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

Represent Influence Negotiate

ACCIDENT & INCIDENT

INVESTIGATION

Course Directors

Lyn Harris & Graham Richens


Welcome

Fire Alarm

Meals, Breaks, Toilets

Smoking area

Mobile Phones

Dress Code, Behaviour.


Aim

To familiarise safety leaders with the

principles of

‘Accident & Incident Investigation’.


Objectives

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.


Brief Introductions

Name

Branch Board

1 thing you would change in your Force?


List 10 causes of accidents in the

Police?

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.


Reasons for Investigations?

Legal?

Criminal

Civil

Moral

Ethical

Financial

Efficiencies.


Legal Reasons For Preventing Accidents

Compensation claims in civil courts

Out of court settlements

Enforcement notices

Corporate fines

Personal fines

Imprisonment.

}civil

} Criminal

10


Benefits of Good Health & Safety Standards

accidents

injuries

sick leave

claims

costs

staff turnover

↑ performance

↑ productivity

↑ morale

↑ legal compliance

↑ reputation.

11


HSE Statistics

2013

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.


Police Service Injury & ill-

health statistics 2010

Fatal Injuries

2

Major/Specified

777

Over 3 day

2 340

Total

3 119


£ 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


Worst Industries?

Agriculture

Construction

Manufacturing

Waste Recycling

Services


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

Online

Phone 08453009923

Accident Book BL510.


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.

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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




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?.


Which events should be

investigated?

Consider:

Potential consequences

Likelihood of adverse event recurring

Not simply the injury / ill health suffered on this occasion

Include ‘Near Misses’.


Consider different approaches

to investigations

HSG245

Accident & Incident Investigation Form

Protocol for Liaison (Work-related deaths)


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.


Benefits arising from an

investigation?

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.


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.


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.


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.


A.I.I. Form Reported by:

Date/time of event:

Incident

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

Overview


Accident / Incident

Investigation

Step 1: Gather Information

Step 2: Analyse the information

Step 3: Identify risk control measures

Step 4: Action plan & implementation.


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.


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?.


A typical ladder accident


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


Immediate and Underlying Causes

Immediate causes: personal and job factors

Underlying causes: organisation and management


Causes

Immediate causes

Premises, Equipment, Procedures, People

Underlying causes

Planning, Risk Assessment, Organisation,

Attitudes, Morale, monitoring, review.


Human failings/factors

human

failings

skill-based

errors

slip

lapse

mistake

violation

no rule

wrong rule

rule breaking

rule/

knowledge

based

mistakes


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

Assault

Step 1 - Gather Information

Step 2 – Analyse.


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


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.


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.


Case Study

Assault

Step 3 - Risk Control Measures

Step 4 – Action Plan.


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.


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.


Questions

?

Safe Journey Home!


Happy

Ending

!

Documents

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