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A.
General. This chapter sets forth guidelines for investigating
workplace accidents. All job-related fatalities and catastrophes,
however reported, shall be investigated as thoroughly and
expeditiously as resources and other priorities permit, but no later
than 24 hours after notification. In addition, MOSH may investigate
accidents which have resulted in one or more of the following
conditions:
Serious
injury
Significant publicity
Extensive property damage
B.
Purpose. The primary purposes of MOSH accident investigations are to
determine whether:
1. A
violation of MOSH standards, laws, regulations or known recognized hazards
that contributed or may have contributed to the occurrence;
2.
The accident could have been avoided had proper safety and health
practices been enforced and followed;
3.
Current MOSH standards should be revised and/or new standards adopted to
remedy the hazardous working condition which led to the accident.
C.
Definitions. The following definitions apply for purposes of this
chapter:
1.
Fatality. An employee death resulting from an employment accident or
illness; in general, from an accident or illness caused by or related to a
workplace hazard.
2.
Catastrophe. The hospitalization of three or more employees resulting from
an employment accident or illness; in general, from an accident or illness
caused by a workplace hazard.
3.
Hospitalization. To be sent to, to go to, or to be admitted to a hospital
or equivalent medical facility for examination or treatment, irrespective
of whether or not treatment was actually provided or the length of stay in
the hospital.
D.
Processing and Reporting of Accidents for Investigation.
1.
Information about an accident, which may be subject to MOSH investigation,
may be received by any MOSH employee at any time. The information could be
received via telephone, newspaper, radio or television. Information about
an accident received directly by a MOSH employee is to be reported
immediately to their MOSH Supervisor who will then report it to MOSH
Operations. In the event the MOSH Supervisor is unavailable, MOSH
Operations is to be contacted.
2. It
is important that the Operations Office immediately receive all
pertinent information that can be obtained from newspapers or other
sources. It is not necessary to have available all the pertinent facts to
make the initial telephone call. As more facts become available, they can
be relayed to the Operations Office in subsequent calls. The following
information shall be reported to the Operations Office as soon as
possible:
(1)
Name of company, location of accident, and type of business.
(2)
Time of accident.
(3)
Type of accident (fire, explosion, building collapse, etc.).
(4)
Number injured/fatalities.
(5)
Number of persons hospitalized.
(6)
Number of persons unaccounted for.
(7)
When MOSH personnel are expected to arrive at the scene.
(8)
Identify who is in charge at scene (if immediately known).
3.
The Operations Office shall immediately notify the Assistant
Commissioner/Authorized Representative and other necessary persons of each
fatality and/or catastrophe. The Operations Office will contact the
Medical Examiner's Office in all fatal cases and obtain a copy of the
death certificate and postmortem examination.
4.
Immediately upon receipt of information involving a catastrophe and/or
fatality, the Operations Office shall assign the investigation to the
Regional Office having jurisdiction, and notify them via telephone.
5.
Accidents not involving a fatality or catastrophe, if received in the
Region, the Region will notify the Operations Office. Even in the absence
of death or multiple injuries, particular emphasis should be placed on
investigating other types of accidents.
E. Emergency Response Protocol.
1. Incident Command
System.
a.
MOSH Staff will function through the Incident Command Structure that
is used by the fire and rescue services. MOSH will work through the
Incident Commander at sites where the Incident Command System has been
implemented. Any deviation from this practice shall only be considered
when the safety of rescue personnel is compromised.
NOTE: MOSH’s
role at emergency response sites is predominantly investigative. MOSH
CO/IHs have no authority to direct rescue operations. MOSH can
assist public safety officials in ensuring safe and healthful
practices, in order to prevent injury and death.
2. Communication.
a. The CO/IH shall keep
the MOSH Supervisor informed of all facts so that information can be
relayed to the Operations Office in a timely manner.
3. Incident
Supervisor.
a.
If a high profile or multiple injury scenario occurs a MOSH Incident
Supervisor will be required to be present.
b.
The MOSH Incident Supervisor will be responsible for directing the
on-site investigation while maintaining communication with MOSH
Operations.
c.
Upon Arrival, the MOSH Incident Supervisor will evaluate the
incident, determine what resources are required and call for any
additional equipment or personnel, if needed.
d.
The MOSH Incident Supervisor will ensure that MOSH personnel follow
all proper procedures and adhere to the investigation policies so
stated in the FOM.
(1)
Responsibilities include but are not limited to:
(a)
Establish contact with the Incident Commander.
(b)
Wear and ensure the use of the appropriate personal protective
equipment by all MOSH Team Members.
