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ACCIDENT & INCIDENT INVESTIGATION · 2014-10-07 · HSG245 Accident & Incident Investigation Form Protocol for Liaison (Work-related deaths) Represent Influence Negotiate Help to

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Text of ACCIDENT & INCIDENT INVESTIGATION · 2014-10-07 · HSG245 Accident & Incident Investigation Form...

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    Course Directors

    Lyn Harris & Graham Richens

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    Fire Alarm

    Meals, Breaks, Toilets

    Smoking area

    Mobile Phones

    Dress Code, Behaviour.

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    To familiarise safety leaders with the

    principles of

    ‘Accident & Incident Investigation’.

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    Discuss causes of accidents & incidents

    Be aware of investigation policies

    Consider different approaches to investigations

    Help to prevent reoccurrences

    Understand reasons & benefits of investigations

    Gain Experience by Case Studies & Practicals.

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    Brief Introductions


    Branch Board

    1 thing you would change in your Force?

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    List 10 causes of accidents in the


    1. Lack of Information 2. Lack of Instruction

    3. “ “ “ Training

    4. “ “ Supervision

    5. Human Error / Failings

    6. Criminality

    7. Poor Policies, Procedures, Practices

    8. Inadequate Equipment or Resources

    9. Tiredness

    10. ‘F’ Factor.

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    Reasons for Investigations?








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    Legal Reasons For Preventing Accidents

    Compensation claims in civil courts

    Out of court settlements

    Enforcement notices

    Corporate fines

    Personal fines



    } Criminal


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    Benefits of Good Health & Safety Standards



    sick leave



    staff turnover

    ↑ performance

    ↑ productivity

    ↑ morale

    ↑ legal compliance

    ↑ reputation.


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    HSE Statistics


    Fatalities = 148

    Major/Specified = 19,707

    Over 7 day “ = 175,000 (formerly 3 day)

    Other Injuries = 78,222

    Work illness = 1.1 Million

    Work costs = £13.8 Billion.

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    Police Service Injury & ill-

    health statistics 2010

    Fatal Injuries




    Over 3 day

    2 340


    3 119

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    £ Cost to

    Greater Manchester Police

    Police Officer strength 2008

    7992x £250 x 8.5 days = £16,983,000

    Support Staff strength 2008

    4353x £150 x 9.5 days= £6,203,025

    235 Officers per 100,000 populous

    Home Office Statistical Bulletin 30th September 2008

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    Worst Industries?




    Waste Recycling


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    RIDDOR – Reportable Outcomes

    Enforcing Authority to be notified of:

    Fatalities result of work accident

    Specified injury

    Hospitalisation of person

    Off work over 7 Days

    Industrial Diseases

    Dangerous occurrence

    Form of Report


    Phone 08453009923

    Accident Book BL510.

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    Accident & Near Miss

    Accident = Event that results in injury, ill health or loss

    Near Miss (HSE) = An event that, while not causing harm, has the potential to cause injury or ill health.

    Dangerous Occurrence (RIDDOR): If something happens which does not result in a reportable injury, but which could have done, it may be a listed dangerous occurrence

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    What are your Forces

    investigation policies,

    procedures, or practices?

    Does your force investigate Acc’s & Near misses?

    Do they Review ‘Risk Assessments’ after?

    Is ‘Reporting’ Encouraged or Discouraged?

    Do they seek to ‘Blame’, or ‘Learn & Develop’?

    Do they work ‘Together’ with all ‘Parties’?

    Is there a Positive Health & Safety Culture?.

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    Which events should be



    Potential consequences

    Likelihood of adverse event recurring

    Not simply the injury / ill health suffered on this occasion

    Include ‘Near Misses’.

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    Consider different approaches

    to investigations


    Accident & Incident Investigation Form

    Protocol for Liaison (Work-related deaths)

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    Help to prevent re-occurrences

    Immediate Response

    Inform All Stakeholders

    Gather & Analyse Information

    Identify Possible Causes

    Suitable Risk Control Measures

    Agree Action Plan & Implementation

    Monitor & Review.

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    Benefits arising from an


    Understanding of how / why things went wrong

    True snapshot of what really happens, and how work

    is Actually done

    Identifies deficiencies in risk control management

    Prevention of further similar adverse events

    Prevention of losses

    Improvement in morale and attitude towards H&S.

