ACCIDENT INVESTIGATION & REPORTING

Welcome

Fire Precautions
Fire Precautions : If continuous alarm sounds leave the building by the nearest exit Report to the tutor at the assembly point

INTRODUCTION
Tea / coffee facilities Toilets

No smoking
First aid / fire Mobile phone / pagers Trainee introductions Please ask questions at any time

OVERALL AIMS
An understanding of the process and

purpose of investigating incidents

Remember : Includes ill health as well as

injury accidents
An understanding of the legal and

organisational requirements for recording and reporting

2003/04 Statistics
235 fatalities

159,809 RIDDOR reported injuries

An estimated 2.2 million people suffering

from an illness caused or made worse by their current or past work An estimated 39 million working days lost 30 million due to ill health & 9 million due to injury

The Reporting of Injuries, Diseases and dangerous Occurrences Regulations (RIDDOR) 1995

Whats the point of RIDDOR?

HSE/EHO need to know about the more

serious accidents, diseases and dangerous occurrences at work so they can perform their statutory role.
They can analyse where and how risks

arise and then investigate/enforce.

What needs to be reported?

Death or major injury:
employee or a self-employed person working on your premises is killed or suffers a major injury (including violence), or; a member of public is killed or taken to hospital

Over-3-day-injury:
employee/self-employed off work, or incapacitated for normal work for more than 3 days;

Disease:
doctor notifies you of reportable work-related disease;

Dangerous occurrence:
categories of near-misses.

The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995

Reporting procedures cover: fatalities and major injuries incapacity to work for more than three days specified diseases dangerous occurrences 2.1

RIDDOR
Covers: employers employees self-employed trainees other people injured on premises

RIDDOR
Major injuries include: fracture of:

skull, spine, pelvis arm, leg, wrist, ankle

amputation through any bone
loss of sight (temporary or permanent

RIDDOR
Major injuries (continued):

certain eye injuries electric shock requiring attention unconsciousness through lack of oxygen acute illness due to exposure to certain materials hospitalisation for more than 24 hours

RIDDOR
Reportable occurrences:

structural collapses

fires and explosions

release of gases or other dangerous substances failure of breathing apparatus while in use scaffold collapse

contact with or arcing of overhead cables

RIDDOR
Reportable diseases: any disease listed in the regulations as reportable

Social Security Act 1975 and RIDDOR

Every accident involving personal injury to an employee must be entered in the accident book by:

the employee, or someone acting on behalf of the employee The accident book must be kept accessible. An employer must investigate all accidents reported

Reporting to enforcing authorities

Since 01 April 2001, you can report accidents and occurrences to the Incident Contact Centre by: telephone fax e-mail post Reporting accidents and occurrences direct to the local HSE Office, on Form F.2508 or F.2508A, is still acceptable.

Report to enforcing authorities

F.2508 must be sent to the enforcing authorities in cases of:
injury at work resulting in more than three consecutive

days incapacity death of an employee within one year of sustaining a reportable injury a reportable disease when diagnosed by a registered medical practitioner

RIDDOR: Answers
Details of employee injury (normal working Monday to Friday 8.00 am to 5.00 pm)
Days off work Hrs in hospital

Tick if RIDDOR applies

Sprained arm (put on light duty with 5 days off normal job)

1 day
30days
1 day

Nil

No

The light duty counts as 5 days off work

2 3 4 5

Broken arm

4 hrs
3 hrs 3 hrs
Nil Nil

Any fracture but not toes and fingers

Broken finger

Broken finger

4 days
1 day

This is because of more than 3 days off work

Dermatitis

Only if confirmed by doctor

Sprained ankle on Thursday, returns to work on Tuesday

2 days

4 days not available for work (includes Sat and Sun)

RIDDOR: Answers
Details of employee injury (normal working Monday to Friday 8.00 am to 5.00 pm)
Days off work Hrs in hospital

Tick if RIDDOR applies

7 8

Amputation of finger Vibration white finger

2 days

6 hrs

Any amputation Only if confirmed by a doctor 3 days or more off work

nil

nil

Twisted ankle

4 days

nil

10 11 12 13

Twisted ankle

1 days

3 hrs

No
No
Over 5 metres high Unconsciousness

Electric shock (not unconscious)

2 days

nil

Electric shock (unconscious)

2 days

25 hrs

Electrical fault causing fire but workshop out of use for only 24 hours 6 metre high scaffold collapses

N/A

N/A

14

N/A

N/A

Accident/Incident Investigation
RIDDOR only requires reporting of

incidents etc. No explicit legal requirement in any H&S legislation to investigate - therefore WHY DO IT?

Accident/Incident Investigation
HSW Act states - employers must

ensure.the health, safety and welfare of employees... etc. Reactive monitoring - to prevent the same or similar from happening again Review/revise risk assessments and associated H&S documentation/working practices

Are you learning the lessons?

Do you investigate incidents & accidents in your company?

Do you do it well? Do you find the underlying causes? Do you take corrective action? Do you review your risk assessments as a

result?
Do you do it?

