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APPENDIX A: ACCIDENT REPORTING CHECKLIST For serious injuries, the paperwork is secondary. Get the injured employee to the hospital ASAP and tell them it is a workplace injury. PAPERWORK All forms need to go PCSU (not RCUH) no later than 24 hours after the accident (federal OSHA legal requirement) and preferably by the close of business on the day that that injury occurred. Faxed copies are fine as long as they are readable but scans/emails preferred (i.e. a photo of the report and email). SUPERVISORS REPORT OF INDUSTRIAL INJURY (3 pages) o Page 1-3: Supervisors should fill out these pages based on interview with employee and witnesses. Admin should provide background information as needed. If able, employee must sign on page 3. Photos of accident site are also required. EMPLOYEE/CLAIMANT CONSENT FORM (1 page) o Check the top box and have the employee sign. o One copy to the doctor, one copy goes back to PCSU (If you don’t have a copy machine, have the employee sign 2 copies) Doctors note for any visit is required and must be turned into PCSU via email/fax ASAP. A clear digital photo of the note attached to an email often easiest. A copy must also be sent to injured person’s supervisor. Attn: Michelle Miyata ([email protected] fax: 956-4710) TIPS FOR FILLING OUT THE INJURY REPORT Use the OANRP address and phone number rather than the employee’s personal information. For Part B, yes or no answers are not adequate. Please elaborate. Safety Officer signature = Dr. Smith Supervisor signature = Supervisor for that employee (or on duty the day of the injury if need be) AT THE DOCTOR’S/HOSPITAL Explicitly state that this is a work place injury. Give them our carrier information: First Insurance Company of Hawaii FiRMS Claims Services P.O. Box 2866 Honolulu, Hawaii 96803 (808) 527-7711 (main line) (808) 545-3120 (fax) All injury related visits require a legible note from the doctor (stating when you were seen, any work limitations, return to work date) EMPLOYEE RESPONSIBILITIES: Report accident to supervisor ASAP Sign pg. 3 of Supervisor’s Report Sign Claimant Consent form Take copy of Claimant Consent form to Doctor Give health carrier info to doctor Turn doctor note to supervisor/PCSU ASAP. Note must clearly state 1) the date for a return to work, 2) whether full duty or not, 3) and if not full duty, clearly define what limitations staff member has regarding work medical status/work limitations. SUPERVISOR RESPONSIBILITIES: Notify Dr. Smith/DKS/JR/KK of accident Fill out Supervisor’s Report Part A, pgs 1-3 Conduct accident investigation/review Sign and submit injury report within 24 hrs Fill out pg 3 of Supervisor’s Report Submit claimant consent form to PCSU Safety Officer (Dr. Smith) signs pg. 3 Followup with employee on their Obtain clearance from RCUH before returning employee to work on light duty.

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Page 1: APPENDIX A: ACCIDENT REPORTING CHECKLISTmanoa.hawaii.edu/hpicesu/SAFETY/appendices.pdf · APPENDIX A: ACCIDENT REPORTING CHECKLIST ... yes or no answers are not ... This section of

APPENDIX A: ACCIDENT REPORTING CHECKLIST For serious injuries, the paperwork is secondary.

Get the injured employee to the hospital ASAP and tell them it is a workplace injury.

PAPERWORK

All forms need to go PCSU (not RCUH) no later than 24 hours after the accident (federal OSHA

legal requirement) and preferably by the close of business on the day that that injury occurred.

Faxed copies are fine as long as they are readable but scans/emails preferred (i.e. a photo of the

report and email).

SUPERVISORS REPORT OF INDUSTRIAL INJURY (3 pages)

o Page 1-3: Supervisors should fill out these pages based on interview with employee and

witnesses. Admin should provide background information as needed. If able, employee

must sign on page 3. Photos of accident site are also required.

EMPLOYEE/CLAIMANT CONSENT FORM (1 page)

o Check the top box and have the employee sign.

o One copy to the doctor, one copy goes back to PCSU (If you don’t have a copy machine,

have the employee sign 2 copies)

Doctor’s note for any visit is required and must be turned into PCSU via email/fax ASAP. A clear

digital photo of the note attached to an email often easiest. A copy must also be sent to injured

person’s supervisor. Attn: Michelle Miyata ([email protected] fax: 956-4710)

TIPS FOR FILLING OUT THE INJURY REPORT

Use the OANRP address and phone number rather than the employee’s personal information.

For Part B, yes or no answers are not adequate. Please elaborate.

Safety Officer signature = Dr. Smith

Supervisor signature = Supervisor for that employee (or on duty the day of the injury if need be)

AT THE DOCTOR’S/HOSPITAL

Explicitly state that this is a work place injury.

Give them our carrier information:

First Insurance Company of Hawaii

FiRMS Claims Services

P.O. Box 2866

Honolulu, Hawaii 96803

(808) 527-7711 (main line)

(808) 545-3120 (fax)

All injury related visits require a legible note from the doctor (stating when you were seen, any

work limitations, return to work date)

EMPLOYEE RESPONSIBILITIES:

Report accident to supervisor ASAP

Sign pg. 3 of Supervisor’s Report

Sign Claimant Consent form

Take copy of Claimant Consent form to Doctor

Give health carrier info to doctor

Turn doctor note to supervisor/PCSU ASAP.

