copy of the investigative report required by this section shall be investigative report required by this section shall be forwarded to the official in charge of the workplace, forwarded to the official in charge of the workplace, the appropriate safety and health committee, and the appropriate safety and health committee, and the exclusive employee representative, if any. the exclusive employee representative, if any.

When should an investigation When should an investigation be conducted?be conducted?

Immediately after all incidents, whether Immediately after all incidents, whether near miss or actual injury/damage near miss or actual injury/damage eventevent

Who should do it?Who should do it?The supervisor in charge of the activity The supervisor in charge of the activity or operation and for severe or serious or operation and for severe or serious injury, the facility Safety Professionalinjury, the facility Safety Professional

Why Me?Why Me?(Or… “Is this why I make the big (Or… “Is this why I make the big

bucks?”)bucks?”) Supervisors are in charge of the Supervisors are in charge of the

operation or activity operation or activity You know the ropes, the job tasks and You know the ropes, the job tasks and

the employees involved - you’re the employees involved - you’re experienced!experienced!

You know the terminology and how You know the terminology and how work should be conductedwork should be conducted

You know the hazardsYou know the hazards You know the layout of the area and the You know the layout of the area and the

equipment equipment

Who should support me in every Who should support me in every work related Injury/Illness work related Injury/Illness

Investigation?Investigation?

Safety OfficerSafety OfficerThe Safety Officer is responsible The Safety Officer is responsible

for obtaining an investigative for obtaining an investigative report for every accident which report for every accident which must be retained for a minimum must be retained for a minimum

of 5 years and is subject to of 5 years and is subject to review and inspection by the review and inspection by the

Department of Labor.Department of Labor.

Can anyone else help me Can anyone else help me investigate?investigate?

In the event more expertise is In the event more expertise is required or after a serious event, of required or after a serious event, of course!course!

Police or emergency servicesPolice or emergency services Safe Patient Lifting CoordinatorSafe Patient Lifting Coordinator Patient Safety AdvocatePatient Safety Advocate Employees at the sceneEmployees at the scene Environmental services – Industrial Environmental services – Industrial

HygieneHygiene ErgonomistErgonomist

Where do I begin?Where do I begin?

Start with the 6 key questionsStart with the 6 key questions

Who?Who?

What?What?

Where?Where?

When?When?

Why?Why?

How?How?

Investigation TipsInvestigation TipsGet to the scene as quickly as Get to the scene as quickly as possiblepossible

Preserve critical information Preserve critical information • PhotosPhotos• MeasurementsMeasurements• LightingLighting• LayoutLayout• Hazards presentHazards present

Get witness statements Get witness statements immediatelyimmediately

Though they witnessed the same event, Though they witnessed the same event, stories vary because of perceptionsstories vary because of perceptions

Stories change when people talkStories change when people talk People forget very quicklyPeople forget very quickly

The Ebbinghaus Curve The Ebbinghaus Curve How quickly we forgetHow quickly we forget

In 1885, Herman Ebbinghaus did an In 1885, Herman Ebbinghaus did an experiment where subjects memorized experiment where subjects memorized a list of meaningless three letter words a list of meaningless three letter words

and tracked how quickly his subjects and tracked how quickly his subjects forgot the words forgot the words

Learners rapidly forget information Learners rapidly forget information 

In the case of meaningless information, In the case of meaningless information, only 20 minutes afterward, they only only 20 minutes afterward, they only

remember 58% of the informationremember 58% of the information

Investigation TipsInvestigation Tips Secure the accident scene and ensure Secure the accident scene and ensure

your own safetyyour own safety Distinguish fact from opinionDistinguish fact from opinion Conduct thorough interviews with those Conduct thorough interviews with those

involved who have knowledge of the involved who have knowledge of the incidentincident

No such thing as too much informationNo such thing as too much information Don’t ask “leading questions” of Don’t ask “leading questions” of

employees or witnessesemployees or witnesses

…”…”You weren’t wearing your seat belt, You weren’t wearing your seat belt, were you?”were you?”

Investigation TipsInvestigation Tips

Don’t assign blameDon’t assign blameGet witness statements immediatelyGet witness statements immediatelyJust the facts ma’am, just the factsJust the facts ma’am, just the facts

Opinions, gossip and hearsay don’t Opinions, gossip and hearsay don’t mattermatter

Listen carefullyListen carefully Document everythingDocument everything Look for causal factorsLook for causal factors

(there are usually several factors that lead (there are usually several factors that lead to the accident – not just one thing!)to the accident – not just one thing!)

