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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)
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.
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)
Date/ Field
leader
Debrief/Operational Review
Positive outcomes: Things to improve: Notes
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
Task
Equipment/materials
Environmental
Personnel
Management
ROOT CAUSE ANALYSIS
Unsafe acts
Unsafe conditions
Management deficiencies
FINDINGS and RECOMMENDED CORRECTIVE ACTIONS
TEAM MEMBERS
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
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”.
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
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.
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?
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
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.
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.
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.
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:
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
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.
UXO Safety Training
Agenda
• Identify UXO Hazard
– By Type and Subgroup
• Determine the Hazards
• Marking a UXO
• Evacuation for a UXO
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
UXO Safety
MOST IMPORTANLY: BE AWARE OF YOUR
SURROUNDINGS AND WATCH WHAT YOU ARE
DOING AND WHERE YOU ARE STEPPING.
Identify UXO by Type
• Dropped
• Projected
• Placed
• Thrown
Dropped Ordnance
Three types for Dropped Ordnance
– Bombs
– Dispensers containing Sub munitions
– Sub munitions
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
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)
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
Dropped Ordnance Photos
Projected Ordnance
• Projectiles
• Mortars
• Rockets
• Guided Missiles
• Rifle Grenades
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”
Mortars
• Cylindrical in Shape
• Primarily Fin Stabilized
• Primer and propellant
• Gas check bands or Obturator ring
• Vent holes in Fin Assembly
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
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’
Rifle Grenades
• Projected from Rifle
• Usually Fin Stabilized
• Relatively small for
Projected munitions
16.96” 14.77”
Projected Ordnance Photos
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”
Thrown Ordnance Photos
Placed Ordnance
• Designed for Area Denial
• May be placed on the surface
• May be scattered
• Mines
– AP ( Anti - Personnel)
– AT ( Anti - Tank)
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”
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
Placed Ordnance Photos
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
Pyrotechnics
• Used primarily for
training
• Very sensitive
• Release Hydrogen
Gas very volatile
• Primarily Simulators
• Equivalent to ¼ stick
of Dynamite
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.
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.
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.
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.
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
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
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
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
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
706th Ord Co (EOD)
Reporting Procedures
24 Hour Response Line: 808-655-7112
Normal Business Hours: 808-655-5313
Identify By Type
1 2 3 4
6 5
Ordnance in the field
Ordnance in the field
Ordnance in the field
Summary
• Identify UXO Hazard
• Determine Hazards
• Marking the UXO
• Evacuation for UXO
• Familiarized with Ordnance Type
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