Accident Investigation Law

Explicit legal duty to investigate accidents

HSE on Accident Investigation 1999

Most accidents are not investigated
safety specialists lead rather

than line managers effort determined by severity of the injury rather than potential of the event little employee involvement if line managers do investigate, little training in investigation skills and techniques immediate technical causes only contd
29

HSE on Accident Investigation 1999

often stops when someone is found to blame fails to get to underlying causes

Even if there is an investigation:

failure to monitor full implementation of

investigation findings failure to systematically record findings so that lessons can be learnt throughout the organisation Most firms dont know why accidents occur !
30

Integrated approach to accident investigation and risk assessment

ie it should be integrated but usually isnt!!

from HSE CD169/2001

Integrated approach to accident investigation and risk assessment

ie it should be integrated but usually isnt !!

from HSE CD169/2001

Near misses are important

Powerful advantages
why not take the free lessons? equivalent learning opportunity

but, without the legal and liability

implications

Team based investigation

RoSPA study - best practice
led by senior managers involving employees, including

safety representatives supported by OS&H professionals acting as facilitators

Team based investigation

Local knowledge, especially operational

Building of trust;
Creates workforce 'champions' for H&S; Check on safety management standards Investigation of lower risk safety issues is

important in creating a positive climate for more structured investigation when major safety failures occur.

Summary
It will help prevent accidents It should fit in with existing risk assessment

practice It should be part of H&S management It will become an explicit legal duty but, most importantly Good accident / incident investigation will improve safety

The Cost of Accidents at Work

So why bother with H&S?

Premiums Uninsured losses Reputation Morale Productivity
Pain and suffering Duty to fellow human being

Fines and costs Court time Civil cases Notices

Humane
Prevent suffering and maintain quality of life No-one should be expected to risk life and

limb in return for a contract of employment

The true cost of an accident

To the victim: pain and suffering extra cost, less income continued disability incapacity for job and other activities the effects on others

The true cost of an accident

To those responsible: worry and stress recrimination and guilt extra work a) reports b) staff replacement loss of credibility

The true cost of an accident

To the working group:

shock and personal grief low morale affected production

Is good health & safety good business?

The true cost of an accident

To the firm: lost working time a) the victim b) others damaged equipment insurance costs prosecution or civil action

We recognise the importance of costing loss events as part of total safety management. Good safety is good business
Dr. J Whiston, ICI Group SHE Manager

Safety is, without doubt, the most crucial investment we can make, and the question is not what it costs us, but what it saves.
Robert McKee, Chairman Conoco (UK) Ltd.

Prevention is not only better, but cheaper than cureProfits and safety are not in competition. On the contrary, safety at work is good business.
Basil Butler, MD British Petroleum plc

We saved 750,000 on insurance premiums through improving our systematic management of health and safety.
Birse Group plc

Accident Costs Iceberg

Insurance Costs

Uninsured Costs

Insurance Costs
Employers Liability Public Liability

Product Liability
Motor Vehicle

Uninsured Costs
Product and material damage

Lost production time

Legal costs Overtime & temporary labour

Investigation time/Administration
Supervisors time Fines

Loss of expertise/experience
Loss of morale Bad publicity

Piper Alpha
167 dead

Estimated cost of over 2 billion

Grangemouth
BP refinery fire in 1987

One person died

Cost 50 million in property damage

Cost further 50 million due to business

interruption

HSE Example
Small engineering firm (15 workers) Workers sleeve caught on rotating drill Both bones in lower arm broken 12 days in hospital Off work for 3 months Admin duties for 5 months Unable to operate machinery for 8 months Managing Director Prosecuted 2 employees made redundant to prevent

company going out of business

Costs to Company
Wages for injured worker over period Lost production/remedial work required Overtime wages to cover lost production Wages for replacement worker Loss of time of manager/MD Legal expenses Fines and court costs Increase in Insurance Premiums = = = = = = = = 10000 8000 3000 7000 4000 3000 4000 6000

Total cost to business = 45000

Costs of slips and trips in GB

To the individual Lost income, pain, reduced quality of life To employers over 500m p.a. Damages, admin. and insurance, lost production, temporary absences To society over 800m p.a. Loss of potential output, medical costs, social security.

What contributes to the slip / trip risk?

Floor Environment Slip/ trip Potential People Contamination Obstacles

Footwear

Unsafe people

Unsafe conditions

Accidents

Some common causes of accidents

Not knowing or not using safe work methods Lack of testing, inspection and maintenance Unsafe manual handling Working too fast or cutting corners Overloading equipment

contd

Some common causes of accidents

Not using: guards, scaffolds, platforms, etc. Ignoring or disregarding: warning signs statutory notices Untidiness or carelessness Horseplay

Safety in the workplace requires

Safe systems of work and good

organisation
Good defect reporting and maintenance

arrangements
Careful, safety-based work planning The correct tools and equipment for the job

in hand
contd

Safety in the workplace requires

Knowledge of, and compliance with, safety

law Adequate information, training, instruction and supervision Common sense and a mature attitude

Reporting accidents
An accident book should be available in all work situations The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 reportable injuries three days or more off work certain listed injuries No report: no proof no future safeguard