Make sure you have the tools Make sure you have the tools you need to conduct your you need to conduct your

investigationinvestigation

Container for investigation materialsContainer for investigation materials Paper and pens/pencilsPaper and pens/pencils Tape measure or other measuring Tape measure or other measuring

devicedevice Clipboard Clipboard CameraCamera Flashlight/extra batteriesFlashlight/extra batteries Protective gear Protective gear

Barricade tapeBarricade tape Nitrile or latex Nitrile or latex

glovesgloves Digital or tape Digital or tape

recorderrecorder Witness formsWitness forms Sign-in sheet Sign-in sheet

(for employees (for employees on scene at the on scene at the time of the time of the incident)incident)

Sticky notesSticky notes Business cardsBusiness cards Baggies Baggies

(sealable)(sealable) FlaresFlares WaterWater Accident formsAccident forms MapsMaps Rain gearRain gear

Contributing factorsContributing factors WeatherWeather Work hoursWork hours LayoutLayout ErgonomicsErgonomics Traffic patternsTraffic patterns Short-cuttingShort-cutting HasteHaste Lack of Lack of

training/experiencetraining/experience

ObstructionsObstructions Work practice Work practice

methodsmethods Equipment conditionEquipment condition Environmental or Environmental or

physical hazardsphysical hazards Skills/abilities of Skills/abilities of

workerworker Lack of enforcementLack of enforcement

And now the report…And now the report…

Write in a narrative styleWrite in a narrative style

Remember the 6 key Remember the 6 key questions! questions!

Who?Who?

What?What?

Where?Where?

When?When?

Why?Why?

How?How?

Which narrative is best to Which narrative is best to describe an accident that describe an accident that happened at your facility?happened at your facility?

Worker slipped and Worker slipped and hurt his knee when hurt his knee when he fell to the floorhe fell to the floor

Or…Or…

On Thursday, May 24, Nurse’s Aid Adam On Thursday, May 24, Nurse’s Aid Adam Briscoe, slipped and fell on water tracked into Briscoe, slipped and fell on water tracked into the building from a rain storm at the hospital’s the building from a rain storm at the hospital’s north entrance. Adam struck his right knee north entrance. Adam struck his right knee against the floor. He was not wearing shoes against the floor. He was not wearing shoes with slip resistant soles. He was texting as he with slip resistant soles. He was texting as he walked into the hospital to report for work and walked into the hospital to report for work and didn’t notice the water. He was treated by his didn’t notice the water. He was treated by his physician who diagnosed a right knee physician who diagnosed a right knee strain/contusion. No weather matting or signs strain/contusion. No weather matting or signs were in place near the door. Maintenance had were in place near the door. Maintenance had been called earlier to mop and put signs up, been called earlier to mop and put signs up, but had not yet responded.but had not yet responded.

Why?Why? 6 key pieces of information were 6 key pieces of information were

identifiedidentified Hazards were identifiedHazards were identified Contributing factors identifiedContributing factors identified Root cause can be determined Root cause can be determined

from informationfrom information Preventive measures can be put in Preventive measures can be put in

place place Future accidents/injuries can be Future accidents/injuries can be

preventedprevented

What will this accident cost?What will this accident cost?

It Depends!It Depends!

Every workplace accident or injury has Every workplace accident or injury has both Direct and indirect costs. The both Direct and indirect costs. The direct costs, we recognize right away. direct costs, we recognize right away.

Can you name some direct costs?Can you name some direct costs?

Direct CostsDirect Costs

Ambulance billAmbulance bill Diagnostics – MRI, CT Scan, X Rays Diagnostics – MRI, CT Scan, X Rays Medication$ Medication$ Physical therapy – Often 16 visitsPhysical therapy – Often 16 visits $urgery$urgery Damaged equipment or materialsDamaged equipment or materials Continuation of Pay (COP)Continuation of Pay (COP)

What is meant by “indirect What is meant by “indirect costs?”costs?”

Indirect costs are “behind the Indirect costs are “behind the scenes” costs that add additional scenes” costs that add additional expenses to the direct costs of an expenses to the direct costs of an accident/injury that we often don’t accident/injury that we often don’t even considereven consider

Can you think of some indirect Can you think of some indirect costs?costs?

Indirect CostsIndirect Costs Hours taken for supervisor to Hours taken for supervisor to

investigate and fill out reportsinvestigate and fill out reports Replacement costs for injured workerReplacement costs for injured worker Workers’ CompensationWorkers’ Compensation OvertimeOvertime Lost productivityLost productivity Low morale (sick calls, short staffing)Low morale (sick calls, short staffing) OSHA complaintsOSHA complaints

Class ExerciseClass ExerciseHousekeeping Aid filed CA-2 for groin pain he sustained Housekeeping Aid filed CA-2 for groin pain he sustained

when stacking chairs. when stacking chairs.