Note must clearly state 1) the date for a return

to work, 2) whether full duty or not, 3) and if

not full duty, clearly define what limitations

staff member has regarding work medical

status/work limitations.

SUPERVISOR RESPONSIBILITIES: Notify Dr. Smith/DKS/JR/KK of accident

Fill out Supervisor’s Report Part A, pgs 1-3

Conduct accident investigation/review

Sign and submit injury report within 24 hrs

Fill out pg 3 of Supervisor’s Report

Submit claimant consent form to PCSU

Safety Officer (Dr. Smith) signs pg. 3

Followup with employee on their

Obtain clearance from RCUH before returning

employee to work on light duty.

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Date/Field Leader Initials

Activity

Comm: (Pacmer/Heli-Radio/Batteries/Cellular Phone) and lunch, water, maps

Weather Report check/changes anticipated

Ta

sks

Ta

sks

Backpacking, hiking and fieldwork

(First Aid/CPR, Medivac Training) Field ops Stand Down Conditions: Severe weather warnings ie: flash flood and high wind warnings

Emergency paperwork

First Aid Kit

Safety briefing

Bright-colored clothing

Footwear

Raingear

Water

Webbing

Using hand/power tools

(Chainsaw Training) Helmet

Saw/Weed whacker chaps

Leather gloves

Eye protection

Ear protection

Footwear

Pesticide usage

(State of Hawaii Pesticide Training)

Rubber gloves

Eye protection

Dry bags, tubs, water

Coveralls (as needed)

Respirator

4WD vehicle usage

(Accident Avoidance Training/4wd eval. Completed, First aid kit)

Winch

4WD tires

Tow straps

Shovel

Use of helicopters

(Training. Flight plan/safety briefing, heli-manager,heli-risk assessment)

Flight suit

Flight helmet

Gloves/cotton clothes

Leather boots

Sling loading by

helicopter

(External Load Training, heli-crash kit for heli-bases)

Swivel/Carabiner

Sling nets/Bag/straps

Eye protection

Ear protection

Hard hat

Leather gloves

Bright clothing

UXO Area Work

(UXO Training) Flak jacket

Helmet

EOD Tech

Rappelling/Rope work

(Rappel/Rope worker Training, Site manager present, gear inspection)

Rappel helmet

Leather gloves

Haul apparatus, fall protection devices

Firearms (NRA training and Hunter’s Ed. Certification)

Ear/eye protection

Bright clothing

Night work Extra flashlight

Comm./safety plan

Adequate rest

Staff Initials for Risk assessment briefing (use back for debriefing)

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Date/ Field

leader

Debrief/Operational Review

Positive outcomes: Things to improve: Notes

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Pacific Cooperative Studies Unit

PROJECT ACCIDENT REPORT

ACCIDENT OR POTENTIAL INCIDENT

Date of occurrence: MM/dd/yyyy Day of week: Choose Day Time: HHmm

Project: Type of injury:

INJURED PERSON

Name: Job Title:

Immediate Supervisor: Safety Officer/Coordinator:

Supervisor’s Report of Industrial Injury Submitted to PCSU by: Date: MM/dd/yyyy

BACKGROUND INFORMATION

Mission and location at the time of the accident or potential incident

Activity at time of the accident or potential incident

ACCOUNT OF THE ACCIDENT OR POTENTIAL INCIDENT

Detailed description of the accident or potential incident and immediate aftermath

When and how was the Supervisor notified and Supervisor’s immediate action

Detailed description of the emergency procedures/plans used (if any and as applicable)

Eyewitness and their account of the accident or potential incident

CONTRIBUTING FACTORS

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Task

Equipment/materials

Environmental

Personnel

Management

ROOT CAUSE ANALYSIS

Unsafe acts

Unsafe conditions

Management deficiencies

FINDINGS and RECOMMENDED CORRECTIVE ACTIONS

TEAM MEMBERS

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Report prepared by: Date: MM/dd/yyyy

Date of electronic submission to PCSU Safety Manager: MM/dd/yyyy

PCSU SAFETY MANAGER COMMENTS

Date of electronic submission to PCSU Principal Investigator: MM/dd/yyyy

PRINCIPAL INVESTIGATOR COMMENTS AND RECOMMENDATIONS

Date of Final Report Approval: MM/dd/yyyy

Date of electronic submission to RCUH Human Resource Director: MM/dd/yyyy

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Guidelines for Completing the Pacific Cooperative Studies Unit (PCSU) PROJECT ACCIDENT REPORT