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    Accident Investigation

    In addition, investigation will enable services to:

    Report certain accidents and dangerous occurrences to

    the HSE, Reporting Injuries, Diseases & Dangerous

    Occurrences Reg’s 2013 (RIDDOR);

    Comply with Social Security (Claims and Payments)

    Reg’s 1979. Preservation of data about injured persons,

    Enables claims for industrial disability to be processed.

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    Rights, Wrongs, & Entitlements?

    1. What Must the Force do?

    2. What should Safety Reps Do / Not do ?

    3. Accidents Good/Bad Practice?

    Reg 6-7 Safety Reps & Safety Committees

    Reg 6 = Inspections after A.I.O.& D’s

    Reg 7 = Provision of Information

    JBB Circular 30 / 2010 Computer Data.

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    Accident / Incident Investigation,

    Issues to be covered

    Circumstances of accident / incident

    What preventive measures were in place

    before the accident

    Breaches of relevant legislation

    What measures are necessary to prevent

    recurrence of accident/incident

    Person(s) who can implement changes.

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    A.I.I. Form Reported by:

    Date/time of event:


    Ill Health Minor Injury Serious Injury

    Major Injury

    Brief details (What, where, when, who and emergency measures taken):

    Ref no:

    Accident and Incident Investigation Form


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    Accident / Incident


    Step 1: Gather Information

    Step 2: Analyse the information

    Step 3: Identify risk control measures

    Step 4: Action plan & implementation.

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    Step 1 - Information

    Gather information

    Where & When did the event happen

    Who was injured / involved

    How did the event happen

    What activities were being carried out

    Anything unusual

    Were safe working procedures foIIowed

    Injuries / ill-health effects caused.

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    Step 2 - Analysis

    Should be objective and unbiased

    Identifies consequence of events that led

    up to accident / incident

    Identifies the immediate causes

    Identifies the underlying & root causes

    Achieved by asking WHY?.

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    A typical ladder accident

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    Fall from a ladder: what happened and

    why? John breaks his leg

    John is on ladder Fall due to gravity John falls off

    Access to the roof

    To replace tiles

    The ladder slips

    Ladder not secured

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    Immediate and Underlying Causes

    Immediate causes: personal and job factors

    Underlying causes: organisation and management

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    Immediate causes

    Premises, Equipment, Procedures, People

    Underlying causes

    Planning, Risk Assessment, Organisation,

    Attitudes, Morale, monitoring, review.

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    Human failings/factors









    no rule

    wrong rule

    rule breaking





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    Attitudes & Behaviours to H&S

    I have to

    I should

    I want to

    It’s automatic

    I’m told I must

    The company says so

    It’s best for me

    I just do it

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    Case Study


    Step 1 - Gather Information

    Step 2 – Analyse.

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    Case Study: Assault

    John is assaulted

    John is at his desk Flying monitor John struck by monitor

    To deal with the public Thrown by assailant He is unprotected

    Angry man Unsecured monitor Screen removed His duty

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    Step 3 – Risk Controls

    Identify risk control measures missing,

    inadequate or not used

    Compare actual conditions/practices with

    those required by legal requirements,

    codes of practice and guidance

    Provide meaningful recommendations that

    can be implemented.

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    Step 4 – Implementation

    Action Plans with SMARTA objectives

    Specific, Measurable, Achievable,

    Relevant, Timescales, Agreed

    ‘Management, safety professionals,

    employees & reps should discuss the

    contents of the action plan

    Prioritise the implementation of risk control

    measures, according to risk assessment.

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    Case Study


    Step 3 - Risk Control Measures

    Step 4 – Action Plan.

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    Case Study: Assault

    Steps 3 & 4

    Fit rising screen to front desk

    Secure computer monitor to counter

    Secure chairs in the area

    Install CCTV camera in front desk area

    Train receptionists to defuse potentially

    dangerous situations.

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    HSE References

    HSG48 - Reducing error and

    influencing behaviour

    HSG245 – Investigating A&I’s

    HSG65 – Successful H&S Management

    Stat’s – Police, Security, Law & Order

    INDG453 Reporting Accidents &

    Incidents at work.

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    Safe Journey Home!

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