(c)
Any unusual situations related to the emergency operations shall be
brought to the attention of the Incident Commander for mitigation.
(d)
Communicate with the MOSH Operations Office.
4. MOSH
Principal Investigator.
a.
MOSH Supervisors shall evaluate the incident and assign the
appropriate resources to any response. A MOSH Principal Investigator
will be assigned along with the appropriate support personnel.
b.
The MOSH Principal Investigator has the following duties:
(1)
Ensure that the investigation follows established procedures defined
in the FOM.
(2)
Generate the case file.
(3)
Determine persons to be interviewed and persons to obtain statements
from.
(4)
Maintain investigation event log.
(5)
When team support is required, ensure that all support personnel are
assigned specific tasks to accomplish. Collate all appropriate
information.
(6) Determine
causal factors and review all information with the MOSH supervisor.
(7) Work in
concert with MOSH Incident Supervisor.
5. MOSH Support
Personnel.
a. MOSH support
personnel could be assigned the following duties.
(1) Sketching
the site;
(2)
Photographing the entire scene;
(3) Taking and
recording measurements;
(4) Inventory
scene of equipment and people; and
(5) Keeping a
record of all persons present.
b.
MOSH support personnel will remain on scene until released by the
MOSH Incident Supervisor or MOSH Principal Investigator.
6. CO/IH Duties. The CO/IH assigned the duty of MOSH Principal
Investigator must look at all aspects of the incident, gather the
appropriate facts, and be able to identify the causal factors of the
accident in a clear and concise manner. Every factor relating to an
incident must be discovered, evaluated, and analyzed in order to
determine the actual sequence of events and causal factors of the
incident. The investigation must be able to accomplish two goals.
o
determine the cause of the accident.
o
prevent it from happening again.
a.
Accidents will be responded to promptly. Once a preliminary
assessment has been made and reported to the MOSH Regional
Supervisor, that supervisor will define the scope of the
investigation and assign the Principal Investigator and team members
as required.
NOTE:
Getting to the scene of an accident promptly is extremely important
to assure that all imminent danger hazards are mitigated or abated.
In all cases, after an accident has happened and time passes it
becomes more difficult to obtain facts accurately. Prompt
investigation improves the likelihood that the accident will not
reoccur due to the elimination of one or more causal factors.
b. When a team of CO/IHs
is necessary, a MOSH Principal Investigator will be designated by the MOSH
Supervisor. The team will provide support under the direction of the MOSH
Principal Investigator. The MOSH Supervisor will ensure that the team has
all the tools available to conduct a comprehensive and effective
investigation. A post investigation briefing will be held to discuss
effective and ineffective investigation methods. A report will be prepared
for the team.
c. The CO/IH must be
able to understand the operation involved in the incident and be able to
effectively explain that operation and what should occur during normal
operations. The CO/IH will have an operating knowledge of the equipment,
operation and process involved by the end of any investigation. The CO/IH
must be able to determine what Direct, Indirect and Basic causal factors
were present at the time of the incident.
F.
Pre-Investigation Activities. It is essential to the proper
conduct of an accident investigation that preparations are carefully
made. MOSH will often be the subject of public scrutiny in the conduct
of such investigations, and it is imperative that they be complete and
professionally competent.
1.
MOSH Operations and the MOSH Supervisor shall determine which accidents
will be investigated. If necessary, preliminary information and photos may
be obtained by support personnel to aid in the supervisor's assessment to
conduct an investigation and or select a principal investigator.
2. No CO/IH shall begin to investigate any accident until directed to do so by
the MOSH Supervisor. When an accident or incident occurs CO/IH's with
expertise in that particular field shall be selected and dispatched to the
location of the accident or as support for the MOSH Principal
Investigator.
G.
Equipment. Prior to leaving for the accident scene, the team or CO/IH,
as applicable, shall select the test equipment and the personal protective
equipment necessary to support the investigation.
NOTE:
Emergency testing equipment or special accident investigation
instruments or protective clothing need not be set aside in MOSH Regional
Offices for emergency or accident investigation use only. All equipment
shall be available for regular use at any time provided it is available
if needed for fatality/catastrophe investigations.
H. Investigative
Procedures
NOTE: All
investigations of serious injuries, catastrophes, or fatalities will be
conducted using the same inspection procedure as outlined in Chapter
III, except as otherwise provided in this chapter.
1. Define the Scope of
the Investigation.
a.
Fatality/catastrophe investigations may include a complete inspection
of the establishment in addition to the accident investigation when
the MOSH Supervisor determines that it is warranted.