The Research Corporation of the University of the Hawaii (RCUH) requires all accidents to be reported within 24 hours through the RCUH Form D-25 Supervisor’s Report of Industrial Accident (henceforth referred to as RCUH Form D-25.) Due to this 24-hour reporting timeframe and sending the initial RCUH Form D-25 to PCSU, some of the reports do not provide adequate information. This PCSU Project Accident Report (henceforth Report) provides a follow up to accidents that require an employee to seek medical attention above first aid level and/or result in loss work time through Workers’ Compensation or Sick Leave. Additionally, if the Project’s Principal Investigator (PI) feels a Report should be completed for an incident that does not meet the above criteria such as an incident that had the potential of resulting in a serious accident or injury, he will notify the Project Manager/Coordinator to submit a Report. This Report provides project accountability after any serious accident or potential incident the PI feels should require a Report. During the process of completing a Report, you may uncover a previously overlooked physical, environmental, or daily operational hazards, unsafe work practices, or the need for additional training. The goal of the process is not to find fault or to point blame but to serve as a process to prevent similar occurrences, share information to other projects on the findings so they may be aware of the hazards, and to improve the safety culture of the project. Projects will submit their completed Report electronically to the PCSU Safety Manager (PCSU SM) within seven days or less following the accident or potential incident. Under certain situations such as the employee’s unavailability for interview within seven days, it will be completed as soon as possible. If the 7-day deadline cannot be met, please e-mail your PI and the PCSU SM with your estimated time of completion. To initiate the information gathering process, put together a Team to conduct the inquiry (injured or potentially affected employee and witnesses), review and analyze the factors (contributing and root causes), and make their findings with the recommended corrective actions. People making up the investigative Team should minimally be the Project Manager/Coordinator, Project Safety Officer/Coordinator, and employee’s immediate Supervisor. The Team approach will work with the larger projects but may not be practical for the smaller projects. Each Project Manager/Coordinator will determine the makeup of their Team. For the smaller projects, if help is needed, ask another island-based PCSU Project Safety Officer/Coordinator to join the Team. To complete the Report, follow the guidelines below. ACCIDENT OR POTENTIAL INCIDENT Date of accident or potential incident The calendar date of the accident or potential incident. Day of week The day of the week for the calendar date. Time The clock time the accident or potential incident occurred in military time (2400-hour clock). Project The employee’s project. If the employee was working with/for another project, list the project that was paying the employee’s salary when the accident or potential incident occurred. Type of injury A brief description such as “Machete cut to right leg while clearing trail, “Sprained left ankle while checking fences”, or “Lower left back strain when lifting water containers”. If there were no injuries in a potential incident, write “none”.

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INJURED PERSON Name Full legal name of the injured or potentially affected employee. Job Title Employee’s RCUH job description title. Immediate Supervisor Full legal name of the employee’s supervisor. Safety Officer/Coordinator Full legal name of the Project Safety Officer or Coordinator. Each PCSU project should have a person that has been delegated this title. Supervisor’s Report of Industrial Injury Submitted to PCSU by Full legal name of the person, who completed and faxed the last version of the RCUH Form D-25 to PCSU. Date Calendar date the RCUH Form D-25 was faxed to PCSU. BACKGROUND INFORMATION This section of the Report is the detailed narrative of the sequence of events that led up to the accident, or potential incident, that either resulted in the employee’s injury or had the potential to result in an accident. Mission and location at the time of the accident or potential incident What mission was the injured or potentially affected employee doing when the accident or potential incident happened and exactly where did it happen? Examples of Information required includes:

When did the mission start, was it part of a multi-day remote field workweek?

How did the employee/crew get to their base camp or trailhead?

For remote fieldwork, did they drive to their base camp, hike, or fly by helicopter?

For a single day trip, did they drive themselves from the baseyard or drive individually from home to the worksite?

What time does the employee/crew start and end their workday?

How long did it take the employee/crew to get to the location of the accident or potential incident?

How many miles did the employee travel?

Describe the terrain/vegetation type.

Describe the weather at the site and time of the accident or potential incident.

Include a map of the area and mark the site of the accident or potential incident, this may be an attachment or inserted within the text. Activity at the time of the accident or potential incident What was the employee doing when the accident or potential incident occurred. For example,

Was the employee hiking, trail clearing with a machete, chain sawing alien trees?

What position was the employee taking such as being on a trail, up a tree, crouching, leaning, or climbing?

Was safety equipment was being used? ACCOUNT OF THE ACCIDENT OR POTENTIAL INCIDENT This is the chronological systematic description of the accident or potential incident, the communication and response, and ends with the employee leaving the hospital or doctor’s office, or taking leave as applicable. The detailed narrative will allow a reader to envision the sequence of events leading up to the time of the accident that resulted in the

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employee being injured or the potential incident, and to the removal, to getting medical treatment, and being released from medical treatment as applicable. Detailed description of the accident or potential incident and immediate aftermath Describe the sequence of events that resulted in the accident or potential incident and the employee’s reaction to the accident or potential incident. Consider the following:

What happened that caused the injury or may have caused the injury?

What did the employee do immediately after realizing s/he was hurt or may have been seriously hurt?

How the injury was initially treated and who treated it?

Were there witnesses and what did they do?

What did the employee do after the wound was dressed? When and how was the Supervisor notified and the Supervisor’s immediate actions Provide a narrative on when and how (radio-whose frequency, cell phone) the employee notified the Supervisor (or someone else if the Supervisor was not available) of the accident or potential incident.