Reporting accidents

Dangerous occurrences: Collapsed or overturned items of plant Explosion or bursting of closed vessels Reportable diseases: Certain diseases associated with specified work activities

THE LAW AND HEALTH & SAFETY

Oberon: This is thy negligence - thou mistakest or else commitst thy knavery wilfully

Shakespeare

UK legal system
Criminal
By HSE or LA Leads to a fine/imprisonment Not insurable

Civil
By injured person Leads to award of damages Must be insured

EXERCISE
You are going to work by bus. You buy a ticket (a contract with the bus co). During the journey, the driver collides with another vehicle and you suffer minor cuts and bruises. By the time everything is sorted out, you are very late for work. You sprint from the bus stop and trip over a paving stone, breaking your arm. Who is, if anybody, is liable for your injuries?

COMMON & STATUTE LAW

Common law is unwritten being derived from local & customary laws and the decisions of judges but is nevertheless binding
It evolves continuously as precedents are established
decisions of a lower court can be overturned by a higher court

Statute law is passed by Parliament, approved by the Sovereign & is written (published law)
It takes precedent over all other forms of Law (Common Law)

etc
Some Statute law is derived from decisions of the European

Union (Directives etc)

BURDEN OF PROOF
Criminal Law exists to punish offenders

and guilt must be established beyond reasonable doubt Civil Law is concerned with compensation and redress: the burden of proof is the balance of probability This is a lower standard of proof and a civil action may succeed where a criminal case has failed

CIVIL COURTS (ENGLAND & WALES)

The County Courts deal with Civil cases. The

judge normally sits alone though a Jury may sometimes be empanelled The High Court of Justice may also deal with civil cases The Court of Appeal (Civil Division) hears appeals from the lower courts Once again, the House of Lords is the ultimate court of appeal Civil cases are often settled out of court

CIVIL ACTION
If an accident occurs and somebody suffers injury or loss and negligence or breach of statutory duty can be proved damages may be recoverable

Documents, including accident reports, risk assessments etc must be disclosed on request

TIME LIMITATIONS
Actions for personal injury claims etc

normally have to be brought within 3 years of the accident In the case of a disease such as asbestosis the limitation is 3 years from the diagnosis of the condition Courts have the discretion to allow time barred cases to proceed in some circumstances

NEGLIGENCE
Donoghue v Stevenson (1932) must take reasonable care

to avoid acts/omissions which you can reasonably foresee would be likely to injure your neighbour
This duty of care is owed to people who are closely &

directly affected by your acts/omissions (e.g. employers, employees, contractors, visitors, suppliers)
defences against actions include: no duty owed, duty not

breached, breach did not lead to damage, risk accepted voluntarily,contributory negligence

Bradford vs Robinsons Rentals (1967): employer liable for reasonably foreseeable frostbite injuries to B

SAFE SYSTEM OF WORK

Wilson & Clyde Coal v English 1938 A leading case which established an Employers duty of care towards employees Masters duty to a Servant Safe premises Safe plant & equipment Competent fellow workers Adequate supervision (cf Health & Safety at Work etc Act)

BREACH OF STATUTORY DUTY

Damages can be recovered if it can be proved that

loss occurred because of the defendants failure to comply with a statutory requirement May be easier to prove than negligence, especially if the breach has been established by a criminal prosecution Main defences: duty not breached, injured party not protected by statute, harm not of type statute designed to protect, contributory negligence Some statutory duties are absolute

VICARIOUS LIABILITY
Employers are vicariously liable for the

actions of their employees provided that the employees were acting in the course of their employment (sometimes even if the activity was expressly forbidden) Limpus vs London Omnibus Co. (1862) Employer Liable for accident caused by negligent employee

DUTIES OF EMPLOYEES
Employees may also be sued. They have a

duty to: - To carry out duties with reasonable care - To avoid loss to Employer (cf Health & Safety at Work etc Act) NB. Employers not liable for activities that do not form part of employees employment servants frolic of his own Storey v Aston (1869) Employer not liable for accident caused during unauthorised detour

REASONABLE PRACTICALITY
Edwards v National Coal Board (1949) Risk must be

insignificant in relation to sacrifice (time, effort & expense): NCB claimed unsuccessfully that it was not reasonably practicable to shore up all mine roads
Marshal v Gotham & Co (1954) If something is practicable,

courts will not lightly hold that it is nor reasonably practicable

Adsett v K&L Steelfounders & Engineers Ltd (1953) The

standard of practicality is that of current knowledge not having sufficient resources is no excuse for inaction

DEFENCE OF NECESSITY
A defendant may claim that his/her actions

arose from necessity (e.g. to prevent a more serious accident) ESSO Petroleum Co v Southport Corporation (1955) A captain of an oil tanker jettisoned oil in bad weather to safeguard the crew: ESSO convinced the court that this was a necessary act and not negligence

