Investigating Critical Injuries
When a workplace injury happens in Ontario, the employer’s joint health and safety committee (JHSC) plays a key role in collecting information and conducting a preliminary investigation so that a report can be prepared and sent to the provincial labour ministry within 48 hours, in accordance with requirements in the Occupational Health and Safety Act (OSHA).
“It is really important to have an incident-investigation process,” says Lori Nicholas, territory manager for Workplace Safety and Prevention Services in Mississauga, Ontario. The former inspector with the Ministry of Labour (MOL) was speaking on critical-injury investigation at the Partners in Prevention conference and trade show in Mississauga on May 2. “When stuff like this happens, you are not thinking clearly.”
Regulation 834 of OHSA defines a critical injury as a serious injury that places life in jeopardy, results in unconsciousness, produces loss of blood, consists of burns to a major portion of the body or causes the loss of sight. While the fracture or amputation of one finger or toe does not constitute a critical injury, the fracture or amputation of more than one finger or toe is considered a critical injury if it is of a serious nature.
A critical injury must be reported to a designated person within the organization as soon as it occurs. Other immediate actions include providing medical care to the injured worker and securing the scene to make sure that the evidence is not disturbed.
A preliminary investigation should also begin as soon as possible, so that one can observe the conditions as they were at the time and identify witnesses. The JHSC must designate one or more members to investigate the incident, and the designated personnel have the right to inspect the place where the incident occurred, including any relevant machine or device, as long as they do not disturb the scene before the investigation by the labour ministry. All findings must be reported to the committee and a director.
“During an investigation process, it is important to remember why you are investigating,” says Nicholas, stressing that the task should be driven by the need to find facts, not faults. She outlines the critical-injury investigation as a six-step process, the first of which is collecting the following required information: the names and addresses of the employer, the worker who was killed or injured, all witnesses and the attending physician or surgeon (if any); the nature and circumstance of the occurrence; the bodily injury sustained; a description of the equipment involved; and the time and place of the incident.
The second step is planning the investigation details, such as determining the resources required, who will be involved in the investigation and the witnesses to be interviewed. This is followed by collecting data, which necessitates an assessment of the incident scene and the collection of information about the equipment, processes, materials or personnel that may have been involved. This may require looking at the brake monitors of a stamping press if it caused an amputation or recording the air pressure of a machine.
Collecting documentation, such as manufacturer’s specifications, material safety data sheets, a pre-start health and safety review and a training record, is also necessary.
“Manufacturer specifications are very important to the way we proactively manage safety at a facility, and I don’t think we use them quite enough,” Nicholas suggests.
After the required information has been collected, the fifth step is to analyze the data to identify the root causes, before communicating the findings to the MOL within 48 hours. Nicholas clarifies that this report does not require employers to indicate the measures that should be implemented to prevent future occurrences, but should contain facts about the incident and the circumstances under which they occur.
“Remember, this is reported within 48 hours, and for those of you who had exposure to critical injuries, how many of those critical injuries were investigated, resolved and determined within 48 hours?” she asks. “You are just sending the information that is required by the MOL; your investigation will probably continue in most cases.”
The human factor
Nicholas points out that people who conduct critical-injury investigations are generally good at determining the facts, but do not go far enough in identifying the immediate causes or hazardous conditions that led to unsafe acts.
According to Nicholas, 85 per cent of all losses stemming from workplace accidents are due to a lack of management control. “There is something that is preventing them from doing the job the way they need to, so that becomes really valuable information,” she suggests.
A workplace incident costs an employer in various ways: financial penalties stemming from oh&s charges and loss of reputation and productivity. “This is all going to cost the company money anyway, so why not really determine what went wrong, so we can fix it?”
The best way to fix things is to conduct a thorough and effective investigation. Interviewing workers who have witnessed or been involved in a workplace critical injury is part of that process, and one that needs to be handled with sensitivity. Interviewers should be prepared to manage people who may exhibit post-traumatic stress symptoms spanning a gamut of reactions that includes shock, anger, anxiety, disbelief, fear, emotional numbness and uncontrolled emotions.
Post-traumatic stress symptoms are normal following a critical incident. Nicholas cites statistics that 30 per cent of people display mild, moderate and strong reactions respectively, and some may even require professional help. “Everybody deals with it differently,” Nicholas says.
Managing tenuous human emotions aside, it is also critical to schedule interviews within the first 24 hours after an incident has occurred to ensure that the information collected from such interviews is reliable, detailed and accurate. Witnesses should also be separated from one another to avoid contaminating information or influencing one another’s memory.
On the interviewer’s part, Nicholas stresses the importance of showing empathy and being respectful. The location selected for an interview should be kept neutral as far as possible. “Go somewhere where you know that person will feel comfortable,” Nicolas advises, citing a cafeteria as an example. “In unionized workplaces, you might have the union representative there.”
The interview process should also be objective and informal. Interviewers should conduct an interview without pre-conceived notions and avoid asking questions that elicit a yes or no answer. It is also helpful to pose questions in different ways to see if they elicit the same responses and verify those answers against documented evidence to determine if it supports the information.
“Don’t assume somebody is lying,” Nicholas cautions, explaining that contradictions and conflicts in witness statements are normal, as people interpret information differently and might have seen the event from different angles.
All information obtained should be recorded and verified with the interviewee, using photos, sketches and diagrams as appropriate or necessary, and review notes with the witness or use witness statements. Lastly, keep lines of communication open. “Safety does not happen because you wish it to. You actually have to take action,” she says.
Jean Lian is the editor of OHS Canada.