Notes

Outline

INVESTIGATING ACCIDENTS AND INCIDENT A Workbook for Employers, Unions, Safety Representatives and Safety Professionals. HSG 245

Statistics 250 killed every year in workplace accidents. 150,000 suffer major injury or 3 day plus injury at work. 1,000 die on the public roads while at work. 2.3 million cases of ill-health caused or made worse by work. Over 40 million working days lost through work-related injury and ill-health at a cost to business of £2.5 billion..

Effective Investigation “An effective investigation requires a methodical, structured approach to information gathering, collation and analysis. The findings of the investigation will form the basis of an action plan to prevent the accident or incident from happening again and for improving your overall management of risk. Your findings will also point to areas of your risk assessment that need to be reviewed”.

Key Terms Immediate Cause The most obvious reason why an adverse event happened (guard is missing, employee slips etc). There may be several immediate causes identified in any one adverse event. Underlying Cause The less obvious “system” or “organisational” reason for an adverse event happening (failure to carry out pre-start-up machinery checks, production pressures, failure to consider the hazard in the risk assessment etc) Root Cause An initiating event or failing from which all other causes or failings spring. Generally management, planning or organisational failings.

Adverse Event Includes: Accident An event that results in injury or ill-health. Incident Includes: Near Miss An event that, while not causing harm, has the potential to cause injury or ill-health. This includes dangerous occurrences. Undesired Circumstance A set of conditions or circumstances that have the potential to cause injury or ill-health (untrained nurses handling heavy patients etc).

Undesired Circumstance

Near Miss

Accident

Refined Domino Sequence

Which Events Should Be Investigated? “It is the potential consequences and the likelihood of the adverse event recurring that should determine the level of investigation, not simply the injury or ill-health suffered on this occasion”. Also consider: Potential for learning lessons. Patterns of adverse events. All adverse events which affect the public.

Example Analysis

Steps Following an Adverse Event Emergency response Take prompt action (first-aid). Make the area safe. Initial report Preserve the scene. Note the names of the people, equipment involved and the names of witnesses Report the adverse event to the person responsible for health and safety who will decide what further action (if any is needed. Initial assessment and investigation response Report the adverse event to the regulatory authority if appropriate (police, RIDDOR etc). Enter details in the accident pad etc.

Investigation Level

Who and What Minimal Level Relevant supervisor looks into the circumstances and tries to learn lessons which will prevent future occurrences. Low Level Short investigation by relevant supervisor or line manager into the circumstances and immediate, underlying and root causes to try and prevent a recurrence and to learn general lessons. Medium Level More detailed investigation by relevant supervisor or line manager, the health and safety adviser and employee representatives and will look for immediate, underlying and root causes. High Level Team based investigation under senior management or director supervision and will look for immediate, underlying and root causes.

Four Steps Approach Gather Information. Where, When, Who, What, How, Was and Why. Analyse Information. Identify immediate, underlying and root causes. Use techniques such as Events and Causal Factor Analysis, HSG 48 Human Failure Analysis, Checklists, Fault Tree Analysis etc. Identify Suitable Risk Control Measures. Systematically evaluated. Optimum solutions found. Prioritised. Develop and Implement the Action Plan.