CONSENT:VOLENTI DEFENCE
Volenti non fit injuria: cannot expect redress if

you consent to an act likely to result in injury or loss Cutler v United dairies (1933) Cutler failed to recover damages after being injured trying to restrain a bolting horse: it was held he consented to the risk Haynes v Harwood (1935) A policeman was able to recover damages after being injured restraining a bolting horse: he had a legal duty to protect life & property and was not held to have consented willingly to the action

CONTRIBUTORY NEGLIGENCE
Where a person suffers damage or loss Partly his/her fault Partly the fault(s) of other person(s) Damages may still be recoverable but the amount will be reduced in proportion to the claimants responsibility Saywer vs Harlow UDC (1958) Contributory negligence was accepted after a woman was injured when she put her foot on a revolving toilet roll while trying to get out of a cubicle

OCCUPIERS LIABILITY ACTS (1957 & 1984)

Duty of reasonable care to lawful visitors

(invitees, licensees, contractors & those with a right under law) Need to ensure premises are reasonably safe. Dangerous defects must be repaired and warning notices displayed as necessary Should expect children to be less careful than adults Common Law duty not to cause trespassers intended harm

TRESPASS: CASE LAW

Tichener v British Railways Board (1984)

BRB not liable for injuries to teenage girl hit by a train even though fence was not maintained (Girl frequently & willingly took risk) British Railways Board vs Herrington (1972) BRB liable for injuries to a 6-year old child who had strayed onto the line Bird vs Holbrook (1828) Landowner liable for injuries to a trespasser caused by a spring loaded gun (trespasser unaware of risk)

THE WOOLF PROTOCOL

Lord Woolf (the Lord Chief Justice) drew

up a Personal Injury Pre-action Protocol aimed at simplifying & streamlining claim procedures Claims must proceed to a strict timetable Defendants must investigate claims & disclose relevant documents within the timetable If the protocol is not complied with, Courts may impose tough sanctions

CRIMINAL COURTS (E&W)

All criminal cases are first dealt with by Magistrates Courts.

these can try summary offences and can commit people accused of indictable offences (& commit people for sentencing) to the Crown Court.
The Crown Court tries Indictable offences. Trial is before a

Judge (with a Jury in contested cases. Can also hear appeals from Magistrates Courts.
The High Court of Justice hears appeals from Magistrates &

some appeals from Crown Courts.

The Court of Appeal (Criminal Division) hears appeals from

Crown Courts it can amend or reverse decisions or remit cases to lower courts
The House of Lords is the ultimate court of appeal

HEALTH & SAFETY AT WORK ETC ACT 1974 (HSAWA)

Section 2: duty to ensure, so far as is reasonably practicable the health safety & welfare of employees safe workplace & safe working practices information, training & supervision adequate welfare facilities health & safety policy safety representatives & committees

Section 3: employers to conduct undertakings so as to ensure so far as is reasonably practicable that persons not in his employment are not exposed to risks to their health & safety

HSAWA - (ii)
Section 4: duty of those in control of premises to

non-employees Section 6: duties of manufacturers & suppliers (includes provision of safety information) Section 7: duty of employees to take reasonable care for their health & safety and that of others affected by their acts/ omissions and to co-operate with employer Section 8: no person to intentionally/ recklessly interfere with or misuse anything provided for health, safety or welfare
Section 9: no charge to employees for H&S items

HSAWA - (iii)
Section 36: where the commission of an

offence is due to the default of another person - that person shall be guilty of the offence Section 37: Directors are responsible (as well as the body corporate) for offences committed with their consent/connivance or attributable to any neglect on their part

HEALTH & SAFETY REGULATIONS

Made under the Health & Safety at Work etc

Act 1974 Often required by European Directives Consultative Documents issued by Health & Safety Commission Signed by the Secretary of State Laid before Parliament Have coming into force (CIF) dates Most may be cited in breach of statutory duties actions (but not HSAWA or MHSWR)

REGULATIONS !
Management of H&S at Work * Workplace Health, Safety & Welfare * Working time * Provision & Use of Work Equipment * Personal Protective Equipment at Work * Display Screen Equipment * Manual Handling Operations * Safety Signs & Signals * Pressure Systems * Electricity at Work * First Aid at Work * Control of Substances Hazardous to Health * Control of Asbestos at Work * Genetic Modification (Contained Use) Regulations * Dangerous Substances & Explosive Atmospheres * Ionising Radiations * Genetic Modification * Reporting of Accidents, Incidents & Dangerous Occurrences

MANAGEMENT OF HEALTH & SAFETY AT WORK REGULATIONS

Assessment of risks

planning, organisation, control monitoring &

review health surveillance competent H&S personnel emergency procedures information & training co-operation with other employers serious dangers/shortcomings

employees to follow instructions & report

WORKPLACE HEALTH, SAFETY & WELFARE REGULATIONS

Maintenance,ventilation, heating & lighting Cleanliness & waste materials Space Workstations, floors & traffic routes Measures to prevent falls or falling objects Windows, skylights & ventilators escalators, walkways, doors & gates toilets, washing facilities, drinking water Facilities for changing, resting & eating

PROVISION & USE OF WORK EQUIPMENT REGULATIONS

Work equipment suitable for use
maintained in good repair information, instruction & training

machine guarding
precautions against specified hazards controls, isolation, stability, lighting markings & warnings mobile work equipment & power presses