Date of injury: on or about 6-1-2011Date of injury: on or about 6-1-2011

Date employee filed claim: 6-30-2011Date employee filed claim: 6-30-2011

Employee took 3 weeks off between date of injury and Employee took 3 weeks off between date of injury and date claim was filed, using all his accrued leave. He date claim was filed, using all his accrued leave. He helped his family move household goods & belongings helped his family move household goods & belongings onto a large truck during a wildfire and moved his family onto a large truck during a wildfire and moved his family to another city. The employee notified his supervisor of to another city. The employee notified his supervisor of this before he took A/L but never mentioned an injury until this before he took A/L but never mentioned an injury until after he returned to work, saying he hurt himself on June after he returned to work, saying he hurt himself on June 1 and it “worsened over the month.” The employee 1 and it “worsened over the month.” The employee requested COP for his time off. The supervisor was never requested COP for his time off. The supervisor was never aware that the worker had allegedly sustained an injury aware that the worker had allegedly sustained an injury until his return to work, so no investigation was done, and until his return to work, so no investigation was done, and no reports were completed.no reports were completed.

The employee’s supervisor alerted WC that The employee’s supervisor alerted WC that employee had hurriedly moved his family during employee had hurriedly moved his family during the fire. He had loaded and unloaded belongings the fire. He had loaded and unloaded belongings onto a large truck and could have been injured onto a large truck and could have been injured moving his family since he had not mentioned a moving his family since he had not mentioned a work injury previously.work injury previously.

Supervisor also stated the employee has a small Supervisor also stated the employee has a small ranch with horses and cattle to care for. He rides ranch with horses and cattle to care for. He rides horses. horses.

The claimant stated he’d had a hernia repair 2 years The claimant stated he’d had a hernia repair 2 years prior and worried it might have returned. He was prior and worried it might have returned. He was examined the day before he filed his claim and examined the day before he filed his claim and while being examined, he made no mention of a while being examined, he made no mention of a work related injury to the treating NP. All told, the work related injury to the treating NP. All told, the employee visited 8 physicians or NP’s, had an employee visited 8 physicians or NP’s, had an ultrasound, a MRI and an Agency Medical Exam ultrasound, a MRI and an Agency Medical Exam that all concurred there was no hernia. that all concurred there was no hernia.

See any potential issues with this See any potential issues with this claim?claim?

What “red flags” do you see?What “red flags” do you see? Could the supervisor still do an accident Could the supervisor still do an accident

investigation?investigation? Was the information he provided to WC Was the information he provided to WC

helpful? If yes, in what way?helpful? If yes, in what way? Was the employee entitled to COP for this Was the employee entitled to COP for this

injury?injury? What corrective actions or What corrective actions or

countermeasures could be taken after an countermeasures could be taken after an accident of this type is claimed?accident of this type is claimed?

Claimant was not entitled to COP because he filed Claimant was not entitled to COP because he filed an Occupational Illness, saying his pain “worsened an Occupational Illness, saying his pain “worsened over time”over time”

Claimant chose NP for treatment - not authorized Claimant chose NP for treatment - not authorized by OWCPby OWCP

Supervisor CAN do “after the fact” accident Supervisor CAN do “after the fact” accident investigation, but asking the 6 key questions, investigation, but asking the 6 key questions, looking at the work area where the injury occurred, looking at the work area where the injury occurred, and observing the employee’s work methodsand observing the employee’s work methods

Maybe not as optimum as “on the spot” Maybe not as optimum as “on the spot” investigation, but still helpfulinvestigation, but still helpful

Supervisor’s information critical to WC because Supervisor’s information critical to WC because otherwise, no factors exist to disprove work injuryotherwise, no factors exist to disprove work injury

Safe lifting training” (always document) for Safe lifting training” (always document) for employee and others who do same workemployee and others who do same work

Discussion with employee on proper Discussion with employee on proper accident reporting proceduresaccident reporting procedures

Periodic observationsPeriodic observations On the spot corrections of unsafe practice On the spot corrections of unsafe practice

or behavior or behavior Change in written policyChange in written policy Change in procedures for clearing room of Change in procedures for clearing room of

furniture to minimize liftingfurniture to minimize lifting

Possible corrective actions

Hmmm… let’s seeHmmm… let’s see

Claimant reported injury “after the fact”Claimant reported injury “after the fact” Claimant reported his intentions to move Claimant reported his intentions to move

family to his supervisor and spoke of family to his supervisor and spoke of having done so after return to workhaving done so after return to work

Claimant engaged in outside activities Claimant engaged in outside activities that could have caused a muscle strainthat could have caused a muscle strain

Claimant used all his leave because “he Claimant used all his leave because “he thought he should” without a physician's thought he should” without a physician's medical rationale supporting his ideamedical rationale supporting his idea

