26-1

Table of Contents
Developing a Guideline for On the Job Emergencies …………………………….... 3
What to do after a Job Related Emergency ………………………………………… 5
Checklist for Handling the Death or Serious Injury of an Employee ….…………. 8
1.
When Emergency Occurs at Work …………………………...…………. 8
2.
When Emergency Occurs outside of Work ………………………………... 8
Incident - Accident Investigation Form ..…………………………………………. . 12
Root Cause Analysis ……………………………………………………………….. 13
Sample Letter of Condolence to Family of Deceased Employee ………………….. 14
26-2

Once a plan has been developed, it's important to contact the local authorities in your district.
This will ensure that your plan meets all local law enforcement regulations.
1.
Develop a Safety Emergency Plan
• Include emergency First Aid procedures
• Get help from trained, qualified emergency personnel
2.
Notification Procedures
Develop a formal method of communicating to ensure that all pertinent departments are notified of an incident. This procedure should specify:
• The names/positions and contact information of those to be notified;
• When they must be notified, listed in order of priority; and
• The person or position responsible for making contact.
3. A Family Assistance Team
Consisting of personnel within the company, this team should be responsible for coordinating the following:
•
Notifying the victim's family;
•
Locating the hospital;
•
Assisting the family, with travel, hotel, expenses, etc.;
•
Handling the victim's personal effects, such as wallet, purse, jewelry, tools, automobile, etc.;
• Obtaining critical incident stress services or counseling for family and co-workers through the company's human resources department
It's important that the family be notified quickly. In small towns, some police reports are still broadcasted over scanners. It's also important to specify in your plan that a company representative should stay with the family until other personal support, such as clergy or relative, arrives.
4. Medical Material Management (Bloodborne Pathogen Policy)
Outline procedures for handling any medical waste in accordance with Federal and state regulations. Many states have regulations regarding the correct disposal of medical waste. In some cases, industrial sites fall under a different set of regulations than other businesses. To be sure your procedure is correct, contact your:
• Local Authorities; and
• Local large hospital.
5. Communicating with the Media
Only a designated person should determine how and when information is communicated to the media. Communications should be kept to a minimum.
6. Incident Investigation
The company should initiate a formal review of the incident and:
• Be sure to cooperate with local authorities;
• Secure all photos and documents in a safe place; and
26-3

• Consult an attorney before releasing any information.
7. Privacy Issues
Employees will want to ensure the victim's family will receive all authorized company benefits. To do this:
• Do not breach confidentiality by discussing what benefits the employee had and did not have;
• Secure permission from the family prior to release any pertinent information; and
• Consult an attorney.
8. The Funeral
If a funeral is involved, make all decisions as soon as possible:
• Decide who will represent the company; and
• Determine whether time attending the funeral is compensatory.
9. Grieving
It is important to take care of your employees while they are grieving. You can do this by:
•
Holding an employee counseling or debriefing session;
• Reorganizing workloads for employees impacted at the jobsite so they have
"light duty" or non-safety-sensitive work to do;
•
Allowing employees to go home early, if they wish;
• Creating a "buddy system" at the workplace for several days; and
•
Assigning teams to work together. This not only helps with grief, it also improves safety.
26-4

1.
The first responder should perform First Aid.
Call for Assistance: Call Emergency Rescue 911 and ( Ph: ___.___.____ )
If you have an EMERGENCY (EX: to report a fatality or imminent life threatening situation)
Contact OSHA’s toll free number immediately:1-800-321-OSHA (6742)
TTY 1-877-889 -5627 DO NOT SEND EMAIL
Promptly notify the Company's workers compensation insurance carrier.
Check the link below for reporting requirements for OSHA state plan states: http://www.osha.gov/html/RAmap.html
.
2.
Report the Emergency
Report the death of any employee or a catastrophe (three or more injured employees), within 8 hours


A death (including heart attacks);
Three or more employees are admitted to the hospital or as required by Federal or State
OSHA;
 Report post accident deaths only if they occur within 30 days of the accident or as required by Federal or State OSHA; and
 Notify OSHA as required:
 For an EMERGENCY (EX: to report a fatality or imminent life threatening situation) Contact OSHA’s toll free number immediately:
1-800-321-OSHA (6742)