CONTROL OF SUBSTANCES HAZARDOUS TO HEALTH REGULATIONS

Risk assessment elimination or control of risk

maintenance of equipment
environmental monitoring health surveillance emergency procedures information, instruction & training

APPROVED CODES OF PRACTICE

ACOPs are prepared by the Health & Safety

Commission Although they are not laid before Parliament, they have a legal status They set out how Regulations may be complied with You do not have to follow the ACOP but if you do not you may have to prove that you complied with the Regulations by other means

ENFORCEMENT OF H&S LAW: POWERS OF INSPECTORS (HSE etc)

Entry to premises Involvement of police

Make necessary examinations & investigations

To direct premises are undisturbed To take photographs, measurements & samples

To order plant to be dismantled

Require witness statements Inspect documents etc

HSE ENFORCEMENT POLICY

See HSE Enforcement Policy Statement Proportionality: relating enforcement to how far the duty holder has fallen short of legal requirements Targeting: concentrating on the most serious risks Consistency: taking a similar approach in similar circumstances Transparency: telling duty holders what is expected of them

NOTICES & PROSECUTION

A Prohibition Notice prohibits an activity (e.g. use of a

dangerous machine)
An Improvement Notice requires improvements (usually

within a time scale)

Organisations can appeal against notices to an Industrial

Tribunal
The HSE names and shames offenders Enforcing Authorities can prosecute offenders for breaches

of HSAWA or Regulations made under HSAWA

MAX PENALTIES UNDER HSAWA

Failing to comply with an Improvement/ Prohibition

Notice: Lower court 20,000 and/or 6 months in prison Higher court unlimited fine and/or 2 years in prison Breaches of sections 2-6 of HSAWA Lower court 20,000; higher court unlimited fine Breaches of regulations etc Lower court 5,000; upper court
unlimited fine

R v ASSOCIATED OCTEL
A contractor working for AO suffered severe burns

when a lamp broke setting fire to solvent vapours The contractors company was prosecuted under Section 2 of HSAWA (duty to employees) AO was convicted under Section 3 of HSAWA (duties to others) AO appealed on the grounds that the work of the contractors was not part of AOs undertaking The appeal went all the way to the House of Lords before finally being dismissed: the work was part of AOs undertaking and they had a duty to ensure the H&S of the contractors

CORPORATE MANSLAUGHTER
A company cannot have a criminal state of mind At present, a company can only be convicted of

manslaughter if the Controlling mind is first proved guilty This is normally only possible with very small companies R v OLL Ltd (1994) following the death of 4 children on a canoe trip OLL fined 60K & the managing director jailed
Changes in the law are imminent

Legal Requirements
Health & Safety at Work etc Act 1974 Management of Health & Safety at Work
Regulations 1999

Failure to comply is a criminal act Employers CANNOT insure against failure

to comply

Section 2
Section 2(1) - employers general duty
Duty to ensure so far as is reasonably

practicable, the health, safety and welfare at work of employees and any others who may be affected by the undertaking.

Legal Standards
Reasonably Practicable or SFARP
Implies a weighing up of the risk against the cost

(in terms of time, money or trouble) of preventing or controlling the risk

Section 2 (cont.)
Provision of such information, instruction,

training and supervision as is necessary to ensure , SFARP, the health and safety at work of employees and any others who may be affected.

Section 2 (cont.)
Duty of Employers to Employees cont. 2.2a - safe plant and systems of work 2.2b - safe use, handling, storage and transportation of articles and substances 2.2c - information, instruction, training and adequate supervision 2.2d - safe place of work and a safe means of access and egress 2.2e - safe working environment and adequate welfare facilities

Section 7
Duty of Employees at Work It shall be the duty of every employee whilst at work: to take reasonable care of their own health and safety and of any other person who may be affected by their acts or omissions to co-operate with their employer so far as is necessary to enable that employer to meet their requirements with regards to any statutory provisions

Section 21
Improvement Notices If an inspector is of the opinion that a person: is contravening one or more of the relevant statutory provisions; or has contravened one or more of those statutory provisions, in circumstances that it is likely that the contravention will continue or be repeated, then he will issue an Improvement Notice.

Section 22
Prohibition Notices If any activity is being, or is about to be, carried out that could result in serious personal injury, then an inspector may issue a Prohibition Notice. This notice will cause the immediate cessation of the activity involved until all measures are rectified.

Enforcement
The HSE can take legal action against an employer/employee in a criminal court for H&S failures: Unlimited fine and/or Custodial sentence (Remember - you cannot insure against failure to comply with H&S legislation) If guilty = criminal record

British Justice
INNOCENT until proven GUILTY beyond ALL REASONABLE DOUBT

Civil Litigation
Provides for compensation to be paid to persons who suffer harm as a result of a work activity. Can insure - Employers Liability Insurance Burden of proof is NEGLIGENCE Proof is on the balance of probabilities Effectively guilty until you prove your innocence

Reportable
Reporting of:

Injuries (accidents & incidents)

Disease

Dangerous Occurrences
(Regulations)

Why investigate?
It is a reactive element in monitoring

phase of your safety management system:

Eliminate the causes and underlying causes to prevent a recurrence; Identifying safety management lapses by examining shortfall between what you plan to happen and what did happen; Identify trends and patterns for future prevention; Evaluates organisations position in relation to potential breaches of law.