Was the Supervisor in the field or in the office, or away and another Supervisor or office staff contacted?

What time was the notification?

What did the Supervisor/office staff do upon receiving the call? Detailed description of emergency procedures/plan used (if any and as applicable) Describe the chronological sequence of events that was used to remove the injured employee from the field. Question to consider include:

Did the project initiate and follow the program’s emergency procedures/plans?

If there was helicopter retrieval, who called the helicopter, time of the call, what company, and pilot name?

Where was the helicopter and pilot at the time of response?

What time did it leave and arrive at the extraction site and where was this site?

What did the employee take with her/him when removed?

Where did the helicopter drop of the employee?

If the employee hiked out, when did s/he start and when did s/he arrive to the vehicle (and where was the vehicle)?

How was the employee transported to emergency room with time of arrival, and time of release?

If the employee did not go to the hospital but went to her/his physician’s office, state so.

If the employee did not seek medical help until the next day or several days later, describe what the employee did when s/he returned from the field until seeking medical attention.

Eyewitness and their account of the accident or potential incident: If there were co-workers in the area, full names with job description titles and a narrative of their account. CONTRIBUTING FACTORS Below is a list of standard topics that may be contributing factors that lead to up to the accident or potential incident. Task This is the activity being performed and the Team will look for answers to such questions such as:

Were the appropriate equipment or materials available and was the employee using them?

What safety precautions did the employee take?

What safety equipment (PPE) was the employee using? If available, a copy of the Job Hazard Analysis should be attached to the Report. A photo of the accident or potential incident area will be helpful to understand the site and should be included in the Report.

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Equipment/materials To answer questions for the equipment and materials used, consider the following:

Was there an equipment failure, and what caused it to fail?

Was the equipment poorly designed for the task?

Was there better equipment available for use?

Were hazardous materials involved, was it clearly labeled, and did the employee know it was hazardous?

Did the safety equipment fail?

Was the PPE appropriate for the job and was it being worn properly?

Was the employee trained to use the PPE? If a tool may have caused the injury or was in use when the injury occurred, include a photo of the equipment into the Report. If a required PPE was used with the equipment, a photo of these items should be included in the Report; an example would be a machete and the glove worn or wrap used on the machete handle, or the chainsaw, chaps, gloves, hearing, head, and eye protection. If defective equipment may have or caused the injury, a copy of the invoice should be including as an attachment to the Report; do not discard the defective equipment but do remove it from service and label as UNSAFE-DO NOT USE. Keep the item in a secured location for later disposition. Environmental This is the environmental (natural, baseyard, road, office setting, etc.) situation at the time of the accident or potential incident and questions to consider may include:

What was the weather condition like?

Was it hot, humid, cool, colder with wind-chill, foggy, smoggy?

What was the vegetation type?

What was there adequate lighting?

Was there too much noise?

Were there toxic fumes, dust, gases present? Personnel The condition of the employee must be included in the inquiry. Questions to consider may include:

Was the employee trained for the task and if so, when?

Was the employee experienced for the work being done?

Was s/he capable of physically performing the task?

Was there an underlying physical condition that contributed to the accident or potential incident?

Was the employee physically exhausted or fatigued at the time?

Was the employee under work or personal stress at the time? Management Management holds the responsibility for the safety of their employees and therefore the roles of management must be included in the process. The Team needs to determine if there were failures in the “system” that may have contributed directly or indirectly to the accident or potential incident. Questions to consider may include:

Were safety rules communicated to and understood by all employees?

Were there written procedures and an orientation provided to the employee?

Were the project procedures being enforced?

Was there adequate supervision being provided?

Was the employee trained to do the work and was it documented?

Were hazards described in the task and was the employee made aware of these hazards?

Were safety procedures previously established to mitigate these identified hazards that resulted in the accident or potential incident?

Was regular maintenance being carried out on the equipment being used?

Were safety inspections being done on the equipment and documented?

Was the office or baseyard area being maintained for employee safety?

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Attach a copy of the employee’s pertinent training record, and any written procedures followed at the time of the accident or potential incident to the Report. If the equipment had an in-house maintenance record, that would also be an attachment to the Report. ROOT CAUSE ANALYSIS Determining root causes may be the most difficult and potentially painful part of this process. There are volumes of work on the subject and you are encouraged to do your own research on the topic. Basically, root cause is a failure within a system or process that when fixed should prevent the problem from reoccurring. Root cause analysis (RCA) is the systematic approach to find the root cause(s) of the problem. Why are we requiring a root cause analysis when you already know HOW the injury happened or HOW it may have resulted in a serious injury? By doing so, you will be able to determine WHY the accident occurred (or may have occurred) and identify corrective actions that will hopefully prevent another occurrence. We will concentrate on the following categories of root causes: Unsafe Acts