TTY 1-877-889-5627
DO NOT SEND EMAIL
Report the overnight hospitalization of any employee within 24 hours – (where applicable
3.
Secure the Scene
Make sure that any equipment involved in a fatality or catastrophe is sec ured but not alte red.
You must not move equipment involved in a work-related accident or incident if there is a death or if three or more employees are admitted to the hospital.
Do not move the equipment until all authorized parties have completed their investigation and do not release the equipment unless:
 Directed by a recognized law enforcement agency; and/or
 Moving the equipment is necessary to:
 Remove any victims; and/or
 Prevent further incidents and injuries.
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4.
Secure information as required
Conduct a preliminary investigation for all serious injuries. You must investigate every losttime injury that workers suffer in connection to their employment and promptly install any safeguard or take any corrective measure indicated or found advisable. Record the names and contact information of known witnesses, parties involved, and anyone that arrives at the scene to investigate the incident involving:
 A death;
 Three or more employees are admitted to the hospital; and
 An accident which is being investigated.
Include in your investigation:
 The immediate supervisor;
 Employees who were witnesses to the incident;


Other employees you believe are necessary to complete the investigation;
 Accident location;
Weather conditions;
 Other contractors on site;


The time the incident occurred;
 People who were present;
What the employee was doing at the time of the accident or incident; and
 What happened during the accident or incident.
5.
See Incident/Accident Investigation Report/Root Cause Analysis on Page 12 & 13.
Members should be advised that the accident investigation form and the root cause analysis would be discoverable in any litigation or OSHA case that occurred as a result of the accident. Members considering the use of these forms should seek legal advice.
6.
Definitions:
Serious Injury
The word serious as used in serious hazard, serious violation, or serious condition means a hazard, violation, or condition such that there is a substantial probability that death or serious physical harm could result.
Injury or illness
An injury or illness is an abnormal condition or disorder. Injuries include cases such as, but not limited to, a cut, fracture, sprain, or amputation. Illness includes both acute and chronic illnesses, such as, but not limited to, a skin disease, respiratory disorder, or poisoning.
Root Cause Analysis
This is only the starting point for the audit trail. Now, the real search for root causes, and the deeper evaluation of the company's programs can begin.
(For Example)
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In an interview, one of the employees revealed that he/she felt that the goggles provided did not fit. Another employee complained of fogging up of the goggles, as the reason that the goggles were not being worn at the time of the injury. An interview with the manager revealed that the manager was reluctant to initiate the company disciplinary policy for the two employees who were excellent workers. (Be careful do not blame the victim.) The company had well written safety and health programs, performed record keeping accurately, and had trained their employees thoroughly. What was missing from their safety and health program?
Answer: Company discipline
Securing and Preserving the Scene –
The accident scene should be preserved as much as possible immediately following an accident. This can be achieved in several ways, including:
● Removing and excluding all persons from the accident scene except essential emergency responders;
● Cordoning the area with rope, tape, or barricades;
● Locking doors and gates;
● Posting warning signs;
● Posting security personnel to control access; and
● Taking photographs and narrated videotape recordings of the accident scene, especially if there is any evidence that easily can be destroyed (e.g., ladders, tools, work areas, items that may have contributed to the accident, safety equipment in the area and PPE the injured may have been wearing, etc.).
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1.
If death or serious accident/illness occurs at work , the supervisor or management will:
Supervisor/ Co-worker
● Call Emergency Rescue 911 or Ph: (___.___.____ )
● Notify Human Resources at Ph: (___.___.____)
● Notify Safety director at Ph: (___.___.____)
● Notify OSHA (Ph: 1-800-321-OSHA (6742)
Management will follow pre-established Protocol such as the following:
● Notify the President’s Office at Ph: ( ___.___.____);
● Notify Marketing and Communications;
● Call employee’s emergency contact person (HR will provide the contact person’s name and phone number if you do not have the information), to advise of the employee being taken to the hospital;
● Contact his/her next level supervisor (i.e. manager, director, associate vice president);
● Notify the company's workers compensation insurance carrier.
● Have a supervisor travel to hospital to meet family, if necessary;
● Upon death, notify remaining employees, indicating details will be forthcoming as
Available;
● Be sensitive to the family – ask for the name of a contact person who can provide funeral details when known, answer questions about the family’s wishes, and arrange for benefits procedures to be completed when appropriate;
● Designate an internal contact person for employees who have any questions or concerns to prevent employees from trying to contact the family directly; and
● Notification of the employee death to others shall be communicated by owner or top management.
2. If death occurs outside of work , the immediate supervisor of the employee will:
● Notify Human Resources at Ph: (___.___.____);
● Human Resources will then contact:
● The President’s Office, which will send notification to:
● The appropriate directors or VP’s; and
● Any other pertinent employee/leader in the supervisory line.
● Contact his/her next level supervisor;
● Notify remaining employees, indicating details will be forthcoming as available;
● Be sensitive to the family – ask for the name of a contact person who can provide funeral details, when known, answer questions about the family’s wishes and arrange for benefits procedures to be completed when appropriate;
● Designate an internal contact person for employees who have any questions or concerns to prevent employees from trying to contact the family directly; and
● Notify the employee death to areas outside of the department/unit but within the division, as determined and communicated by the appropriate personnel officer.
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Handling Arrangements
● Plan for counseling for employees, if needed immediately.
● In consultation with HR, work with grieving employees to arrange for appropriate time off as needed (immediately if they witnessed the death).
● Have designated contact person keep track of all notes, flowers, etc. that arrive following the death so they can be responded to and collected for the family.
Planning for Funeral/Memorial Service
● Flowers – determine where they are to be sent according to family’s wishes.
● Donations – determine where they are to be sent according to family’s wishes.
● Time off – consider impact on business, but also recognize that many employees may feel a need to attend the service.
How do I help my employees handle the loss of their co-worker?
● Notifying employees of the death of a co-worker can be one of the toughest jobs a supervisor ever has to do. While it is important that employees be notified promptly, it is also important that the supervisor carefully plan what to say.
● It is reasonable to expect that many, if not all, employees who worked with the deceased will be unable to complete their work the day of the announcement. This reaction should be anticipated and arrangements should be made, in consultation with HR, to allow those who need time off to receive it. Human Resources and the supervisor will work together to account for any time off and how it may be compensated.
After the Funeral, Process All Eligible Employee Benefits –
Human Resources will:
● Contact and schedule time to meet with beneficiaries;
● Locate beneficiaries for all benefits;
● Confirm state law regarding final pay for deceased employees and associated tax issues and comply promptly with all rules;
●
Treat accrued but unused vacation, sick, personal days, etc., in accordance with state law and company policy;
● Determine how many death certificates will be needed to process benefits paperwork including: Life insurance, Accidental death and dismemberment, and other benefits programs; and
● Communicate to the family any actions required for a retirement fund payout if applicable.
● Determine Workers Compensation death benefits, if applicable;
● Terminate health insurance according to practice; and
● Handle COBRA paperwork for spouse/dependents.
Other Considerations for Supervisors
● Department follows normal checklists to ensure all equipment, keys, credit cards, etc., are returned and security issues are addressed.