RecordkeepingRecordkeeping

Information on CA-1(Injury) and CA-2 Information on CA-1(Injury) and CA-2 (Illness) Forms should be compared to (Illness) Forms should be compared to the information on VA Form 2162the information on VA Form 2162

This provides a means of checks and This provides a means of checks and balances between Injury balances between Injury Compensation and SafetyCompensation and Safety

OSHA can audit this information. It OSHA can audit this information. It should be the sameshould be the same

1. 1. Which form is completed by the Which form is completed by the supervisor of the employee involved in supervisor of the employee involved in any accident regardless of the extent any accident regardless of the extent of the injury or amount of damage?of the injury or amount of damage?

a. No forms are necessarya. No forms are necessary

b. VA Form 2162b. VA Form 2162

c. Note to selfc. Note to self

2. The local facility retains their copy of 2. The local facility retains their copy of the VA Form 2162/301/300 for a ____ the VA Form 2162/301/300 for a ____ year period per OSHA regulationsyear period per OSHA regulations

a. 1 a. 1

b. 7 b. 7

c. 5 c. 5

d. 2 d. 2

3. Writing a good accident 3. Writing a good accident report is important becausereport is important because

A. It’s not important because nobody will A. It’s not important because nobody will see it after I send it insee it after I send it in

B. It is a legal document that can be used B. It is a legal document that can be used after- the-fact by attorneys, OSHA, after- the-fact by attorneys, OSHA, OWCP, TORT OWCP, TORT

C.C. It helps Safety with record keeping, It helps Safety with record keeping, Worker’s Comp to challenge claims Worker’s Comp to challenge claims successfully, OSHA for recordkeeping, successfully, OSHA for recordkeeping, and the TORT Claims Administrator and the TORT Claims Administrator

D.D. Both B & CBoth B & C

4.4. Which form is completed after Which form is completed after an employee has a hazardous an employee has a hazardous materials exposure incident.materials exposure incident.

a. CA-1 or CA-2a. CA-1 or CA-2b. VA Form 2162b. VA Form 2162c. Both a and bc. Both a and b

5. 5. The information on a CA-1 or CA-2 The information on a CA-1 or CA-2 form should match the form should match the information on a VA Form 2162.information on a VA Form 2162.

a. True a. True

b. False b. False

6. Which of the following 6. Which of the following questions should a supervisor questions should a supervisor ask when writing a successful ask when writing a successful accident investigation?accident investigation?

Who, what, where, when, why and how Who, what, where, when, why and how much?much?

Who, what, where, when, why and how?Who, what, where, when, why and how? Who is at fault, what, where, which, Who is at fault, what, where, which,

when and how many?when and how many? Who, which, where, how, why and when?Who, which, where, how, why and when?

7. Why should I investigate 7. Why should I investigate accidents?accidents?

A.A. To determine contributing factors To determine contributing factors that may have caused the accidentthat may have caused the accident

B.B. To try and prevent future accidents To try and prevent future accidents of this type from happening againof this type from happening again

C.C. To try and determine root causes or To try and determine root causes or systems failuressystems failures

D.D. All of the aboveAll of the above

8. What’s the big deal about 8. What’s the big deal about investigating near misses?investigating near misses?

A.A. Nothing, but it gets you out of the office Nothing, but it gets you out of the office for a whilefor a while

B.B. Near misses have the potential to Near misses have the potential to become future accidents with injuries. become future accidents with injuries. By investigating them, you have a By investigating them, you have a chance of mitigating those factors that chance of mitigating those factors that could otherwise have led to an injurious could otherwise have led to an injurious eventevent

C.C. You can identify workplace hazards or You can identify workplace hazards or unsafe practicesunsafe practices

D.D. Both B & CBoth B & C

9. Why is the Power Initiative 9. Why is the Power Initiative so important and what part do I so important and what part do I

play in it?play in it?

A.A. When an employee files a claim form, I can When an employee files a claim form, I can fill out the supervisor’s part of the claim – fill out the supervisor’s part of the claim – the CA form and the VA Form 2162 the CA form and the VA Form 2162 immediately. immediately.

B.B. I can assist Worker’s Comp in designing a I can assist Worker’s Comp in designing a temporary light duty job assignmenttemporary light duty job assignment

C.C. I don’t play any part in this. It is not my jobI don’t play any part in this. It is not my job

D.D. Both A & BBoth A & B

10. There have been 6 lifting 10. There have been 6 lifting injuries in your unit. Would you injuries in your unit. Would you

classify them asclassify them as

A. A trendA. A trend

B. A categoryB. A category

C. A causeC. A cause

D. A hazardD. A hazard

Module endModule end