Safety policies or procedures violated

Improper PPE or PPE not used

Improper work technique used

Using equipment without proper training or authorization

Failure to warn or secure

Operating at an unsafe speed

By passing safety devices

Not using proper safety guards in place

Improper lifting or loading

Improper use of tool, equipment, item

Servicing/maintaining equipment improperly

Horseplay

Drug or alcohol use

Unnecessary haste

Unsafe act of another

Not trained for the task

Too fatigued to perform safely

Inattention to surrounding or footing

Others Unsafe conditions

Poorly designed or congested workstation or office layout

Working with hazardous materials

Inadequate ventilation

Improper storage of materials

Improper tool or equipment

Insufficient knowledge of job

Slippery conditions

Poor housekeeping

Excessive noise

Inadequate guarding against hazards

Defective tool or equipment

Insufficient lighting

Inadequate fall protection

Poor weather conditions

Poor visibility

Others

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Management deficiencies

Inadequate or missing safety policies or procedures

Failure to train or to provide refresher training for the task

Lack or inadequate written plans, procedures, SOPs

Safety policies or procedures not being monitored or enforced

Supervision or program oversight inadequate

Hazards not identified

PPE not provided

Insufficient supervisor training

Improper maintenance

Inadequate supervision

Inadequate workplace inspections

Inadequate equipment

Unrealistic scheduling or deadlines

Undue pressure on subordinates

Others

After determining the various root causes, provide a narrative on each cause that includes why it was included, history behind the cause leading up to the accident or potential incident, and any other pertinent information. This is where the Team will need to put on their collective analytical thinking cap!

FINDINGS and RECOMMENDED CORRECTIVE ACTIONS This is the final narrative to include in the Report and it should be a summary of the Team’s findings with a set of well-considered recommendations designed to prevent a reoccurrence. These recommendations (once approved by the PI) must be eventually included in the project’s safety SOP or other documents. For example, if additional training is identified, once the PI approves the recommended action(s), the training must occur and be documented.

Recommendations should be specific, constructive, identifying the contributing factors and root causes.

Recommendations shall not include disciplinary actions. If human error was the cause, the recommendation is to remedy the situation to prevent a reoccurrence. Disciplining should occur through normal personnel procedures such as mid-season or end-of-year performance evaluation, or other administrative processes.

TEAM MEMBERS List the full names and job titles of each Team member that participated in preparing the Report.

Report Prepared By This the full name of the person that produced the Report. If more than one person prepared the Report, include each person’s full names.

Date The date the Report was completed. If the Report was returned for more information, the revision date will be used for the subsequent submission.

Date of electronic submission to PCSU Safety Manager The date the Report or revised Report electronically submitted to the PCSU SM.

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PCSU FOLLOW UP Once the Report has been electronically submitted, the PCSU SM will review the Report within three working days of receipt. If the PCSU SM feels the Report has not provided enough information, he will email the Final Report Preparer(s) the Report with his explanation/recommendations for improvement in the “PCSU Safety Manager Comments” section of Report; the Project’s Principal Investigator will be Cc:. Once the PCSU SM feels the Report provides a full explanation of the HOW and WHY of the accident or potential incident and concurs with the findings and recommendations that will provide adequate safeguards to prevent a reoccurrence, he will forward the updated Report to the Project’s PI. The PI will review the Report within five working days of receipt. If he feels the Report is not complete, he will email the Report back to the Final Report Preparer(s) and PCSU SM with his concerns in the “PI Comments and Recommendations” section. The process continues until the PI is satisfied with the Report and its findings and recommendations. The PI will send the approved Report with his final remarks in the “PI Comments and Recommendations” to the Program Manager/Coordinator with Cc: to the PCSU SM and log the “Date of Approval”. The PI will forward a copy of the approved Report to the RCUH Director of Human Resources as PCSU’s follow up to the initial RCUH Form D-25 on the accident or potential incident and log the “Date of electronic submission to RCUH Human Resource Director”.

ADDITIONAL INFORMATION OR SUGGESTIONS FOR COMPLETING THIS REPORT More information is better than having the PCSU SM or PI return the Report for additional information. A detailed and concise product may be up to 10+ pages with photos and attachments; the more serious or involved the injury or potential incident, the longer the report. The teamwork approach lessens the burden and shortens the individual’s time. Do not gloss over the accident or potential incident, a thorough review process may uncover previously overlooked physical or environmental hazards and may prevent a similar occurrence for other projects. Keep an open-mind and be objective, do not try to protect your turf. When interviewing the employee or witnesses:

Meet in a private room if possible with no distractions.

Interview witnesses separately.

Put the person at ease.

Emphasize the reason for the interview, that is, to determine what happened and why; not to place blame or punish.

Let them talk.

Do not lead, interrupt, prompt, ask leading questions, show your emotions, or jump to conclusions.

Do not ask yes/no questions but open-ended questions.

Have someone on the Team take the extensive notes while others take shorter notes.

Confirm that you have the facts correct.

Close on a positive note. When meeting to consolidate your notes, if questions arise, feel free to “re-interview” the employee or witness to clarify or fill in the missing details. When meeting to determine the Root Cause Analysis, meet in an area where there are no distractions, turn off cell phones.