● Department arranges for packing and delivery of personal belongings – ask family how they want this handled; offer to do it for them if preferred. A close colleague or supervisor is best choice if family prefers not to be involved.
● Department needs to be aware that employees may have a hard time using the deceased employee’s tools, truck, or other equipment.
● Department and HR should keep in touch with the employee’s family, as appropriate.
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● Take a personal approach to the notification by asking the manager or supervisor, who has had a working relationship with the deceased, to be a speaker.
● Utilize a team approach with at least two managers making the notification. This will help reduce the professional and personal pressure that might be felt by the notifiers.
● Prior to notification, confirm as many facts of the incident as possible.
● Receive authorization to release factual, confirmed information and clarify specific information that is permissible to release. There may be confidential or investigative information disclosed to you but not to be released to the workgroup.
● Notify face-to-face, particularly within the workgroup. Telephone calls or emails may be permissible with other people or groups who may not have as personal of a relationship with the deceased.
● Keep the group small to enhance communication; a large group may be seen as impersonal.
What to Say
● Examples of how to start the conversation include:
● “I’m afraid that I have some sad news for you”;
● “I’ve just been informed of news that I need to share with you”;
● “I wish I didn’t have to tell you this, I’ve just learned that (employee or dependent name) passed away”;
• Pause, monitoring reaction of employee(s) and begin to provide information as you know them.
• If substantial time has passed before the notification was made, explain why.
• If information must be withheld explain why. You may wish to say, “I am unable to share that information due to an on-going investigation,” or “The family asked that
I provide only the information that I have given you.”
• Ask if there are any questions. If you don’t know an answer, it’s okay to say that you don’t have the information.
• Offer the Employee Assistance Program services. A possible statement is, “I know that this loss is upsetting for many employees, I would like to remind you that the
Employee Assistance Program is available as a resource if anyone would like to speak to a counselor.” Provide grief and loss handouts to employees available from
• the Employee Assistance Program.
• Allow time for individual questions or individual employee meetings following a group notification. Prior to leaving workgroup notification, you may wish to say,
“Dealing with the death of a co-worker is an emotional event. I am available to meet privately with anyone who has additional questions or needs to speak with me.”
Additional Statements
• “I wish I didn’t have to tell you this.”
• “I’m sorry this happened.”
• “Grief is something about which we all have reactions and feelings.”
• “It’s common to react with emotion with this kind of news.”
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• “I’ll check back with everyone and see how you are doing tomorrow.”
• “This is a difficult time not only for the family of < employee name> but also for all of us who have worked with < employee name> . It’s a very sad time.”
Avoid These Statements
• “Time heals all wounds.” • “We must move ahead with our lives.” This statement may seem insensitive.
• “You don’t need to know that information.” A better statement is, “I am unable to answer that question or provide that information because < explain the reason>
.”
• “It must have been his/her time.”
• “We have to be strong for < employee name>
.”
• “<
Employee name> would have wanted us to move ahead and live life.”
• “Someday we’ll understand why this happened.”
• “Let’s focus on our memories and not our loss.” This may seem insensitive; right now focusing on the grief is appropriate.
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Please Print All Information
Instructions: Use this form to document accidents resulting in an injury or illness, vehicle and equipment accidents, public and private road incidents, events involving third parties, property damage and near miss events. Use the “Root Causation Analysis” to identify work tasks, potential hazards and control methods.
Check Box Indicate Type of Report Status of Report
Occupational
Injury/Illness
X
Equipment/Vehicle Property Damage Near Miss Preliminary
X
Final
Employee First - MI - Last Name (Person Injured , Involved, Driver) Social Security No. Employee No. Job Classification
   
