All Accident Are Incident

8/18/2019 All Accident Are Incident

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All accidents are incidents, but not all incidents are accidents. That's a very brief answer to

the common query about the difference between the two terms.

Applying this definition makes it obvious the category "incidents" is larger than the category

"accidents". If all accidents are unplanned, unepected events !see later for a full accidentdefinition, some incidents that result in damage or in#ury are highly planned events, such

as terrorist attacks or bank robberies.

Accident$incident investigation is covered in %lement A& of the %()*+ iploma syllabus,

which is titled -oss ausation and Incident Investigation. The module covers loss causation

and analysis and reporting and recording, but we'll concentrate here on incident investigation

!sub/element A&.0.

The sub/element on investigation is divided as follows in the syllabus1

• outline !implied legal requirements and +*% guidance, particularly +*2 &34

Investigating Accidents and Incidents / A 5orkbook for %mployers, 6nions, *afety

7epresentatives and *afety 8rofessionals

• outline purposes to discover underlying causes, root/cause analysis, prevention of

recurrence, legal liability, data gathering and identification of trends

• description of investigation procedures and methodologies to include incident report

forms, gathering of relevant information, interviewing witnesses, analysis of

information and the involvement of managers, supervisors, employees, safety

representatives and others in the investigation process

• outline use of failure tracing methods / such as fault tree analysis and event tree

analysis !%TA / as investigative tools.

ote that in the second point "causes" is in the plural / there is more than one cause for every

accident.

What is an accident?

An early definition of accidents involving in#ury at work was proposed by -ord9acaughton in the case of :enton v Thorley ; o in <=>0, as follows1

"*ome concrete happening which intervenes or obtrudes itself upon the normal cause of

employment. It has the ordinary everyday meaning of an unlooked/for mishap or an untoward

event which is not epected or designed by the victim."for students of the %()*+ ational

iploma

This definition refers to a worker suffering a mishap which had a degree of unepectedness,

but it's too narrow as it's only concerned with accidents that result in in#ury, and not all

accidents do.



A trawl of some 3> accident definitions found in general, legal, medical, scientific and health

and safety literature suggests the ideal accident definition should include reference to causes

and effects. auses should include unepectedness, unplanned events, multi/causality and

sequence$chain of events. %ffects should include in#ury, disease, damage, near miss or loss.

Taking the best of the definitions, one that covers all the bases might run as follows1 "Anaccident is an unepected, unplanned event, in a sequence of events that occurs through a

combination of causes? it results in physical harm / in#ury or disease / to an individual,

damage to property, a near miss, a loss or any combination of these effects."

All accidents should be investigated? not #ust those that result in in#ury. Any accident

investigation should focus on the multi/causal accident and not uni/causal in#ury !where there

is one.

Immediate and underlying causes

It's also important that investigators identify and differentiate between immediate and

underlying !root causes, possibly by using event tree analysis, a logical system to tie events

to their basic causes.

Immediate causes may be defined as substandard acts or conditions that lead directly to the

accident. These might be removal of a machine guard, employee error, non/use of personal

protective equipment, lack of concentration, stress, fatigue and poor housekeeping.

(ehavioural safety advocates would subdivide these immediate causes into unsafe acts !@@

and unsafe conditions !<>. The other & are the unpreventable !or "acts of 2od"

according to research in the <=&>s by +5 +einrich, the father of behavioural safety.

6nderlying or root causes may be defined as inadequacies in the occupational safety and

health !)*+ management system that allow the immediate causes to arise unchecked,

leading to the accidents.

These may include1 unrealistic demands or epectations placed on employees, poor

maintenance, inadequate training or instruction, poor supervision, inadequate selection and

placement of employees, incomplete risk assessments, unsatisfactory systems of work, and

even poor accident investigations which only highlight one or two immediate causes.

These underlying causes !sometimes referred to as basic causes can be grouped loosely into

three interrelated categories1

• !lack of management control factors

• personal or #ob factors

• environmental factors.

A thorough accident investigation process should therefore highlight all accident causes /

usually between <> and &> for each accident / and then provide the basis to develop controlmeasures designed to eliminate both immediate and underlying causes, resulting in a



continual improvement in the )*+ management system. 7emember, every negative needs a

positive and every cause needs a control.

)rganisations should ask themselves the following questions about their accident

investigation processes1

• o we currently investigate all accidentsB

• o we meet the 7I)7 !7eporting of In#uries, iseases and angerous

)ccurrences 7egulations requirementsB

• o we need to review our internal accident investigation and reporting procedures

• o we have adequate accident investigation$reporting documentationB

• o we have enough, competent, responsible persons appointed and trained toinvestigate accidentsB

The +*%'s +*2 &34 workbook presents a four/step investigation process1

• *tep <1 gather the information

• *tep &1 analyse the information

• *tep 01 identify risk control measures

• *tep 31 implement the action plan.

The investigation process

To gather the information !*tep <, the investigators need to ask a series of questions which

aim to tease out all the facts$contributory causes !immediate and underlying of the accident

!see bo left.