Why investigate?

Accident Reporting & Investigation

Objectives for this section:
to understand:
accident definition accident causation accident costs accident prevention accident reporting/notification accident investigation

Accident Reporting & Investigation

Common Uninformed Comments
accidents just happen we dont have many accidents safety is expensive the insurance will pay safety is just common sense

 Accident Definition

Accident Reporting & Investigation

what is an accident?
unplanned & uncontrolled event that led to, or could have led to:
injury to persons, damage to property/plant/equipment, impairment to the environment or some other loss to the company

Accident Reporting & Investigation

Accident Definition
accident types
minor dangerous occurrence near miss plant/equipment damage minor injury lost time injury disablement/fatality

Accident Reporting & Investigation

Accident Definition
Frank Bird (Accident Triangle)
600 near misses 30 property damage 10 minor injuries 1 serious injury (lost time or fatal)

THE ACCIDENT

BASIC TYPES OF ACCIDENTS

THE ACCIDENT
MINOR ACCIDENTS:
Such as paper cuts to fingers or dropping

a box of materials.

THE ACCIDENT
More serious accidents that cause injury

or damage to equipment or property:

Such as a forklift dropping a load or

someone falling off a ladder

THE ACCIDENT
Accidents that occur over an extended

time frame:
Such as hearing loss or an illness resulting from exposure to chemicals

THE ACCIDENT NEAR-MISS

Also know as a Near Hit An accident that does not quite result in

injury or damage (but could have).

Remember, a near-miss is just as serious

as an accident !

THE ACCIDENT

ACCIDENTS HAVE TWO THINGS IN COMMON

THE ACCIDENT
They all have outcomes from the accident

THE ACCIDENT
They all have contributory factors that cause the accident

Accident Reporting & Investigation

Accident Causation
environment personal fault unsafe act unsafe condition accident injury/damage

Accident Reporting & Investigation

Accident Causation
causal factors
individual job organisation

Accident Reporting & Investigation

Accident Causation
causal factors
individual knowledge skills training experience personality attitude risk perception

Accident Reporting & Investigation

Accident Causation
causal factors
job task workload equipment controls procedures environment

Accident Reporting & Investigation

Accident Causation
causal factors
organisation culture leadership resources work patterns communications

ACCIDENT CAUSATION MODELS - 1

ACCIDENT
INVESTIGATE PROCESS AND OUTCOME STEERED BY INVESTIGATORS PRE-CONCEPTIONS OF CAUSATION
CONCLUDE PRIMARY CAUSE IS EITHER:

UNSAFE ACT, or;

UNSAFE CONDITION

DEVISE A RULE FORBIDDING BEHAVIOUR

DEVISE A TECHNICAL SOLUTION

Accident Reporting & Investigation

Accident Causation
Kings Cross Fire (1987) - 31died
discarded cigarette accumulation of rubbish poor cleaning regime wooden escalator failure of fire fighting equipment lack of emergency training poor safety culture

Accident Reporting & Investigation

Accident Causation
Herald of Free Enterprise (1987) - 189 died
failure to close bow doors no checking/reporting system commercial pressures internal friction disease of sloppiness

Accident Reporting & Investigation

Accident Causation
Clapham Junction (1988) - 35 died & 500 injured
signal failure incorrect maintenance degradation of working practices training problems communication problems poor supervision excessive working hours failure to learn lessons

Accident Reporting & Investigation

Accident Causation
Piper Alpha (1988) - 167 died
maintenance error inexperience poor maintenance procedures communications breakdown permit to work system fault safety procedures not practised

Accident Reporting & Investigation

Accident Causation
Automotive Supplier (1999) - 1 died
poor safety culture lack of guarding lack of training poor perception of risk no safe systems of work no risk assessment programme no effective accident system no communication

OUTCOMES OF ACCIDENTS
NEGATIVE ASPECTS
Injury & possible death Disease Damage to equipment & property Litigation costs, possible citations Lost productivity Morale

OUTCOMES OF ACCIDENTS

POSITIVE ASPECTS
Accident investigation Prevent recurrence Change to safety programs Change to procedures Change to equipment design

The Aim of the Investigation

The key result should be to prevent a

recurrence of the same accident.

Fact finding: What happened? What was the root cause? What should be done to prevent recurrence?

The Aim of the Investigation IS NOT TO:

Exonerate individuals or management.

Satisfy insurance requirements.

Defend a position for legal argument. Or, to assign blame.