Date of Incident

Type Mobile Equipment or Vehicle (or N/A)
Project No. (or N/A)
A.M. P.M


.
Day of Accident Date of Hire Day, Month, Year Time on
 
License /Equipment No. Employee Has

Project Name (or Department)
Co. License?
Y/N

Specific Work Area
Job
Date Issued


Treatment
Given?
Y/N

 
Name of Facility Where Treatment Was Given


Days Months Years
Task/Job
Hazard Analysis
Completed?
Client Name
Name of Treating Medical Professional

Y/N

Describe Type/Extent of Injury/Illness/Damage ( in detail )…body parts, nature of injury/illness, equipment/material damaged, etc.

Enter Witness Name/s, Telephone Number or How/When To Contact and Name of Company (if other than the Company)

Describe Event ( in detail )…work actions occurring (or not) that lead up to the incident, equipment/materials being utilized, etc.



List Identified Root Cause/s - (See next page)


Solutions - (See next page)

First Name Middle Initial Last Name
F oreman:
S uperintendent:

Report Completed By:

Who’s Responsible

To Be Completed By:

First Name Middle Initial Last Name
G eneral Foreman:
P roject Manager:

Title Date
 
Retain Copy in Department/Project file. Send copy to the Safety Officer. Send original to the internal insurance contact.
** SEE ROOT CAUSATION ANALYSIS FORM ON NEXT PAGE
26-12

Root Cause Analysis
(mark ‘yes’ or ‘no’ for all applicable questions, completing Comments and Recommended Action portions w hen marking ‘yes’)
Part 1 Equipment
Was equipment/tools/materials a contributing factor?

yes

no, proceed to Part 2
Mark as Causal Factors
Applicable

yes
 no

yes

no
1.1 Did equipment/tool defects contribute? If no, go to 1.2.
1.1.1 Was there an equipment/tool inspection process?

yes

no
1.1.2 Was the inspection process completed as required?
 yes

no 1.2 Was the correct equipment/tool/material utilized? If no, go to 1.3. If yes, go to 1.6.

yes

no 1.3 Was the correct equipment/tool/material readily available?

yes

no 1.4 Did the employee know where to obtain the correct
equipment/tool/material?

yes

no 1.5 Was substitute equipment/tools/material used in place
of correct ones?
Comments Recommended Action
Part 2 Work Environment Was the location of equipment/material/employee(s) a contributing factor?

yes

no, proceed to Part 2
 yes

no 2.1 Did the location/position of equipment/material/ employees contribute to the incident?




yes
 no 2.2 Was the hazardous scenario recognized by the employee?
 yes

no 2.3 Was the employee supposed to be in the vicinity of the equipment/material?

yes
 no 2.4 Was the hazardous scenario visible to the employee?

yes
 no 2.5 Was there sufficient space to conduct work activities?

yes
 no 2.6 Were there any contributing environmental conditions?
(noise levels, temperature, illumination, ventilation)
Part 3 Employee Were the work activities conducted by the employee a contributing factor?

yes

no, proceed to Part 3
 yes

no

yes
 no
3.1 Was there a written task/risk assessment or known rule for this work? If no, go to 3.2.
3.1.1 If yes, did this assessment/rule anticipate the incident?


 yes

no
 yes

no
3.1.2 If yes, did the employee know the proper procedure?
3.1.3 If yes, did the employee deviate?
 yes

no 3.2 Was the employee mentally and physically capable of performing the work?

yes
 no 3.3 Was there a lack of required PPE utilization? If no, go

yes

no

yes

no

yes

no to 3.3.
3.3.1 If yes, was appropriate PPE available?
3.3.3 If yes, did the employee know how to use it?
3.3.2 If yes, did the employee know the PPE was required?
 yes

no
 yes

no
3.4 Was available PPE used properly?
3.5 Was the PPE adequate?
 yes

no 4.1 Was there a failure by supervision to detect a
Part 4 Supervision Was the supervisory system a contributing factor?

yes

no, then the Root Analysis is completed.
hazardous condition, deviation from safety policy or
infrequently performed task?
 yes

no 4.2 Was there a failure by supervision to take corrective
action for a known hazardous condition, deviation from
safety policy or infrequently performed task?
 yes

no 4.3 Was supervisory responsibility for accident detection
and prevention adequately defined and understood?
 yes

no 4.4 Was supervision adequately trained to fulfill assigned responsibility for accident detection and prevention?
Sample recommended action topics include, but are not limited to: re-training or new training, new/more equipment, new processes, responsibility assignments, re-do or new risk assessments, staffing sizes, work assignment loads, etc. Break the topic down into action items you feel will correct this incident from recurrence.
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Dear______,
Although we realized that ( name of employee ) was seriously ill ( or critically injured ), we were deeply saddened to learn of ( his/her ) death. The professional and personal relationship we had with ( name of employee ) has been a source of enrichment and enjoyment to all of us. We shall miss
( him/her ) greatly.
( Name of employee ) was held in the highest regard by our employees and by many others with whom he/she worked. ( He/she ) set an example that will continue to be an inspiration to us all. Please accept our sincere sympathy for your loss.
Human Resources will send you benefit information shortly or you may call them directly for immediate attention at ___.___.____. In the meantime, please call me at ( your telephone number ) if you have any questions or if we may be of assistance.
Sincerely,
( Your name & title )
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