Accident investigation Introduction The Health and Safety Executive (HSE) recently published new guidance on how to investigate

accidents and incidents. The publication of HSG245 Investigating Accidents and Incidents: A Workbook for Employers, Unions, Safety Representatives and Safety Professionals follows the HSE's decision not to amend the Management of Health and Safety at Work Regulations 1999 in order to make accident investigation an explicit legal requirement. Commenting on the release of the publication, Jonathan Russell, of the HSE's enforcement policy branch, stated, To have one accident is bad enough, but to have a further accident because lessons were not learnt is inexcusable. HSE believes that the best people to make workplaces safer are the staff and managers who work in them. By producing this guidance we aim to provide a tool for them to find out what went wrong, learn lessons and take action to reduce, or hopefully prevent, accidents in the future. General overview The guidance commences by highlighting that accident or incident investigation and analysis form an essential part of managing health and safety and that learning the lessons from what you uncover is at the heart of preventing accidents and incidents. A number of definitions are given at the start of the publication, including that of undesired circumstances which are described as a set of conditions or circumstances that have the potential to cause injury or ill health. Investigation of such circumstances is useful. Clearly, this definition is open to interpretation and individuals will have to make judgments. The introduction goes on to detail the legal reasons for investigating accidents, what information and insights can be gained from such investigation, and the benefits of investigating. To summarise, carrying out an investigation will ensure that the organisation is operating within the law, will help the organisation understand how and why things went wrong and will help to prevent future adverse events of a similar nature (thereby having a number of positive impacts on the organisation). Mention is made of the Woolf Report and civil actions the guidance states that an accident investigation would demonstrate to a court that your company has a positive attitude to health and safety. In terms of deciding when an investigation should take place, the guidance states that it is the potential consequences and the likelihood of the adverse event that should determine the level of investigation and not simply the extent of injury or ill health suffered.

The guidance also emphasises that any investigations should involve staff at all levels to ensure the utilisation of knowledge and skills within the organisation. The level of involvement of staff should be based on the level of investigation to be carried out. When considering what makes a good investigation, the guidance indicates that any investigation should be conducted with accident prevention in mind it should not be a method of apportioning blame. Apportioning blame will make staff defensive and uncooperative, and operator error is rarely the sole cause of an accident. On this basis, the investigation should identify the immediate causes, the underlying causes and the root causes that led to the undesired event. The objective is not only to establish how the adverse event happened but also, more importantly, what allowed it to happen. Step-by-step guide The first task after any adverse event is to provide an emergency response (such as first aid). It is then recommended that the scene be preserved, names of those involved and/or witnesses taken, work equipment/conditions involved noted and necessary regulatory reporting undertaken. HSG245 states that an effective investigation requires a methodical structured approach to information gathering, collation and analysis and, as such, suggests a four-step approach. The four steps featured in the guidance are as follows. 1. 2. 3. 4. The gathering of information. The analysis of information. Identification of risk control measures. The action plan and its implementation.

The information gathering process is based on a series of 17 questions that will assist in the discovery of what happened, and the conditions and actions that influenced the adverse event. After the gathering of information stage, the guidance goes on to describe the analysis stage, which calls for an examination of the facts and determination of what happened. No one particular method for completing this task is given as the HSE does not endorse any one course of action. However, an Adverse Event Analysis section is included in the document. This highlights again that laying blame on an individual is counter-productive. The guidance divides human error into three broad types skill-based errors, mistakes and violations. Disciplinary action should only be considered when a deliberate or malicious violation has taken place. The third step calls for the identification of suitable risk control measures based on the hierarchy of risk elimination, risk control at source, and measures that minimise risk by relying on human behaviour.

The final step is formulation and implementation of an action plan the plan being based on the SMART principle (specific, measurable, attainable, realistic, timescales). Interestingly, the guidance recognises that financial constraints may have to be considered. However, it states that failing to put in place measures to control serious and imminent risks is totally unacceptable. Forms The guidance document includes some useful forms. The Adverse Event Report and Investigation Form enables the user to collate all the necessary information from the investigation into one user-friendly format. Part 1 is an overview while Part 2 allows brief details of the initial assessment including RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995) reporting, event type and investigation level to be added. Part 3 covers the 17 questions that need to be asked to gather the information for the analysis process. Part 4 then allows the risk control action plan to be detailed. Two worked examples and a blank proforma are included. Perhaps the most interesting section of HSG245 is Adverse Event Analysis: Rooting Out Risk. This section is intended to help in the analysis process. For the immediate cause analysis, four areas are detailed, namely the place, the plant, the process and the people. For each area a matrix is given with a series of questions requiring a yes or no answer. If the answer to the question is no, the user is then referred to one or more of the areas that could have resulted in an underlying or root cause, namely control, co-operation, communication, competence, design, implementation and risk assessment. Each of these headings then has another series of questions that require answering, plus additonal supplementary questions based on health and safety management. Proformas are then provided (one each for place, plant, process and people) into which the identified immediate, underlying and root causes can be detailed, along with the measures necessary to remedy them. A further form is provided to detail any management issues that have been identified as weaknesses, and the necessary remedial actions required. Again, two worked examples and a blank proforma are provided. HSG245 Investigating Accidents and Incidents: A Workbook for Employers, Unions, Safety Representatives and Safety Professionals (ISBN 0 7176 2827 2, price: 9.50) is available from HSE Books (www.hsebooks.co.uk).