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When preparing the Report, again, do it in an area where there are no distractions. Remove defective equipment from the field and secure in a safe place in the office; tag as UNSAFE-DO NOT USE. Make sure you follow up with the recommendations and corrective actions once approved by your PI. Share what you have learned from this process with your staff.

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3.930 RCUH Safety & Accident Prevention Program

RCUH Form B-3 Created 7/2002, Revised 02/2004, 05/2004, 3/2005, 09/2009, 10/2009, 04/2010, 10/2013) Page 1 of 3

RESEARCH CORPORATION OF THE UNIVERSITY OF HAWAII SUPERVISOR'S REPORT OF INDUSTRIAL INJURY

CONFIDENTIAL Upon completion of this report, please fax to (808) 956-9423 or email ([email protected]) to RCUH HR within 24 hours of

Injury/Illness/Accident. Original form should be sent to John A Burns Hall, 4th

Floor, 1601 East West Road, Honolulu, HI 96848

(Part A and Part B MUST be completed)

1. EMPLOYEE'S NAME (Last, First, MI)

2. PROJECT NAME

3. CLASSIFICATION:

Regular Student

Temporary Volunteer

4. EMPLOYEE’S RCUH ID#

5. EMPLOYEE'S ADDRESS (No., Street, City, State, Zip Code)

6. MARITAL STATUS

Single Married

7. DATE OF INJURY

8. JOB TITLE

9. TIME WORKSHIFT BEGAN

__________A.M./P.M.

10. TIME OF INJURY

________A.M./P.M

11. ACCIDENT LOCATION & ADDRESS (Ex., Loading

dock north end; 2432 N. St. Hilo, HI)

12. DATE INJURY REPORTED

TO SUPERVISOR (MM/DD/YY)

13. WITNESS(ES) NAME (Last, First)

14. HOW DID THIS ACCIDENT OCCUR? (Please fully describe the events that resulted in injury or occupational disease. Explain what happened.)

15. DESCRIBE THE SURROUNDING/ENVIRONMENT WHERE THE INJURY/ILLNESS OCCURRED (e.g. steep, wet slippery

slope, etc.)

16. WHAT WAS THE EMPLOYEE DOING WHEN INJURED OR BECAME ILL? (Please be specific. Identify tools, equipment or

material the employee was using.)

17. OBJECT OR SUBSTANCE THAT DIRECTLY INJURED EMPLOYEE? (e.g. the machine employee struck against or struck him,

the vapor or poison inhaled or swallowed, etc.)

18. EMERGENCY CARE AND PATIENT STATUS

First Aid Only (i.e., employee was not referred to hospital or doctor)

Referred to hospital/doctor, current status unknown (provide medical note if treated)

Treatment at hospital/doctor (provide medical note and include doctor contact information below)

Physician Name:

Address/Hospital Name:

Phone Number:

Email:

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3.930 RCUH Safety & Accident Prevention Program

RCUH Form B-3 Created 7/2002, Revised 02/2004, 05/2004, 3/2005, 09/2009, 10/2009, 04/2010, 10/2013) Page 2 of 3

19. EMPLOYEE STATUS

Was employee paid in full for day of accident? Yes or No

Has employee returned to work? Yes or No If “Yes”, enter date returned: _____/_____/_____ (MM/DD/YY)

Will employee lose time from work? Yes or No If “Yes”, please explain:___________________________________

_________________________________________________________________________________________________

Indicate any other information about the employee’s status: __________________________________________________

_________________________________________________________________________________________________

20. IDENTIFY SPECIFIC BODY PART(S) INJURED.

***Describe the injury/illness: __________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

***Mark (“X”) the injured body part(s) on diagram below and have employee initial by the injured body part(s).

FRONT BACK

LEFT RIGHT LEFT RIGHT

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3.930 RCUH Safety & Accident Prevention Program

RCUH Form B-3 Created 7/2002, Revised 02/2004, 05/2004, 3/2005, 09/2009, 10/2009, 04/2010, 10/2013) Page 3 of 3

PART B: ACCIDENT INVESTIGATION:

1. What type of safety equipment and/or procedure was involved in this work process? Did the employee use the equipment or follow the procedure?

2. What kind of actions do you plan to implement to prevent this type of accident from recurring?

3. Have you instructed the employee on how to avoid the recurrence? How?

4. Was a Safety Rule violated? If so, has the employee been disciplined for violating the safety rule?

5. Please include photographs of the accident site to help better describe the location, environment, or other factors

that caused/contributed to the accident. Number each photo and provide an explanation of what each photo represents. DO NOT include photos of the injury or injured employee.