Depending on the circumstances surrounding the accident, it may be
necessary to conduct the inspection before, concurrent with, or after
the accident investigation.
b. If, in the course of
investigation, the CO/IH or team, as applicable, determines that
conditions are such that a complete inspection of the establishment should
be made, the CO/IH or designated team member shall contact the MOSH
Supervisor in charge and explain the situation, requesting further
instruction. Other areas, operations, or practices in the establishment
may have similar circumstances to those which caused the accident and they
should be identified to prevent other accidents.
c. Section 5-806 of
the Act provides criminal penalties for an employer who is convicted of
having willfully violated the Act if that violation caused death to any
employee. In an investigation of this type, the nature of the evidence
available is of paramount importance. There should be close liaison
between the CO/IH, the Assistant Commissioner/Authorized Representative,
and counsel for MOSH in any investigation which might involve a criminal
violation.
2. Assign/Select
Principal Investigator.
a. MOSH Supervisors
shall evaluate the incident and assign the appropriate resources to any
response. A MOSH Principal Investigator will be assigned along with the
appropriate support personnel.
3. Preliminary
Briefing.
a. Description of
incident
b. Define normal operating procedures (What is normal)
c. Diagram/Map area
(1) Provide appropriate measurements distance, weight, voltage, etc.
d. Location
e. Possible witness list
f. What events preceded incident
g. What happened that was different from normal procedures
4. Accident Scene.
h. Respond to scene
as quickly as possible.
(1) Investigations of
catastrophes and other accidents covered by this chapter require that the
CO/IH get to the location of the accident as promptly as possible. The CO/IH
should reduce the time spent in the opening conference by limiting remarks
to bare essentials of identification, the purpose of the visit, and the
request for an escort by employee and employer representatives. The CO/IH
should inform the employer that he/she will be available for more
extensive discussion at the closing conference.
(2) Other Agency. If
another federal or State agency is responsible for or participating in the
investigation, the MOSH Supervisor shall ensure that the CO/IH and/or the
team members are fully instructed in the relationship and the areas of
responsibility.
i. Assess scene for
hazards and take action to mitigate exposure to them.
j. Secure area. Do
not disturb evidence unless it is a safety issue.
k. Photography.
(1) Overview
from all reasonable angles
(2) Closeups
(3) From all
appropriate angles, front, back and side
l. Prepare diagrams and
sketches mark and label properly.
(1) Sketches
should be identified showing related case number, location of area
sketched and employer's name.
(2) Orient each
area sketch with an arrow pointing north.
(3) The
following information should be included in all sketches:
(a)
"Prepared by __________" (b) The
Statement "Not to Scale"
(4) Important
objects shall be labeled inside their outlines. If there is not
sufficient space in which to label an object, it may be necessary to
use letters or some other identifiers with a key located at the
bottom of the diagram or on an attached page.
(5) Indicate
distances between objects.
(6) A sketch or
diagram can also be used to orient photographs. A letter or number
should identify the location and direction of each photograph and
that identifier placed on the back.
m. Keep notes and names
of all people you have contacted at the scene.
n. MOSH policy
regarding information released to the public or news media dealing with
investigation of fatalities, catastrophes or other accidents is NOT
to comment on ongoing investigations. Any information would be released
from the Office of the Commissioner of Labor and Industry. It is not MOSH
policy to provide a continuing flow of facts or to issue periodic updates
on the progress of the investigation.
o. If the family or
estate representative contacts the agency, they shall be referred to the
Office of the Assistant Commissioner for MOSH. The Assistant
Commissioner/Authorized Representative will summarize by telephone MOSH's
involvement, scope and direction of the investigation. The Assistant
Commissioner/Authorized Representative will endeavor to keep the
individual making the contact informed of the final disposition of the
MOSH investigation.
5. Conducting
Investigative Interviews and Taking Statements. The fundamental purpose of
interviewing is to obtain an accurate and comprehensive account from the
person being interviewed of all pertinent facts, interpretations, and
opinions that relate to the accident being investigated. To accomplish
this objective, the CO/IH must conduct the interviews in a professional
manner. The person being interviewed must be free to describe the accident
and provide other information without being influenced either by the CO/IH's
personality or the setting in which the interview is taking place.
a.
A CO/IH must know whom to interview in order to start the
investigative proceedings, and the best place to start is to ask the
employer to develop a list of names (to be provided at the opening
conference). Also, ask each person interviewed for the names of others
who were present.
b.
Much of your investigation will consist of interviewing. Some of the
people interviewed may have witnessed the accident. Others may be able
to provide only one or two facts, such as work habits of the injured
or the history of past troubles with equipment. Do not predetermine
that a person is not worth interviewing, especially if that person has
indicated that he or she has something to say.
c.
