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WATER DISTRICT

ADMINISTRATIVE PROCEDURE

SUBJECT: Number Effective Date: Page 1 of 15

SAFETY INCIDENT -
IX-9 Issued: 09130109
INVESTIGATION
PROCEDURE

PURPOSE:

The Safety Incident Investigation Procedure provides a systematic approach to safety incident
investigation to determine initiating events, contributing events, root cause, and contributing
causes. The incident investigations must identify appropriate recommendations that address the
problems and identify root causes. These may include and are not limited to upgrading facilities,
engineering controls, standard procedures and policies, personal protective equipment, and/or
training for affected employees. Implementation of this procedure is intended to prevent and/or
mitigate similar incidents and accidents in the future.

POLICY:

All safety incidents, including work-related injuries, accidents, regulatory violations, and near
misses, will be investigated to determine root causes, and recommendations will be developed,
communicated, and implemented to prevent recurrence of the accidentlincident. This procedure
applies equally to District and District responsibilities for non-District personnel and equipment.
All safety incidents, accidents, and near misses are included within the scope of this policy. (A
near miss is a condition or an incident where but if not for a fortunate break in the chain of
events, there is near certainty that an injury or property damage would have occurred).

ROLES AND RESPONSIBILITIES:

SAFETY OFFICER is responsible to:

Timely review all Cal-OSHA recordable injuries, vehicular accidents, accidents

involving property damage, and near miss events to assess cause and prevention;

Monitor corrective actions as appropriate to remedy an unsafe working condition,

facility, equipment, location or practice;

Ensure correct documentation and report the results of the incident investigation,
including findings and recommendations, to the District Safety Committee, the
department manager(s) involved, and the Assistant General Manager-Engineering
& Construction for their review. Ensure report results have been adequately
reviewed by key managers and supervisors prior to final issuance of report
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findings. (See "Reporting and Communication" for final distribution and website
posting.)

4. Ensure District procedures and policies are updated by the responsible manager
and that Safe Practices Manuals are updated to reflect improvements based on the
findings or recommendations of the investigation.

MANAGERS are responsible to:

1. Immediately report accidents and near miss events to the Safety Officer;

2. Participate in investigations of serious incidents as a member of the Accident

Review Panel as assigned (see "Accident Review Panel");

3. Review all accidentslinjuries of subordinates and implement corrective action and

safety modification and/or employee training as recommended by the incident
investigation.

SUPERINTENDENTS 1 SUPERVISORSICONTRACT ADMINISTRATORS are responsible to:

1. Immediately report accidents and near miss events to their Department Manager,
perform an initial investigation, and timely submit AccidentIInjury Reports to the
Safety Officer within 24 hours for accidents and within 48 hours for near misses
(note that while Contract Administrators are not responsible for
contractor/consultant personnel safety, they must comply with this policy in
reporting and investigating as defined herein related to District responsibilities);

2. Review all accidents/injuries of subordinates and assess corrective action(s) and

the need for safety modification and/or employee training.

THE DISTRICT SAFETY COMMITTEE and SITE SAFETY COMMITTEES are responsible to
receive the safety incident investigation report for review from the Safety Officer, and as
requested, assist with the incident investigation as members of the Accident Review Panel as
requested by the Assistant General Manager - Engineering and Construction and as assigned by
the Chair of the Safety Committee (see "Accident Review Panel").

ALL EMPLOYEES are responsible to immediately inform supervisors of accidents, near miss
events, unsafe conditions, unsafe equipment, and known unsafe practices, and participate in the
incident investigation as required to meet the objectives of this administrative procedure. Should
there be any doubt to whether an incident be reported, employees should err on the side of
conservative reporting and communication.
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INVESTIGATION PROCEDURES:

All safety incidents are to be investigated in a timely manner (no more than 24 hours) to
determine the root cause(s) and contributing factors involved. The extent of the investigation
depends on a number of factors including the severity or potential severity of the incidents.

DISTRICT FORCES

The employee's supervisor is responsible for performing an initial investigation within 24 hours
to find out the root cause(s) of the incident, notifying and consulting with the Safety Officer as
needed to complete the investigation and for correcting the situation, in consultation with the
Safety Officer, to prevent its recurrence. The purpose of safety incident investigation is poJ to fix
or find blame, but to identify the root cause and find preventative measures that can help to
prevent future accidents. Appendix A provides a root cause analysis form to assist in the
investigation process.