Accident Reporting & Investigation

Accident Costs

insured costs uninsured costs

Accident Reporting & Investigation

Accident Prevention

reasons humane economic legal

Accident Reporting & Investigation

Accident Prevention
control measures
safety procedures/work instructions adequate training effective communications good housekeeping guards/safety devices/warning signs adequate working environment regular safety inspections risk assessment

Accident Reporting & Investigation

Accident Reporting/Notification
internal report form HSE RIDDOR report injury claim requirement

Accident Reporting & Investigation

Accident Investigation
reasons
identify root causes identify faults identify corrective/preventative action prevent recurrence

THE INVESTIGATION

Objectives
Recognise the need for an investigation
Investigate the scene of the accident

Interview victims & witnesses

Distinguish fact from fiction Determine root causes Compile data and prepare reports Make recommendations

ACCIDENTS & ILL HEALTH REASONS FOR INVESTIGATION

to record what happened RIDDOR legal reporting requirement compensation claims/insurance to find out what & why it happened immediate causes (What) underlying causes (Why) to prevent recurrence the next incident could be more serious

Traditional approach to accident investigation

Safety management has concentrated on accident investigation as it is a good deal easier than proactive prevention Key features: Search for the primary cause, and Debate whether the primary cause was and unsafe act or unsafe condition

HEINRICH'S TRIANGLE (1950)

1 29 300
MAJOR INJURY MINOR INJURIES NON-INJURY INCIDENTS

Accident causation
First accident model was Heinrich (1931).

Domino theory
Social environment Fault of person Unsafe Act
Unsafe condition

Accident

Injury

Acts and Conditions

UNSAFE ACT UNSAFE CONDITIONS

Human errors Failure to follow

No guarding

Trip hazards
Poor maintenance Poor design

procedures Violations mistakes

HSE Guidance on accident investigations [HSG 65]

Need for line managers to take responsibility

for investigation;
need for adequate training for investigators;

importance of investigating both accidents

and other incidents and near-misses - esp. those with potential for serious injury;
need to deal with immediate consequences at

scene by treating, helping and rescuing persons and making site safe;
contd

HSE Guidance on accident investigations [HSG 65] contd

investigating to appropriate depth, depending on its

seriousness; guidance on investigation process to investigators, including: structured approach appropriate use of observation, documents and interview evidence; use of model to guide collection of evidence and its assembly for evaluation need to explore immediate and underlying causes developing specific objectives for implementing findings need to record essential data

Attending the accident scene

OBSERVE

Look at the scene and the surrounding area Take measurements and produce a diagram Take photographs INTERVIEW The injured person and/or witnesses (preferably separately) At the scene if possible(within 48 hours) Note down beforehand some key questions to be answered - CHECKLIST Ask open-ended questions in a friendly manner KEEP AN OPEN MIND (be aware of your bias)

Interviews
Start with initial discussions with preferably

the injured person and peers/witnesses (Mainly what happened)

Then move on to interview supervisors

and senior managers (Mainly why)

Do not rush into statement taking, get an

overview first

Statements
Introduce yourself (if necessary)and explain

your role what needs to be done

Invite safety rep or another person they would

like to sit in, but not answer questions

If trainee under 18 years, interview with an

adult, preferably a parent

Run through your questions and what they

witnessed and make notes to help structure a statement Each persons summary

A modern approach
Immediate causes and underlying causes

HSG65 Accidents are Multi-causal Understanding of the complexities of human factors Understanding of management systems Promotion of a safety culture

HS(G)65 Appendix 5 Immediate causes (what) 4 Ps

Premises
Plant/Substances Procedures People

Premises
Physical layout

Condition of building
Environment (weather) Tripping & slipping hazards

PLANT/SUBSTANCES
Machinery guarding

Substance in use toxic, harmful

Mobile plant

Item of work equipment hand tools,

chairs

PROCEDURE
Written system of work/operating

procedure to be followed Safety Policy Work instruction Quality standard Custom and Practice does not have to be a document

People
Human factors

State of health (eye sight)

Abilities

Errors skill based (slip or lapse), rule

based, knowledge based or violations Behaviour pressures, culture

Underlying causes Root causes (Why)

5) Planning 6) Risk Assessment 7) Control 9) Communication 10) Competence 11) Monitoring 12) Reviewing

(Supervision) 8) Co-operation

HSG65 APPENDIX 5
IMMEDIATE CAUSE 1. PREMISES 2. 6. 5. PLANNING UNDERLYING CAUSE 9.
ORGANISATION COMMUNICATION

PLANT AND SUBSTANCES

ASSESSING RISKS

10.
ORGANISATION COMPETENCE

3. PROCEDURES 4. PEOPLE

7.

ORGANISATION CONTROL

11.
MONITORING

8.
ORGANISATION CO-OPERATION

12.
REVIEW

Hazards Ideal
Management Arrangements Underlying Causes

Reality

RCS

Workplace Precautions
Accident

Immediate Causes

Essential data in investigation reports

Details of injured person - age, sex,

experience and training, etc;

Description of circumstances - place, date,

time and conditions;

Details of the event - actions leading directly

to event/ direct injury causes;

Underlying causes;

contd

Essential data in investigation reports

Details of outcomes: nature of injuries, ill-health, losses; severity of harm; immediate management response and its adequacy; First-aid response; Potential consequences: what was the worst that could have happened? What prevented it from happening? How often could it recur and how many affected?