Additional comments relating to Accident Prevention and/or investigation:

STATEMENT OF CERTIFICATIONS (Any falsification of this report may result in disciplinary action)

__________________________________________ _________________________________________________________________ ___________________ Employee Name Employee Signature Date _________________________ ______________________ ______________________________________________ Work Phone Number Home Phone Number E-mail Address __________________________________________ _________________________________________________________________ ___________________ Supervisor Name Supervisor Signature Date _________________________ ______________________ ______________________________________________ Phone Number Fax Number E-mail Address __________________________________________ _________________________________________________________________ ___________________ Project Safety Coordinator Name Project Safety Coordinator Signature Date _________________________ ______________________ ______________________________________________ Phone Number Fax Number E-mail Address

REVIEWED BY PRINCIPAL INVESTIGATOR:

__________________________________________ _________________________________________________________________ ___________________ Principal Investigator Name Principal Investigator Signature Date _________________________ ______________________ ______________________________________________ Phone Number Fax Number E-mail Address REMINDERS:

1. If this is more than a “first aid” type injury or if the employee will lose time from work, the Employee must be seen by a Physician. 2. Complete and Attach EMPLOYEE/CLAIMANT CONSENT FORM (B-4) to this report and send both in to the RCUH Director of Human Resources immediately. Fax to 808/956-9423 AND mail original forms

to John A Burns Hall 4th Floor Makai Wing, 1601 East West Road, Honolulu, HI 96822.

3. Scan and email photo(s) of the injury(ies), location/work environment, object that may have caused the injury, etc. to [email protected]. 4. Refer to RCUH 3.580 Workers’ Compensation and 3.930 Safety and Accident Prevention Program policies for more information. 5. Provide the Employee with the “Guidelines to Employee Memo” located on the WC policy.

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UXO Safety Training

Agenda

• Identify UXO Hazard

– By Type and Subgroup

• Determine the Hazards

• Marking a UXO

• Evacuation for a UXO

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UXO Safety

• NEVER approach a suspected UXO

• DO NOT use a radio within 100 meters of a UXO

• DO NOT attempt to remove any part of a UXO

or items near a UXO

• NEVER disturb a UXO

• Avoid areas marked as containing UXO’s

• Clearly mark an area that contains UXO’s

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UXO Safety

MOST IMPORTANLY: BE AWARE OF YOUR

SURROUNDINGS AND WATCH WHAT YOU ARE

DOING AND WHERE YOU ARE STEPPING.

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Identify UXO by Type

• Dropped

• Projected

• Placed

• Thrown

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Dropped Ordnance

Three types for Dropped Ordnance

– Bombs

– Dispensers containing Sub munitions

– Sub munitions

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BOMBS

• Key ID features

• Large

• Cylindrical Shape

• Box, Conical or Retarding Fins

• Heavy Metal Construction

• Lifting Lugs

• Generally 2 Fuze Wells

37 inches

26.11 inches

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Dispensers

• Dispensers, very

similar to bombs,

however they deliver

a smaller payload

• Key ID Features

• Large like Bombs

• Light Metal

Construction

Sub munitions Inside

(payload comes out here)

76 inches

118 inches

141.50 inches

(payload comes out here)

(opens here)

7.60 feet

7.70 feet

10.9 feet

(payload comes out here)

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Sub munitions

• Sometimes called

Bomblets or

Scatterable Munitions

• May be dispensed by

Artillery or Aircraft

• Small

Fragmentation Ball

2.17”

2.59”

Trip Wires [4]

4.75” Trip Wires [8]

Bomb BLU-24/B Bomb BLU-26/B Mine BLU-54/B

Arming

Ribbon

3.

2

0

8.80 inches

Fin assemblies

15.55 inches

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Dropped Ordnance Photos

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Projected Ordnance

• Projectiles

• Mortars

• Rockets

• Guided Missiles

• Rifle Grenades

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Projectiles

• Greater in Dia than .50 cal

• Steel Construction

• Cylindrical in Shape with Pointed Nose

• Stabilization: Fin or Spin

• Rotating Bands or Fins

OD Body Yellow Markings

43.95”

OD Body

Yellow Markings

8”

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Mortars

• Cylindrical in Shape

• Primarily Fin Stabilized

• Primer and propellant

• Gas check bands or Obturator ring

• Vent holes in Fin Assembly

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Rockets

• Self Propelled

• Stabilized by Fins of

Venturis canted to

provide spin

• Rocket Motor

• Warhead section

23.20”

Nose Fuze

25.20”

25”

25”

Internal Fuze

26”

34.40”

2 19/32”

20”

Metal Cap

30

Motor

Rocket

Thrust

Spin

Direction

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Guided Missiles

• Allow control after

launch

• May be as small as 1-

2 feet or up to 30 feet

in length

• Venturis

TOW

Dragon

45.80”

29.29”

PATRIOT

17.40’

Internal Radar

SPARROW

Movable Fins

12.10’

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Rifle Grenades

• Projected from Rifle

• Usually Fin Stabilized

• Relatively small for

Projected munitions

16.96” 14.77”

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Projected Ordnance Photos

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Thrown

• Small, held and

thrown with one hand

• Provision for safety

until thrown

• May contain means of

stabilization, i.e.

parachute or other

orientation device

OD

Body

Yellow

Band

4.5”

15.94”

Parachute Deployed Fuze

14.25”

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Thrown Ordnance Photos

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Placed Ordnance

• Designed for Area Denial

• May be placed on the surface

• May be scattered

• Mines

– AP ( Anti - Personnel)