Upon notification of an accident or near miss, the supervisor in consultation with the Safety
Officer as needed, must:

Supervisor Guidelines
Accident Near Miss
provide for immediate medical
attention

reporting and investigation forms and investigation forms

interview injured personnel and interview witnesses
witnesses I

examine the injured employee's work I examine the employee(s) work area for
I area including field evaluation, for I causative factors I
( causative factors I I
I review established procedures to 1 review established procedures to I
ensure they are adequate and were ensure they are adequate and were
followed followed
review training records of affected review training records of affected
employees employees
determine all contributing causes to the determine all contributing causes to the
I accident 1 near miss
I
report the incident to the Safety Officer report the incident to the Safety Officer
take corrective actions, in consultation take corrective actions to prevent
I with the Safety Officer, to prevent the I recurrence I
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accident/exposure from reoccurring

record all findings and actions taken or record all findings and actions taken or
to be taken to be taken
communicate "lessons learned" in communicate "lessons learned" in
safety traininglmeetings safety traininglmeetings
Note: The guidelines listed provide a checklist for an initial investigation. Additional or
modified steps should be used as appropriate to fit the case.

The supervisor's initial findings and any immediate corrective actions must be documented on
accidentlinjury forms and sent to the Safety Officer within 24 hours of notification of the
accident. Near miss reports are sent to the Safety Officer within 48 hours. The supervisor shall
determine appropriate corrective actions in consultation with the Safety Officer. It is important
that information collected be objective, accurate and complete. A subject matter expert and/or an
Accident Review Panel may be included in an incident investigation as needed to ensure an
objective, accurate and complete investigation (see "Accident Review Panel").

If an accident results in the hospitalization of an employee or fatalities, the supervisor or

department manager must notify the Safety Officer immediately. The Safety Officer will lead the
investigation (not the Supervisor/Superintendent/ContractAdministrator) and must report the
incident to the local Cal-OSHA office within 8 hours.

The Safety Officer will review each accident or injury report within 24 hours of receipt to ensure
that the investigation was thorough, that all immediate corrective actions are completed, and that
long-term follow-on actions are clearly defined with adequate schedule and resources for
completion. Investigations and/or corrective actions that are incomplete will be routed back to
the supervisor for further follow-up, with specific recommendations noted by the Safety Officer.
Investigations should strive to clarifjr discrepancies and conflicts of information so to identifj
root causes. However, in the case of conflicts of information that cannot be resolved, all relevant
information should be included in the investigation to ensure a complete perspective of the event.
The supervisor, superintendent and/or manager will work with the Safety Officer to establish
action deadlines. Corrective actions not implemented in a reasonable period of time as identified
by the agreed deadline will be brought to the attention of the supervisor's manager by the Safety
Officer and to the Safety Committee.

CONTRACTOR/CONSULTANT FORCES

Where safety incident investigations involve District contractor or consultant forces, the focus of
the investigation is on the District's role, responsibilities and lessons in the incident (for
example, reviewing how the District reviewed and enforced its contract requirements). The
investigation is not focused on the contractor's safety procedures and policies. It is focused on
learning and communicating how the District can improve its safety culture such as through its
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safety procedures, policies and District staff actions. The investigation is to be conducted with
the same approach, procedure and purpose as a District-forces investigation as defined above.

OTHER CONSIDERATIONS

For all serious incidents, as determined by the Assistant General Manager - Engineering &
Construction, an Accident Review Panel (see "Accident Review Panel") is assembled to
investigate. A serious incident is generally defined as an incident by either scale of impact,
complexity of causes, magnitude of importance of lessons and improvements, or potential for
conflicts of interest and requires an independent team of investigators.

If during the course of the safety incident investigation it becomes evident that a violation of
District policy may have occurred, the Department Manager notifies the Human Resources -
Risk Division Manager of the violation, who conducts the appropriate evaluation and
notifications required by District policy and Memorandums of Understanding. The safety
incident investigation is not a Human Resources-led process, and does not assess blame or need
for personnel actions. Any Human Resources-led investigation collects its own relevant
information and statements for its specific purpose of evaluating a potential District policy
violation.