They should then analyse the information !*tep & to establish the facts and chronology of the

events / immediate and underlying / that led to the accident.

The analysis should be specific and unbiased and should identify the sequence of

events$conditions and the combination of causes, using event tree analysis to map out all the

causes in a chronological, logical and linked way.

*pecifically, the analysis should clearly establish what happened and why. The investigative

team, ideally three/strong, should identify whether human error or procedural violations have

been contributory factors. It should also identify what other factors contributed to the

accident, whether they are #ob/related, organisational or linked to plant and equipment.

It's sometimes difficult to pin down the people issues because of the fear of blameapportionment and$or fault/finding. It's highly unlikely that a supervisor, charged to



investigate an accident on their patch, will come up with "lack of supervision" as one of the

contributory causes. +ence the need for a team of three investigators.

)nce you have found all the causal factors and eplored all the branches of the event tree to

their ends, then, and only then, can the investigative team get into control mode.

ever discount facts or possible causes that don't fit easily into the picture or the event tree.

These red herrings may be signs of another branch of the event tree that the investigation has

yet to follow. It's usually best to use the term "event tree" rather than "fault tree" as the latter

has definite negative connotations, which have no place in positive accident investigations.

Control measures

In control mode !*tep 0 your team should effectively identify all risk control measures that

were missing, inadequate or misused. They should compare activities, conditions and

practices as they actually were in the run/up to the accident with what should have been in place according to current best practice, agreed systems of work, legal requirements, codes of

practice, guidance and standards.

The team should identify those etra measures that are required to eliminate all immediate

and underlying causes by providing meaningful recommendations which can be properly

implemented to prevent a recurrence, and hence continually improve the )*+ management

system.

8articular questions which may help here include1

• 5hat risk control systems !7*s and workplace precautions !58s are neededB

• o similar risks eist elsewhereB If so, what and whereB

• +ave similar accidents happened beforeB If so, what and whereB

*tep 3 / the action plan and its implementation / is the final step in the accident investigation

process. This step should provide a clear action plan with *9A7TT ob#ectives !ones that are

specific, measurable, agreed, realistic, time/bound and trackable to deal effectively with all

the immediate and underlying causes of the accident. It should include lessons that have been

learnt which may be applied to prevent other accidents of a similar type$nature.

It should also provide feedback to people involved at all levels in the organisation to ensure

the findings and action plan recommendations are correct, realistic and fully address all the

issues. This plan should include feeding the findings back into a prompt review of the

eisting risk assessment, as any accident is an indicator that a review may well be overdue.

The team should also ensure that the results of the investigation are shown to all concerned,

with the emphasis firmly on the resulting action plan, timescales, responsibilities and

accountabilities, and how the plan will be implemented and its progress chased and

monitored.



The risk control action plan should establish which 7*s and 58s should be implemented in

the immediate, short or medium term. The team should also note which risk assessments and

systems of work need to be reviewed, updated and publicised, and whether the accident

details and the resultant findings and recommendations have been recorded and analysed

from both a numerical and causal viewpoint !that is, reactive monitoring.

They should also flag up whether there are any common causes or trends which suggest the

need for further, deeper and detailed investigation. :inally, they should put a figure on the

overall cost of the accident / both insured and uninsured / and also cost the associated control

measures.

6sing the four/step process to investigate all accidents from a causal viewpoint will certainly

improve overall )*+ performance in the workplace. ursory investigations where the only

control measure cited is "employee told to take more care" must be despatched to the health

and safety history books in favour of the much more scientific approach outlined above. They

certainly have no place in the %()*+ iploma syllabus.

Need to know

Cuestions to ask in an accident investigation include the following1

• 5here and when did the accident happenB

• 5ho was in#ured$suffered ill healthB

• 5hat was damagedB

• 5ho was involvedB

• +ow did the accident happenB

• 5hat activities were being carried out at the timeB

• 5hat did witnesses see, hear, smell, feel, tasteB

• 5as there anything unusual or different about the working conditionsB

• 5ere there adequate safe systems of work and did people stick to themB

• 5as the activity being properly supervised$managedB

• 5hat were the outcomes of the accident / in#ury, disease, damage, death, near miss,

lossB

• 5hat was the cause of any in#uryB



• 5hat were the immediate and underlying causes of the accidentB

• 5hat does the relevant risk assessment sayB

• 5as the risk knownB If yes, why was it not controlledB If no, why notB

• id the work organisation !or lack of it impact on the accidentB

• 5as maintenance and cleaning adequateB

• 5ere the people involved suitable and competentB

• id the workplace layout influence the accidentB

• id the nature, shape or form of the materials influence the accidentB

• id the work equipment influence the accidentB 5as it difficult$awkward to useB

• +ad the people involved received adequate information, instruction and trainingB

• 5as this clearly documentedB

• 5as adequate safety equipment provided and used correctlyB

• 5hat other conditions influenced the accidentB

This is an article in the Know-How Series prepared on behalf of the National Examination

Board in Occupational Safety and Health (NEBOSH by !awrence Bamber" BSc" #$S"

%&$OSH" &$'" )SSE

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All Accident Are Incident