Accident investigation
Notified of accident Scene made safe Collect facts to answer 5 Qs: What, when, where, who, how?

By:

1. observation

2. documentation

3. interviews

Refer to relevant standards for comparison: [a] legal or good practice, and; [b] safety management plan.

Analyse differences between what happened and what should have happened to identify causes and underlying SMS lapses
Target report at decision-makers Feed into monitoring/review stages of SMS for validation/verification comparison

Follow-up to implement necessary changes to SMS plan AND site

Accident Reporting & Investigation - team

Accident Investigation
investigation team
supervisor safety rep engineer manager safety officer

Accident Reporting & Investigation - objectives

Accident Investigation
investigation objectives
establish chain of events identify root causes identify faults identify corrective/preventative action

Accident Reporting & Investigation - techniques

Accident Investigation
investigation techniques
attend promptly ensure medical attention leave scene undisturbed take photographs/sketches take measurements take samples gather documentation interview witnesses

Accident Reporting & Investigation - techniques

Accident Investigation
investigation techniques
interviewing witnesses explain purpose their version of events do not listen to hear say ask open questions avoiding leading or implying do not apportion blame express appreciation

Accident Reporting & Investigation - report

Accident Investigation
investigation report
identify team summarise consequential events identify root causes describe other weaknesses identify corrective/preventative action allocate responsibility & timescale

ACCIDENTS ..... DONT JUST REPORT THEM & PREVENT THEM !

Working together improving safety

What are you doing to involve your workforce?

What is workforce involvement?

Involve the workforce as equal partners

Actively seek their views

Value their positive contribution Enable effective involvement in all areas of

H&S management Be ready to change things and challenge previous management practices Nurture, support and sustain the partnership.

Do you shape up?

Have the workforce as well as

managers been involved in writing the company safety policy? Are all H&S Committee members equal partners? Have safety reps, supervisors and others been trained to enable them to play an equal role in the H&S Committee? Does your company provide cover for workers to enable attendance at safety meetings and training courses?

Do you shape up?

Are employees involved in long term H&S

Are workers involved in writing safe working

procedures? When accidents are investigated are safety reps fully involved? Do H&S audits include safety reps as well as managers?

Where is all this from?

HSE booklet HSG217 Involving employees

in health and safety Aimed at the chemical industry but should apply to everyone Does it apply to you?

Health and Safety Management

Safety Representatives Safety Officers And Safety Committees

Members and Meetings

All work areas Meetings discuss

should be represented Members should be interested,concerne d and willing to learn more about h&s Willing to meet once a month and to communicate with workers

workers concerns Possible solutions Approaches to management negotiations Ongoing concerns and progress reports to union

Functions of Committee
Conduct regular inspections and

surveys on safety and health Respond to workers concerns on OHS Make reports and recommendations to improve compliance with law and standards Propose policies, work plans, projects and activities to reduce accidents and illness Propose and organise training programmes for the workforce

Functions of Committee
Promote and support activities on OHS

Follow up progress of proposals

Report on results achieved, point out

obstacles and problems Investigate, record and report on all accidents, ill health and near misses Propose regulations on health and safety Organise occupational health services

What makes a committee work?

Have a plan and objectives and actively pursue

them with the broadest support possible

Communicate and educate to get that support Need facilities, time off, info and training Agendas in advance, proper minutes, decisions If union reps make coherent proposals in writing:

describe the problem, include the facts; suggest improvements; decide who will do what; timetable and budget.

Directors Responsibilities
The board needs to recognise its role in engaging

the active participation of workers in improving H&S

You should encourage workers at all levels to

become actively involved in all aspects of your health and safety management system
The best form of participation is a partnership for

prevention, where workers and their representatives are involved in identifying and tackling potential or actual problems, rather than being consulted only after decisions have already been taken
Directors responsibilities for health and safety UK HSE IND(G)343

Employers role- Planning and Coordination

Understand the legislative requirements and have a

written health and safety policy.

Identify hazards, make a site specific health and safety plan and method statements before work starts

Designate OSH responsibilities - safety officer to

implement safety management on site

Conduct inspections, and meetings with all

subcontractors and with workers to inform, communicate and coordinate and to provide training
Have the necessary information on site regarding

hazards and conduct regular tool box meetings

Use the safety committee as the motor for prevention

Building Partnerships
PLANNING ORGANISATION
H&S

MEASURING

management system HSG65

PARTNERSHIP
POLICY

ARRANGEMENTS

AUDIT & REVIEW

commitment agreed goals

leadership

respect for legitimate interests

shared vision positive culture change

openness transparency

trust honesty

Partnership building blocks

This is what you need to do

Involve the workforce as equal partners
Actively seek their views Value their positive contribution

Enable effective involvement in all areas of

H&S management Be ready to change things and challenge previous management practices Nurture, support and sustain the partnership.

If you do that
We will genuinely be working together You will be improving H&S The workers will be healthier and safer You will be financially healthier and safer

it works !

THANK YOU AND QUESTIONS

For attending this course