– AT ( Anti - Tank)

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Anti Tank

• Anti Tank Mines

• Key ID Features

• Large In Size

• May Have A Tilt

Rod/Pressure Plate

• Most Likely Contains A

Booby Trap Device

9.40” 10.60”

12.40”

47.20”

Plastic

Tilt Rods

12” 11.90”

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Antipersonnel

• Anti Personnel Mines

• Key ID Features

• Small In Size

• Lightweight Construction

i.e. Rubber, Plastic,

Wood

• Normally Found Around

AT Mines

5.50”

2.20”

3.5”

2.70”

4.72”

Elsie Emplaced

2 7/8”

1 7/16”

Black With White

Markings

markings

Safety Clip

Explosive Charge in Plastic

Container

Pressure

Fuze

Plastic Body

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Placed Ordnance Photos

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Training Ordnance and

Pyrotechnics

• Training Ordnance

– Training ordnance most cases has the same

appearance as ordnance simulated

– Not inert

– May contain up to 11 pounds of explosives

– Do not handle

– Many pieces of training ordnance are BIP only

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Pyrotechnics

• Used primarily for

training

• Very sensitive

• Release Hydrogen

Gas very volatile

• Primarily Simulators

• Equivalent to ¼ stick

of Dynamite

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Safety Precautions/Hazards

• (1) Do not allow NONESSENTIAL

personnel on the site.

• (2) Upon identification of the UXO, move to

a safe distance (300 meters) and make certain

that the correct evacuation measures are being

enforced.

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Safety/Hazards (cont)

• (3) DO NOT TOUCH OR DISTURB THE UXO. Disturbances, either mechanical or otherwise, may cause the UXO to detonate.

(4) If the presence of liquid droplets, dead animals, dissolved paint, or peculiar odors is detected, the presence of chemical agents may be assumed. Put on your protective equipment immediately.

• (5) DO NOT TOUCH LOOSE WIRES OR COMPONENTS OF THE UXO.

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Safety/Hazards (cont)

• (6) Do not attempt to remove parachutes from any UXO.

• (7) Leave recovery to Explosive Ordnance Disposal (EOD) personnel.

• (8) DO NOT smoke or allow others to light a flame around the UXO.

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Safety/Hazards (cont)

• (9) Identify the UXO from a distance using

binoculars.

• (10) Do not use radios in the immediate area.

They can cause some UXO’s to detonate.

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Marking Ordnance

• Extremely Important

• Clearly visible from all avenues of approach

• DOES NOT disturb the ordnance

• May be as simple as “Engineer tape” or actual

UXO marker:

• Last action should be to mark the ordnance

then leave the area

28 centimeters

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Reporting Ordnance

• Report the ordnance to your supervisor

• Report the incident to the local EOD unit

• Methods of Reporting

– Tactical: 9 Line Format from SMCT

– Training area: Notify Battalion TOC

– In Theatre/On FOB: Notify Mayor’s Cell

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9 Line UXO Reporting

• Line 1. Date-Time Group: DTG item impacted or was discovered.

• Line 2. Reporting Activity (unit identification code [UIC]) and location (grid coordinates of UXO).

• Line 3. Contact Method: Radio Frequency, call sign, point of contact (poc), and telephone number.

• Line 4. Type of Ordnance: Dropped, projected, placed, or thrown. If available, supply the subgroup. Give number of items, if more than one.

• Line 5. NBC Contamination. Be specific as possible.

• Line 6. Resources Threatened: Report any equipment, facilities, or other assets that are threatened.

• Line 7. Impact on Mission: Provide a short description of your current tactical situation and how the presence of the UXO affects your status.

• Line 8. Protective Measures: Describe any measures you have taken to protect personnel and equipment.

• Line 9. Recommended Priority: Recommend a priority for response by EOD technicians, immediate, indirect, Minor, No Threat

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Training Area

• In the event a UXO is encountered in a training area, immediately report the incident to Battalion TOC.

• The information required will include:

– Location of the suspected UXO

– Shape of the UXO

– Estimate the Dimensions of the UXO, critical measurement is the Diameter

– POC on the ground, preferably the individual that has had eyes on the ordnance, method of contact

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Evacuation Distances

• Minimum Evacuation Distance for a UXO is

300 Meters in Radius

• If ordnance is found near a material that could

enhance an explosion the evacuation distance

is 1000 Meters in Radius

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706th Ord Co (EOD)

Reporting Procedures

24 Hour Response Line: 808-655-7112

Normal Business Hours: 808-655-5313

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Identify By Type

1 2 3 4

6 5

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Ordnance in the field

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Ordnance in the field

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Ordnance in the field

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Summary

• Identify UXO Hazard

• Determine Hazards

• Marking the UXO

• Evacuation for UXO

• Familiarized with Ordnance Type

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FOR MORE INFORMATION

• Check out www.train.army.mil

• Click On Library

• Select “Warrior Training Tasks”

• In Search Box Type “AWT”

• Select Skill Level 1

• Select Warrior Task 26- React to UXO Hazards (Task # 093-401-5040)

• Launch Lesson

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