The best interview meets the criteria of being complete, correct, and
pertinent. The CO/IH's goal is to hear and record all the information
given. Focus your interview questions on the events that led up to the
incident. The best interviewers use a simple formula that should
"get it all". That formula is to ask the seven key
questions:
(1)
Who? Who was injured? Who installed the equipment? Who was responsible
for it? The nature of the accident will determine the exact questions
you should ask.
(2)
What? What happened? What did the people do? What equipment or
facilities were involved? This line of questioning should lead you
into actions, events, and physical objects.
(3)
Where? Where was each worker located? Where was the overhead crane?
Where was the fire fighting equipment? The "where" questions
have a way of helping you determine what caused the accident and
discover the conditions that brought it about.
(4)
When? The answers to the "when" questions should contain
more information than a clock reading. Though time is important,
relationships are often even more important. "When"
questions often elicit information on relationships between pairs of
activities or events.
(5)
How? This type of question should provide information on the
interaction and relationship among the activities and events (going
beyond their timing and into the functional relationships among them).
"How" questions refer not only to the action of equipment
but to action of the injured as well.
(6)
Why? Answers to "why" questions should give you some clues
as to corrective measures, since the answers will focus on unsafe acts
or hazardous conditions.
(7)Is
there anything you care to add to this statement?
d.
Victims usually make terrible witnesses. They remember very little due
to trauma. Interview persons with like duties to determine what should
have been.
e. Witness --
someone who was there when it happened or saw something prior to the
incident.
f. Statements
(1) Written and
structured
(2) Best format
is a question and answer format
(3) Put persons
at ease, discuss what transpired
(4) Commit to
paper
(5) Sign, date
and witness
I. Reports.
1. The final step in an
accident investigation is the preparation and submission of a final
report. OSHA Form 170 will be used whenever a CO/IH or team investigates
an accident covered by this chapter. In addition to the required forms, a
narrative and log shall be prepared and submitted. Collate, review and
discuss the information you compiled during the investigation with your
MOSH Supervisor.
2.
Prepare a clear and concise report. The narrative will contain at least
the following:
a.
Where and when the accident occurred.
b.
Who and what were involved.
c. An
account of the accident.
d.
Sequence of events that led to the accident.
e.
Determination of the causal factors:
(1)
Basic Cause
(2)
Direct Cause
(3)
Indirect Cause
f.
What violation to the Act existed at the time of the incident.
g.
Recommendations.
h.
What has been done to prevent the reoccurrence of the incident.
EXAMPLE:
On 9/2/84 at 9:00 a.m. I was telephoned at home and
informed by Perry Augusta, Supervisor, that an accident
had occurred at Harry's Dry Cleaning Plant located at
5601 Montgomery Street, Poolstown, Maryland 26195. I
responded to the scene and arrived at 10:15 a.m. the
same day. The establishment is of single story block
masonry construction on concrete slab 17,000 sq. ft..
This establishment uses a chemical process for cleaning
of patrons' garments. The process entails removing soils
from the garments through use of a non-aqueous synthetic
solvent (perchloroethylene). Upon arrival I observed a
tubular welded mobile scaffold 20 feet high (4 Bucks)
with no guardrails. All windows in plant were open and
exhaust fans were running. I detected a faint smell of
ether.
Initial
information revealed that employee Charles Ward,
maintenance worker, was working with one other
co-worker, John Davy, installing electrical conduit for
new equipment. According to Mr. Davy, Mr. Charles Ward
fell from the top of the scaffold. Mr. Davy was not on
the scaffold at the time of the fall because he had felt
dizzy, lightheaded and had a headache so he came down
for an early break.
i.
The CO/IH's log should be developed during the investigation and
should chronologically list the CO/IH's activity during the
course of the investigation. If more than one CO/IH was involved
in the investigation (team effort), one log shall be submitted
for each CO/IH. The log may be developed following this example,
which covers only one day.
EXAMPLE:
9/2/84
0900
Assigned investigation
1015
Arrived at scene
1030 Held
brief opening conference
1040 Viewed
accident site
1100
Interviewed John Davy, Maint. Worker
1130
Interviewed Mary Wright, Presser
1200
Interviewed Mark Castell, Machine Operator
1300
Reviewed safety program
1430
Reviewed safety data sheets
1500
Contacted Supervisor to request assistance from Health
Effects Unit
1530
Contacted Industrial Hygiene Office for assistance with
MSDS
1615
Talked with Dr. Marshall from Medical Examiner's Office.
He called in reference to accident site.
1630
Discussed case with Supervisor in Regional Office.
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