accident investigation mike waltersbtckstorage.blob.core.windows.net/site1476... · action plan •...
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Health and Safety Executive
Health and Safety Executive
Accident Investigation
Mike Walters
HM Principal Inspector of Health and Safety
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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
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Accident Investigation
Value and Purpose
– Prevent reoccurrence
– Costs of accidents
Which incidents need investigation
– Accident
– Case of ill health
– Near miss
– Property damage
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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
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Immediate Actions
• Treat injured
• Action to prevent a recurrence/escalation
• Capture situation – photographs,
measurement, samples, equipment,
statements
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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
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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
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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
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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
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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
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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!
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Process
• Information gathering
• Analysis
• Risk control measures
• Action plan and implementation
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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
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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
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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
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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
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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
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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
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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
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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
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Summary
• Benefits – to learn lessons, prevent future
ill-health and injury
• Systematic investigation
• Need to establish root cause
• Plan remedial actions
• Implement findings
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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]