Health and Safety Executive

Health and Safety Executive

Accident Investigation

Mike Walters

HM Principal Inspector of Health and Safety

Investigation of Accidents and Cases

of Ill Health

• Value, purpose and systems

• Which Incidents need investigation

• Reporting and record keeping

• Who should undertake the investigation

• Process and Checklist for incident

investigation and reports

• Remedial actions action plan & review

Accident Investigation

Value and Purpose

– Prevent reoccurrence

– Costs of accidents

Which incidents need investigation

– Accident

– Case of ill health

– Near miss

– Property damage

Establish a System to…

• Identify immediate & underlying causes

• Implement preventative measures

• Review risk assessment & control measures

• Target key areas

• Comply with law

• Establish and record facts

• Detail system in policy

Immediate Actions

• Treat injured

• Action to prevent a recurrence/escalation

• Capture situation – photographs,

measurement, samples, equipment,

statements

Which Incidents to Investigate

• Be guided by the significance

• Consider potential as well as actual

• More serious or greater potential requires

more effort

• Look at sickness records – e.g. (work

related) musculo- skeletal disorders

• Problems with non employees – agency

workers and contractors

Reporting and Record Keeping

• Which matters are reportable under

RIDDOR

• How do you deal with contractors /

agency workers – who reports

• Confidentially of ill health issues

Who Should Investigate

Likelihood of

recurrence Potential

Minor Serious Major Fatal

Certain 2 3 4 4

Likely 2 3 4 4

Possible 2 3 4 4

Unlikely 1 2 3 4

Rare 1 2 3 4

Level of

Investigation

1 = Minimal 2 = Low 3 = Medium 4 = High

Who Should Investigate

• Minimal – Supervisor – try and learn lessons

• Low – Supervisor + Manager – look at root cause

• Medium – as low + employee rep and H&S rep - immediate , underlying and root cause

• High – Team based overseen by senior managers or directors

Who Should Investigate

• Workforce & Management (Line Managers, H&S

professionals, TU reps, Senior Managers etc)

• Those involved in the investigation should have

– Appropriate training in accident investigation

– Knowledge of type of work being undertaken

– Access to relevant information

• Internal

• External

• Led by, or report to, Decision Maker

Cause of Incidents

• Immediate

– Agent or substance involved

• Underlying

– Unsafe acts or conditions

• Root

– Failure from which other failures grow

often remote in time and space

If you do not get at the roots the weed will grow again!

Process

• Information gathering

• Analysis

• Risk control measures

• Action plan and implementation

Gathering the Information -1

• When and where

• Who has suffered and who was involved

• How did it happen – equipment involved

• What activities were being carried out

• Anything unusual

• Was there a SWP and was it followed

• The (potential) injury or ill health effect

• How was injury caused

Gathering the Information - 2

• Was the risk known, if so was it assessed

and why was it not controlled

• Did organisational arrangements have an

effect

• Was maintenance / cleaning relevant

• Were people involved competent

• Did workplace layout have an effect

• Did materials involved have an effect

Gathering the Information -3

• Were there difficulties with plant or

equipment

• Was safety equipment sufficient

• Did other conditions influence incident

• Are there similar conditions elsewhere

Analysing Information

• Establish the facts

• What happened and why - Keep asking

why until it is no longer meaningful

• Analysis

• What were the immediate, underlying and

root causes

• Consider all the relevant issues

– A checklist can help

Incident Analysis Checklists

(HS(G)65 & HS(G)245)

• Premises

• Planning

• Communication

• Plant and substances

• Assessing risk

• Competence

• Procedures

• Control

• Monitoring

• People

• Co-operation

• Review

Human Factors

• Skill based errors – a slip or lapse of memory

• Mistake – error of judgement

• Violation – rule breaking

• Job factors

• Physical issues, competence, personal

• Organisational – work pressure, supervision,

culture

• Plant and equipment – controls, design

Remedial Action

• Analysis is likely to have identified risk

control measures which can be changed.

Some are easy, cheap and practical and

can be altered quickly other may not be

practicable, possible or realistic.

• Do similar risks exist elsewhere

• Have similar events occurred before

Action Plan

• Which risk control measures should be

implemented and in what timescale

– Who is to arrange and it should be checked

• Which risk assessments, safe systems of work

should be reviewed / updated

– Undertaken and implemented

– Are others effected

• Are records of incident in a form that would help

in the future

• Implement analyse and review

Summary

• Benefits – to learn lessons, prevent future

ill-health and injury

• Systematic investigation

• Need to establish root cause

• Plan remedial actions

• Implement findings

References

• INVESTIGATING ACCIDENTS AND INCIDENTS HS(G)245 A Workbook For Employers, Unions, Safety Representatives & Safety Professionals [www.hse.gov.uk/pUbns/hsg245.pdf]

• Root Causes Analysis: Literature Review CRR325/2001 [www.hse.gov.uk/research/crr_pdf/2001/crr01325.pdf]

• Safety Representatives and Safety Committees – The Brown Book [www.tuc.org.uk/sites/default/files/BrownBook2015.pdf]

• Reducing Error and Influencing Behaviour HS(G)48 (Second edition) [www.hse.gov.uk/pUbns/priced/hsg48.pdf]

• Managing for Health & Safety HS(G)65 [www.hse.gov.uk/pubnS/priced/hsg65.pdf]