REPORTING AND COMMUNICATION

A monthly status report on all serious incidents will be routed from the Safety Officer to
supervisors for discussion at safety tailgate meetings. Supervisors' review of minor
injurylincidents should also be discussed at safety tailgate or staff meetings. The status reports
will be recorded and reviewable on the District safety website and will be continuously
maintained on the District server under the direction of the Safety Officer. Actions resulting
from safety investigations will be tracked by the responsible manager and results will also be
recorded and reviewable on the District's safety website as reported by the Safety Officer. In
addition, all final safety investigation reports will be routed to the following Distribution as a
standard protocol: Chair of the Safety Committee, AGM-EngineeringIConstruction, AGM-
Planning/O&M, AGM-Administration, Director of O&M, Director of Construction, Engineering
Manager, Human Resources-Risk Division Manager, Watershed and Lands Manager, Director of
Finance, Environmental Compliance Officer, Water Operations Manager, Maintenance Manager
(Storage and Conveyance), Maintenance Manager (Distribution).

Department HeadsIDivision Managers are responsible for correcting any deficiencies found
during the investigation process, and communicating the incident investigation results to District
staff.

The Safety Officer is responsible for verifying that corrective action(s) islare implemented. All
serious incidents are tracked and communicated on an incident log maintained by the Safety
Officer.
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ACCIDENT REVIEW PANEL

The Accident Review Panel assesses the preventable or non-preventable nature of accidents or
injuries and identifies any applicable safety problems which may exist. It also recommends
revision to safety procedures, facility or equipment modification, and/or safety training, where
appropriate, to minimize similar incidents in the future.

The Accident Review Panel is comprised of the Safety Officer and Manager most closely
connected with the specific safety incident, and an appropriate representative from the District
Safety Committee and/or Site Safety Committee. The Safety Committee Representative should
be experienced or have knowledge or expertise relevant to the subject of the investigation, and
will be assigned by the Chair of the Safety Committee. A subject matter expert may be selected
to be part of the panel as well, for example, if the Safety Committee Representative(s) are not
familiar with the operations related to the incident. The Panel is convened on an as needed basis
as determined by the Assistant General Manager - Engineering and Construction. The Accident
Review Panel is recommended for review and findings for serious incidents (see "Investigation
Procedures") that require a higher degree of experience, greater number of resources and a
greater level of independence than a standard investigation by
Supervisor/Superintendent/Contract Administrator.

The Accident Review Panel shall use a Root Cause Analysis procedure to conduct the
accidentlinjury review. The review must not seek to establish fault or blame. See Appendix A.

APPROVED:

General Manager
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Appendix A
CCWD Root Cause Analysis Procedure

Employee / Incident Information:

Employee Name:
Date of I-Iire: Job Title:
Total Years in Job classification: Shift Start Time: Shift End Time:
Exact location of incident (BldgILevellArea):

Type of activity at time of incident (i.e., concrete cleanup):

Specific task at time of incident (i.e., finishing, sweeping):

How long had the worker been performing specific task:

Typical task for the week:

Typical task for the day:

Injury / Illness Information:

Date of Incident: Day of Week: Time of Incident:
Type of Injury: Part of body injured:
Employee's Direct Supervisor:
Working on a crew? (Yes No
Name of Witnesses
(list):
PPE worn at time of incident
(list):
Include Pertinent Photos of Incident Scene
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Interview Forms

Interviewee # :
Name (Interviewee):
Job Title:
Date of Interview:
Name (Interviewer):
Job Title:

Note: Interviews should be structured to allow full discussion of incident and to provide as much
information as possible, relevant to deJining root causes. Thefollowing questions should be
used as guidelines to encourage discussion during the interview.
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Incident Timeline:
Describe in detail the sequence of events involving this incident in as much detail as possible.
The timeline should include when the incident started and what constituted the start and include
information on the activities prior to the incident, and any information that may be relevant (for
example, activity assigned, tail-gate discussions [if any] on the activities, directions or actions
directly or indirectly related). It is better to include too much detail than risk leaving something
out that could be relevant. For example, many incidents have multiple factors, each of which
would not necessarily lead to an incident, but together make an incident very likely.
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.
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Environment: Yes No
This is used to find out what the physical conditions in the environment were like
during the time of the accident.
1. Did temperature or weather have an effect on the incident?
2. Was poor housekeeping a problem? If yes, explain:
Comments:
3. What were the physical conditions of the area when the accident occurred?
Comments:
4. Was there another activity in the area that contributed to the way the work was
conducted, how work was scheduled, or altered the way tasks were done, etc.?
5. Was the work area congested?
6. Did noise, lighting, dust etc. have any effect on the incident'?
7. Were there any other hazards from the surrounding area that played a part in the
incident?
Contributing Factors:

Personnel: This section is to examine the condition of the injured worker. Y e s No

1. Was the injured worker familiar with the job and procedures?
2. Was the employee properly trained?
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3. Was fatigue a factor? How many hours have they worked in the past day and
past week? If yes, please explain.
Comments:
4. Was the injured worker authorized and qualified to do this operation?
5. Did the way the work was conducted result in awkward postures, excessive
stress or other musculoskeletal risk factors?
6. Was there enough time to do the task safely?
7. Assuming there was enough time to do the task safely, was there external
pressure to cut costs, cut time etc. that would have impacted safety?
Contributing Factors:

Job Procedure: Yes No

This pertains to the actual work being performed at the time of the accident.
1. Was a safe work procedure usedr?
2. Was there a written procedure?
3. Had conditions changed to make the normal procedure unsafe?
4. Was there a job hazard analysis? Were the protective measures identified by
the job hazard analysis?
5. What was the injured worker doing at the time of the accident?
6. Were approved procedures being followed?
7. Could the location of the work area or access to the work area been improved?
8. Was the hazard identified in safety inspections?
9. Did the worker(s) identify the hazards? rl
10. Was training conducted?
1 1. Were safety procedures reviewed prior to the start of the activity?
12. Was there adequate safety signage present?
13. Were the protective measures identified in safety inspections?
14. Were written plans or procedures for protection present or available? 0.
15. Were the protective measures readily available?
16. Did the worker follow the established procedures or requirements? 17
17. Did the worker obey safety signs or barricades?
18. Did the worker use tools or equipment in a safe manner?
19. Was there an inadvertent error or not paying attention?
20. Did the worker recognize the hazard'?
2 1. Did the worker perceive production pressures?
Contributing Factors:
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Management: Y e s No
Management holds the legal responsibility for the safety of the jobsite; therefore we
need to examine the role of both the supervisors and management systems in place.
1. Were safety rules pertinent to work performed communicated to and
understood by all employees?
2. Were they being enforced?
3. Was there adequate supervision?
4. Was sufficient time allocated to perform the jobltask safely?
5. Were workers trained to do the work?
6. Had hazards been previously identified?
7. Had procedures been developed to overcome them?
8. Were unsafe conditions corrected?
9. Are daily tailgateltailboard topics and hazards being communicated in
tailgateltailboard meetings?
10. Is safety being fully discussed in the lead meetings or are these meetings being .

held at least weekly?

11. Is information from the lead meeting making it to staff?
12. Are site orientations not being conducted, not effective or otherwise not
addressing the hazard? If yes to any, comment.
13. Are high hazard pre-task meetings being held?
14. Are sub pre-construction meetings being held for every subcontractor and
safety adequately discussed?
15. Are items addressed in the safety inspections being addressed in a timely
manner or otherwise being communicated to the correcting
0
supervisorlmanager?
16. Are workers taking the necessary steps to communicate hazards to supervisors
or coworkers?
17. Are hazards being communicated to all affected parties in a timely manner?
18. Are there any other barriers to hazard communication on the project?
Contributing Factors:
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Root Cause Analysis Roll Up

Summary:
Please go through the last five sections of the Root Cause Analysis Worksheet and summarize all
of the contributing factors to the incident.
Contributing Factors Corrective Action Person Due Date
Responsible
1. Equipment:

2. Environment:

3. Personnel:

4. Job Procedure:

5. Management:

Root Cause:
1.

2.
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Root Cause Analysis Final Report

Department:
Injury Date:
Jobsite of the Injured Worker:
Occupation of InjuredIImpacted Worker:
NatureISeverity:

Incident Summary:

Interviewee(s) (and title(s)):

Interviewer(s) (and title(s)):
Person(s) injured:

Contributing Factor(s):
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Root Cause (s):

Corrective Action Plan: Person Responsible: Due Date: