1.0 Unit 7

Incident Investigation, Recording and Reporting

1.0 Unit 7: Incident Investigation, Recording and Reporting

Overall aims.

Understand:

the need for an organisation to have a system for internally reporting, recording and investigating accidents, cases of work-related ill-health and other occurrences;

local requirements for notifying certain events to external agencies.

Specific learning outcomes.

Be able to:

explain the purpose of and procedures for investigating accidents and other events at work;

utilise records of accident and ill-health experience in an organisation;

explain the local requirements for notifying events to external agencies.

Reference:

Recording and Notification of Occupational Accidents and Diseases, ILO.

Tuition time: 4 hours.

1.2

Role and Function of Accident and Incident Investigation

Introduction.

Why do we investigate accidents and incidents?

The simple answer is to ascertain why the accident happened and put measures in place to ensure that the same - or similar - accidents don't happen again.

It is more than that, however; finding the root cause of an accident and ensuring that measures are put in place to ensure that it can't happen again are a vital part of any investigation.

Before we move on to studying the investigation process, we have provided you with an example investigation and in this section, we explain the role of the accident investigator and the function of accident and incident investigation in the workplace.

The names of the persons involved, dates and times etc. are all omitted as you would expect. Our intention is to provide you with a scenario that will support the section entitled Investigation Process.

1.3

Example Investigation

The last thing that any manager wants to do is report an accident or incident to the EHO or HSE. When thinking of this, two things come to mind:

One -  you may feel that you or your safety management systems have failed.

Two -  you may worry that reporting accidents and incidents to the enforcing authorities - and a possible follow-on visit by them - may reveal even more failings, a bit like going to the dentist with a slight toothache and ending up having to have three teeth taken out.

However, we know that as part of your accident prevention strategy, accident investigation and reporting plays a vital role and as you are now also aware, having read through RIDDOR, you have a legal duty to report certain accidents and incidents.

Below is the detail of how and why we need to investigate and report accidents and incidents, but to put it into context, we have included an example for you:

1.3.1

Setting the Scene

We begin with the the accident investigation.

The incident took place on a large project that included, amongst other aspects, the refurbishment of places of worship. There were eleven sites in all, some used by members of the public, others closed and awaiting refurbishment.

Consider the type of work activities that this might entail. The work was mostly preparation and painting of walls, ceilings, floors and woodwork to the interior of these old buildings, preparing the surfaces ready for painting and then applying the paint.

The employees were working as painters and decorators. In all, there were 125 men and women, mostly inexperienced in the world of work and - to some extent - not particularly motivated individuals. The project was funded by the government to help the unemployed back into work.

1.3.2

The Accident

A telephone call was received from one of the Site Supervisors to say that  one of the men had fallen and an ambulance had been called. He gave information concerning the suspected injury and the employee's name.

The Site Supervisor had followed the procedure; he had not disturbed the site of the accident and had sent a colleague to the hospital with the injured employee. The colleague would report back on the injury and the initial thoughts of the Accident & Emergency Department.

The Project Manager needed to telephone the injured employee's named contact. All of the employees, at their induction, had to complete a form stating who should be the first person to be contacted in the case of such an event.

The Painting & Decorating team on the site were made up of 12 young people in the age range 18 to 24 and one experienced tradesman, plus the Site Supervisor.

The scene of the accident was a corridor just off the main church hall: two chairs, a table and glass on the floor. A sketch of the area was quickly made and included some dimensions such as corridor width, position of broken glass etc.

1.3.3

The Accident Continued

The input of members of the team was then solicited on the events of the accident.

The team member who was with the injured person at the time of the accident was taken into another area and interviewed; notes were made as the events of the accident were explained. The Site Supervisor was then interviewed, notes again being made as he spoke.

At the end of these initial interviews, both interviewees were told that they might need to be re-interviewed.

Later, each of the other team members was asked if they knew anything of what had happened. Three of the team stated that the injured team member (employee A) had been to them to ask if he could borrow the step ladder they were using and all had said no, as they were using them.

An understanding of the events leading up to the accident was now emerging:

The time of the accident was 2.30.

Two members of the team were involved.

A make shift access platform was used. A certain amount of rushing could be

attributed to the accident.

A sketch of the immediate area of the accident was made. This meant that the scene could be cleared and made safe.

1.3.4

What Had Happened?

In brief, two members of the team had been asked to prepare the area of the corridor ready for painting. The injured employee A and his colleague (employee B) had been asked by the Site Supervisor to replace the bulb in the corridor that he, the Site Supervisor, suspected had blown. This must be your first action, the Site Supervisor had told them, make the area safe first.

Employees A and B tried to find the step ladders but all ladders on the site were in use and they had given up because it was nearly tea break, as employee B had stated in his interview. Employee B had, however, dragged a small table, a fixed leg chair and a swivel chair from an adjacent office.

Employee A placed the fixed leg chair on the table and used the swivel chair as a step up. All went well until employee A removed the suspected blown light bulb and

placed the new bulb in the light fitting. To his surprise, it lit up. The switch had been left in the `on` position. It startled employee A and his reflex action had made the chair slip and caused him to fall. 

1.3.5

What Had Happened? ContinuedThe enforcing authority at the time was the HSE. They

were contacted and provided with the details as required under RIDDOR (see below). Form F2508 was also completed. Employee A had suffered a suspected fracture to his right arm and suspected concussion, which meant a night in the hospital.

It is not always possible immediately to do carry out the investigative procedure outlined above. End of day accidents, shift patterns or accident sites that require some distance of travel can all delay the start of the investigation process.

Within three days of the accident, employee A's statement was taken. Apart from one or two minor inconsistencies between witness statements A & B, the report was concluded and signed off.

The documents were filed and the data processed. What was left to do was perhaps more important - establishing the root cause of the accident and ensuring, through suitable control measures, that the same or similar accident never happened again.

All parties blamed each other. Employee A blamed employee B for rushing him and bullying him into climbing on the table; he also blamed the Site Supervisor for not having enough step ladders on site at any one time. Employee B blamed the Site Supervisor for the same reason as employee A but he also blamed employee A for not taking the step ladders off another team member. The Site Supervisor blamed them both for improvising.

After the accident, a toolbox talk was given on correct access equipment use. The site team also discussed the importance of reporting all accidents and near-miss incidents in the future.

Why is it important to sketch or photo graph the scene of an accident?

1.   ?   all the above2.   ?   so that you can refer to it3.   ?   to keep a record

4.   ?   in case the scene is disturbed

1.4

Basic Accident Investigation Procedures

Basic accident investigation procedures:

Interviews, plans, photographs, relevant records, checklists.

Identifying immediate causes (unsafe acts and conditions) and root or underlying causes (management system failures).

Identifying remedial actions.

1.4.1

Accident Investigation Process

The intention of the above example is to help you put into context the points made below.

Accident investigations are conducted to find out the cause of accidents and to prevent similar accidents in the future. Further to this, legal requirements are placed on employers through RIDDOR or through an appointed competent authority under ILO Recording and Notification of Occupational Accidents & Diseases.

The investigation can also be used to determine costs and will, by the nature of the investigation, highlight compliance with statutory requirements.

Near-miss accidents should also be investigated in the same manner as loss events. Investigating the near-miss will identify hazards that can then be corrected. The forklift truck that nearly hit a pedestrian on a blind corner may have a simple corrective action to prevent a major accident.

1.4.2

Who Undertakes the Investigation?

Ideally, an investigation would be conducted by someone expert in accident causation, experienced in investigative techniques, fully knowledgeable of the work processes, procedures, persons and industrial relations environment of a particular situation. However, in the real world it is normally a manager from within an organisation, supported by a member of the safety team.

It is important that whoever undertakes the investigation does so in an impartial manner. Looking for someone to blame at the start of the investigation has only one outcome - failure. The important point is that even in the most seemingly straightforward accidents, seldom is there only a single cause.

For example, an "investigation" which concludes that an accident was due to worker carelessness and goes no further fails to seek answers to several important questions such as:

Was the worker distracted?

Was a safe work procedure being followed? Were safety devices in order? Was the worker trained?

1.4.3

Who Undertakes the Investigation? Continued

As discussed earlier, as little time as possible should be lost between the moment of an accident or near miss and the beginning of the investigation. In this way, one is most likely to be able to observe the conditions as they were at the time, prevent disturbance of evidence and identify witnesses. The tools that members of the investigating team may need (pencil, paper, camera, film, camera flash, tape measure, etc.) should be immediately available so that no time is wasted.

Here, the actual work procedure being used at the time of the accident is explored. Members of the accident investigation team will look for answers to questions such as:

Was a safe work procedure used? Had conditions changed to make the normal

procedure unsafe? Were the appropriate tools and materials

available? Were they used? Were safety devices working properly? Was lockout used when necessary?

For most of these questions, an important follow-up question

is "If not, why not?"

1.4.4 Material

To seek out possible causes resulting from the equipment and materials used, investigators might ask:

Was there an equipment failure? What caused it to fail? Was the machinery poorly designed? Were hazardous substances involved? Were they clearly identified? Was a less hazardous alternative substance possible and

available? Was the raw material substandard in some way? Should personal protective equipment (PPE) have been

used? Was the PPE used?

Again, each time the answer reveals an unsafe condition, the investigator must ask why this situation was allowed to exist.

1.4.5 Environment

The physical environment, specifically sudden changes to that environment, is a factor that needs to be identified. The situation at the time of the accident is what is important, not what the "usual" conditions are.

For example, accident investigators may want to know:

What were the weather conditions? Was poor housekeeping a problem? Was it too hot or too cold? Was noise a problem? Was there adequate light? Were toxic or hazardous gases, dusts, or fumes present?

1.4.6

PersonnelThe physical and mental condition of those individuals

directly involved in the event must be explored. The purpose of investigating the accident is not to establish blame against someone, but the inquiry will not be complete unless personal characteristics are considered. Some factors will remain essentially constant while others may vary from day to day:

Were workers experienced in the work being done? Had they been adequately trained? Could they physically do the work? What was the status of their health? Were they tired? Were they under stress (work or personal)?

1.4.7

Management

Management holds the legal responsibility for the safety of the workplace and therefore the role of supervisors and higher management must always be considered in an accident investigation. Answers to any of the preceding types of questions logically lead to further questions such as:

Were safety rules communicated to - and understood by - all employees?

Were written procedures available? Were they being enforced? Was there adequate supervision? Were workers trained to do the work? Had hazards been previously identified? Had procedures been developed to overcome them? Were unsafe conditions corrected? Was regular maintenance of equipment carried out?

1.4.8

Were Regular Safety Inspections Carried Out?

This model of accident investigations provides a guide for uncovering all possible causes and reduces the likelihood of looking at facts in isolation. Some investigators may prefer to place some of the sample questions in different categories; however, the categories are not important as long as each pertinent question is asked.

Obviously, there is considerable overlap between categories; this reflects the situation in real life. Again, it should be emphasised that the above sample questions do not make up a complete checklist, but are examples only.

1.4.9 How Are the Facts Collected?

The steps in accident investigation are simple: the accident investigator gathers the information, analyses it, draws conclusions and makes recommendations. Although the procedures are straightforward, each step can have its pitfalls.

As mentioned above, an open mind is necessary in accident investigation; pre-conceived notions may result in some wrong paths being followed while leaving some significant facts uncovered. All possible causes should be considered. Making notes of ideas as they occur is a good practice but conclusions should not be drawn until all the information is gathered.

1.4.10 Injured Worker(s)The most important immediate tasks - rescue operations,

medical treatment of the injured and prevention of further injuries have priority and others must not interfere with these activities.

When these matters are under control, the investigators can start their work.

1.4.11

Physical Evidence

Before attempting to gather information, examine the site for a quick overview, take steps to preserve evidence and identify all witnesses. In some cases, an accident site must not be disturbed without prior approval from the appropriate enforcing authority, the coroner, or the police.

Physical evidence is probably the most non-controversial information available. It is also subject to rapid change or obliteration; therefore, it should be the first to be recorded. Based on your knowledge of the work process, you may want to check items such as:

positions of injured workers; equipment being used; materials being used; safety devices in use; position of appropriate guards; position of controls of machinery; damage to equipment; housekeeping of area; weather conditions; lighting levels; noise levels.

You may want to take photographs before anything is moved, both of the general area and specific items. Later, careful study of these may reveal conditions or observations missed previously. Sketches of the accident scene based on measurements taken may also help in subsequent analysis and will clarify any written reports.

Broken equipment, debris and samples of materials involved may be removed for further analysis by appropriate experts. Even if photographs are taken, written notes about the location of these items at the accident scene should be prepared.

1.4.12 Eyewitness AccountsAlthough there may be occasions when you are unable to

do so, every effort should be made to interview witnesses. In some situations, witnesses may be your primary source of information because you may be called upon to investigate an accident without being able to examine the scene immediately after the event.

Because witnesses may be under severe emotional stress or are afraid to be completely open for fear of recrimination, interviewing witnesses is probably the hardest task facing an investigator. Witnesses should be interviewed as soon as practicable after the accident. If witnesses have an opportunity to discuss the event with each other, individual perceptions may be lost in the normal process of accepting a consensus view where doubt exists about the facts.

Witnesses should be interviewed alone, rather than in a group. You may decide to interview a witness at the scene of the accident where it is easier to establish the positions of each person involved and to obtain a description of the events. On the other hand, it may be preferable to carry out interviews in the quiet of an office where there will be fewer distractions. The decision may depend in part on the nature of the accident and the mental state of the witnesses.

The steps involved in an accident investigation include...

1.   ?   Gather information2.   ?   All of the above3.   ?   Make recommendations4.   ?   Draw conclusions

5.   ?   Analyse information

What aspects of the accident information should be recorded first due to rapid change or obliteration?

1.   ?   Who was to blame2.   ?   Physical evidence

3.   ?   Witness statement

1.4.13

InterviewingInterviewing is an art that cannot be given justice here,

but a few do's and don'ts can be mentioned. The purpose of the interview is to establish an understanding with the witness and to obtain his or her own words describing the event:

DO put the witness (who is probably upset) at ease; emphasise the real reason for the investigation - determining what

happened and why; let the witness talk and listen to what they say; confirm that you have the statement correct; try to sense any underlying feelings of the witness; make short notes only during the interview.

DO NOT intimidate the witness; interrupt; prompt; ask leading questions; show your own emotions; make lengthy notes while the witness is talking.

1.4.14

Interviewing Continued

The actual questions you ask the witness will naturally vary with each accident but there are some general questions that should be asked each time:

Where were you at the time of the accident? What were you doing at the time? What did you see/hear? What were the environmental conditions

(weather, light, noise, etc.) at the time? What was (were) the injured worker(s) doing at

the time? In your opinion, what caused the accident?

How might similar accidents be prevented in the future?

If you were not at the scene at the time, asking questions is a straightforward approach to establishing what happened. Obviously, care must be taken to assess the credibility of any statements made in the interviews. Answers to a first few questions will generally show how well the witness could actually have observed what happened.

Another technique sometimes used to determine the sequence of events is to replay them as they happened. Obviously, great care must be taken so that further injury or damage does not occur. A witness (usually the injured worker) is asked to re-enact in slow motion the actions that preceded the accident.

1.4.15 Background InformationA third - and often overlooked - source of

information can be found in documents such as technical data sheets, maintenance reports, past accident reports, formalised safe-work procedures and training reports. Any pertinent information should be studied to see what might have happened and what changes might be recommended to prevent recurrence of similar accidents.

1.4.16

What Should I Know When Making the Analysis

At this stage of the investigation, most of the facts about what happened and how it happened should be known. This has taken considerable effort to accomplish but it represents only the first half of the objective.

Now the key question - why did it happen?

To prevent recurrences of similar accidents, the investigators must find all possible answers to this question.

You have kept an open mind to all possibilities and sought out all pertinent facts. There may still be gaps in your tracing of the sequence of events that resulted in the accident. You may need to re-interview some witnesses to fill these gaps in your knowledge, or you may have to resort to assumptions. Some authorities claim that assumptions have no place in accident investigations. On the other hand, it may be better to make assumptions based on what evidence is available, than to leave questions unanswered.

When your analysis is complete, jot down a step-by-step account of what happened (your conclusions) working back from the moment of the accident, listing all possible causes at each step. This is not extra work; it is a draft for part of the final report. Each conclusion should be checked to see if it is supported by evidence, the evidence is direct (physical or documentary) or based on eyewitness accounts, the evidence is based on assumption.

This list serves as a final check on discrepancies that should be explained or eliminated.

1.4.17

Why Recommendations Should Be Made

The most important final step is to come up with a set of well-considered recommendations designed to prevent recurrences of similar accidents.

Once you are knowledgeable about the work processes involved and the overall situation in your organisation, it should not be too difficult to come up with realistic recommendations. Resist the temptation to make only general recommendations to save time and effort.

For example, you have determined that a blind corner contributed to an accident.

Rather than just recommending "eliminate blind corners" it would be better to suggest: installing mirrors at the northwest corner of building X (specific to this accident) and installing mirrors at blind corners where required throughout the worksite (general).

Never make recommendations about disciplining a person or persons who may have been at fault. This would not only counter the real purpose of the investigation, but it would jeopardise the chances for a free flow of information in future accident investigations.

In the unlikely event that you have not been able to determine the causes of an accident with any certainty, you probably still have uncovered safety weaknesses in the operation. It is appropriate that recommendations be made to correct these deficiencies.

1.4.18 The Written Report

If your organisation has a standard form that must be used, you will have little choice in how the written report is to be presented. Nevertheless, you should be aware of, and try to overcome, shortcomings such as:

Where limited space is provided for an answer, the tendency will be to answer in that space despite recommendations to "use back of form if necessary."

If a checklist of causes is included, possible causes not listed may be overlooked.

Headings such as "unsafe condition" will usually elicit a single response even when more than one unsafe condition exists.

Differentiating between "primary causes" and "contributing factors" can be misleading. All accident causes are important and warrant consideration for possible corrective action.

Your previously prepared draft of the sequence of events can now be used to describe what happened. Remember that readers of your report do not have the intimate knowledge of the accident that you have, so include all pertinent detail. Photographs and diagrams may save many words of description. Identify clearly where evidence is based on certain facts, eyewitness accounts, or your assumptions.

If doubt exists about any particular part, say so. The reasons for your conclusions should be stated and followed by your recommendations. Weed out extra material that is not required for a full understanding of the accident and its causes, such as photographs that are not relevant and parts of the investigation that led you nowhere. The measure of a good accident report is quality, not quantity.

1.4.19

What Should Be Done if the Investigation Reveals "Human Error"

A difficulty that has bothered many investigators is the idea that one does not want to apportion blame. However,

when a thorough worksite accident investigation reveals that some person or persons were apparently at fault, then this fact should be pointed out. The intention here is to remedy the situation, not to discipline an individual.

Failing to point out human failings that contributed to an accident will not only downgrade the quality of the investigation, it will also allow future accidents to happen from similar causes because they have not been addressed.

1.   ?   it will reduce our insurance premiums2.   ?   because we should apposition blame3.   ?   to prevent similar occurrences4.   ?   because the law says we should

A good point when interviewing a witness is to .....

1.   ?   Put the witness at ease2.   ?   Ask leading questions

3.   ?   Prompt

1.5 Unsafe Acts & Unsafe Conditions Unsafe Acts

Unsafe acts

are made by people; they are not made by systems or by faulty equipment. People make unsafe acts.

As an example, an

employee was loading a vehicle using a fork lift truck. At the end of his shift, he parked the truck across a walk way. He had left the forks in the down position; however, he had parked in the walkway. Later that evening when the security guard was making his rounds in the dimly-lit yard, he tripped over the forks, falling and injuring his knee.

We can also refer back to the example made at the beginning of this unit, where an employee used a chair to gain access and fell when the chair became unstable.

Categories of unsafe acts:

Speeding. Rendering safety devices inoperative. Working in an unsafe position or posture. Working without permission. Using unsafe methods. Horseplay. Failure to wear PPE or safety clothing. Lack of concentration, fatigue or ill-health. Using unsafe equipment. Using equipment unsafely. Working on moving or dangerous equipment.

Active unsafe acts are, for example, where the employee deliberately removes a guard or uses unsafe equipment. These can be difficult to deal with as many will go unnoticed.

No matter how many times you explain to some people that unsafe acts are by their very nature dangerous, some

people don't realise the hazards and will continue to act irresponsibly.

An example of a passive unsafe act is smoking; we are all aware of the dangers of smoking, yet some people still smoke.

1.5.1 Unsafe Conditions

1.5.2

Unsafe Conditions can be Mechanical and or Physical

Unsafe conditions can be Mechanical and or Physical

MECHANICAL

Sometimes, is it not possible to make guards that are 100% effective at all times. Interlocking and automatic guards should not be thought of as infallible. There are many regulations relating to guards and fencing; however, guards fail for all sorts of reasons.

Some machines are left unguarded because they are presumed safe by position. In real terms, no machine is safe by position, because this relies on people, or the proximity of people to that machine.

Machines can start for some unexpected reason, by mistake or without the appropriate authority. A suitable safe system and or permit to work should remedy this.

PHYSICAL

Physical conditions such as heat, light, ventilation, humidity and noise can contribute to an unsafe place of work.

Temperature

Thermal comfort is an important factor and people have been found to work safer in temperatures that range from 16 - 24 C. It stands to reason that those who have heavier workloads perform better at the lower end and those that are more sedentary the higher end.

Very hard work or the use of protective clothing will lower the temperature range, but this range will be raised where high air movements cool the body temperature.

Noise

The effects of noise are extremely complex. We know that it can damage our auditory mechanism and at high levels, above 120 db, which are sustained over a period of time; we know that this can lead to permanent damage. Lower levels interfere with our speech, communication and concentration and can interfere with our work and how we work safely.

1.5.3 Unsafe Conditions

Inadequate guarding, wrong height, size of mesh etc. Unguarded machinery. Defective, slippery, damaged, sharp surfaces. Unsafe design of machines or tools. Unsafe arrangements, housekeeping, congestion,

blocked exits. Inadequate lighting, glare, reflections. Inadequate ventilation, contaminated air. Unsafe clothing, no gloves, or mask. Unsafe process, mechanical, chemical, electrical,

nuclear. Humid, cold or noisy environments.

Unsafe acts and unsafe conditions can interact. For instance, a person may overcome a poorly-designed guard. You could argue that the poorly-designed guard was an unsafe act in itself. When unsafe acts and unsafe conditions interact, the risk of an accident increases as shown below.

1.5.4 Organisational Factors

The following are organisational factors:

Management system pressures. Financial restrictions. Lack of commitment. Lack of policy. Lack of standards. Lack of knowledge and information. Restricted training and selection of tasks.

1.5.5 Job Factors

The following are job factors in indirect causes of accidents:

Poor layout of task. Work schedules and patterns. Procedures and instructions.

All of these factors need to be considered to determine the real causes of an accident or incident. These factors can also be considered as part of an accident prevention programme. They should be considered at the concept stage of any new project to ensure a "pro-active" approach to

safety. In other words,

Prevention is better than cure.

Is speeding an unsafe act or unsafe condition?

1.   ?   unsafe condition

2.   ?   unsafe act

Is the removal of a guard an unsafe act or unsafe condition?

1.   ?   unsafe act

2.   ?   unsafe condition

Is a missing guard an unsafe act or unsafe condition?

1.   ?   unsafe act

2.   ?   unsafe condition

1.6 Root Cause & Immediate Cause

We will now consider Root Cause and Immediate Causes in more detail. We have included several examples for you to consider.

Definition of Root Cause :-"the most basic cause that can be reasonably identified and that management has control to fix"

Typically, an incident report will place emphasis on developing a description of the consequences rather than causes of the incident, explaining what happened, but not why it happened.

It is only by adopting investigation techniques that explicitly identify root causes, i.e. the reasons why an incident occurred, that organisations may learn from past failures and avoid similar incidents in the future. Root Causes analysis is simply a tool designed to help incident investigators determine what, how and most importantly, why an incident occurred.

They are a method of describing and schematically representing the incident sequence and its contributing conditions; a method of identifying the critical events or active failures and conditions in the incident sequence and based on this identification; a method for systematically investigating the management and organisational factors that allowed the active failures to occur, i.e. a method for root cause analysis.

In selecting or developing a root cause analysis method, the analyst needs to consider whether the method specifically facilitates the identification of safety management and organisational inadequacies, oversights which relate to their own operations. The method needs to identify those factors that exert control over the design, development, maintenance and review of their risk control systems and procedures.

Typically, an incident report will provide an organisation with a description of events which principally focus on the status of the system at discrete moments along a timeline. Reports also usually place the emphasis on developing a description of the consequences rather than causes of the incident, explaining what happened, but not why it happened. Such analyses are almost invariably technically orientated, involving detailed descriptions of plant, equipment, reactions and their governing logic systems.

It is only by adopting investigation techniques which explicitly identify root causes, i.e. the reasons why an incident occurred, that organisations may learn from past failures and avoid similar incidents in the future.

Root cause analysis is simply a tool designed to help incident investigators describe what happened during a particular incident, to determine how it happened and to understand why it happened.

In simple terms asking why something happened at each event of the investigation should lead you to the root cause. Knowing the root cause of an accident/incident will allow control measures to be implemented that are designed to prevent such a similar recurrence and at the root of the problem.

1.6.1 Example 1

Note:

The main occupier of the track is Rail Ready. Contractor A is the Technical Services, and are not

employees of Rail Ready. Contract B is a local construction company, often used by

Rail Ready. Contract C is a local fencing and security company.

A report from a train driver employed by Rail Ready to his Supervisor stated that he witnessed a child on the tracks near a busy junction. He claims that the child - aged approximately eight years old - was crossing the lines and that his train nearly hit the child.

The Supervisor makes his report to the Health & Safety Manager for that region and copies this report to his immediate manager.

The H&S Manager investigates the incident and reports the following:

"At approximately 10 am on the morning of Tuesday 24th March 2009, a child was seen by the driver of train 22345 north-bound to Manchester near the junction of Evergreen, Birmingham.

CCTV also caught the image of a child crossing this junction at the time witnessed by the train driver. Video evidence is contained within this report."

1.6.2 Example 1(cont.)

The report continues:

"I visited the scene and noted the following:

A lane runs parallel to the track, from the A19. This lane is used by walkers of dogs etc, (photos included).

The lane is located on the south side of the track. It is a dead end and is not suitable for road vehicles.

The wooden fence is there to prevent members of the public gaining access to the tracks.

A section of perimeter fence was missing.

The missing section of fence was approximately 2 metres in length. The fence was laying in the undergrowth near the scene. I replaced the fence using wire to secure it and telephoned the District Rail Manager who sent a crew to make the temporary fix permanent.

I can confirm that this work was carried out that afternoon.

I noted that works had been carried out at the track side, near the position of the missing fence (what appeared to be recent earth works and disturbance of the ground)."

1.6.3 Example 1(cont.)

"I visited the District Rail Manager the following day and discussed the matter with him.

He informed me that work had been carried out by a team of contract technicians, Contractors A, and that this work was to a railside signal box, some two weeks earlier at that location.

Another contractor C, had first removed the section of fence and yet another contractor B, had been engaged to ready the ground area for the technicians.

I interviewed contractor A, a Technical Supervisor, who informed me that his team had arrived at that the site and that the fence had been removed and the area cleared so that his team could install a new signal box.

I interviewed the contactor B, who was engaged to make the area accessible and to excavate an area, ready for the sitting of the signal box. He informed me that the section of fence referred to had indeed been removed by another contractor C, so that his men and work equipment could gain access to side of the track.

I interviewed the contractor C, who was engaged to remove the fence. He explained that his contract was to remove the fence to allow excavation equipment to gain access to the south side of the track. He said to me that no mention was made of re-instalment of the fence, once the job had been completed.

I noted that the paper systems used in this instance made no reference to ensuring that the fence should be replaced.

I also noted that the contract to each contractor, A, B or C, made no mention of the fact that the site should be secure at any time."

1.6.4 Example 1(cont.)

Let us now examine what went wrong:

Incident : near miss accident. Child on tracks. Why? Causal Factors/Immediate Causes/Unsafe Acts. Curiosity? Walking the dog and dog ran off? Taking short cut? How did child gain access to track? Through gap in fence? Why a gap in the fence? Contractor C did not replace fence when work completed. Why? Contract from Rail Ready did not specify that contractor C should

replace fence. Why? Typing error, poorly-written contract, assumption - another

department's job to ensure safety? Written Safe Procedure for these works lacking in instruction. Why? Poorly-written safe procedure, typing error, assumption? Why was the site not monitored by Rail Ready H&S Dept? Communication error; H&S not aware of works. No monitoring of safety for prevention of access while works being

carried out. Why was it that contractors A & B did not undertake to make the site

secure? No mention in contract, assumption that contractor C would do this. Root Cause . Poor communications between Rail Ready, all the contractors and

their own departments, including H&S.

1.6.5 Example 2

The Plant Manager walked into the plant and found oil on the floor. He called the Supervisor over and told him to have maintenance clean up the oil.

The next day, while the Plant Manager was in the same area of the plant he found oil on the floor again and he subsequently berated the Supervisor for not following his directions from the day before. His parting words were to either get the oil cleaned up or he'd find someone that would.

1.6.6 Example 2

(cont.)

Root Cause Example

The Plant Manager walked into the plant and found oil on the floor. He called the Supervisor over and asked him why there was oil on the floor. The Supervisor indicated that it was due to a leaky gasket in the pipe joint above. The Plant Manager then asked when the gasket had been replaced and the Supervisor responded that Maintenance had installed four gaskets over the past few weeks and each one seemed to leak.

The Supervisor also indicated that maintenance had been talking to Purchasing about the gaskets because it seemed they were all bad. The Plant Manager then talked with Purchasing about the situation with the gaskets. The Purchasing Manager indicated that they had in fact received a bad batch of gaskets from the supplier. The Purchasing Manager also indicated that they had been trying for the past two months to try to get the supplier to make good on the last order of 5,000 gaskets that all seemed to be bad.

The Plant Manager then asked the Purchasing Manager why they had purchased from this supplier if they were so disreputable. The Purchasing Manager said because they were the lowest bidder when quotes were received from various suppliers. The Plant Manager then asked the Purchasing Manager why they went with the lowest bidder and he indicated that was the directive he had received from the Director of Finance.

The Plant Manager then went to talk to the Director of Finance about the situation. When the Plant Manager asked the Director of Finance why Purchasing had been directed to always take the lowest bidder, the Director of Finance said, "Because you indicated that we had to be as cost conscious as possible and purchasing from the lowest bidder saves us lots of money."

The Plant Manger was horrified when he realised that he was the ultimate reason there was oil on the plant floor. 

Everyone in the organisation was doing their best to do the right things, and everything ends up messed up. The root cause of this whole situation is local optimisation with no global thought involved.

This also provides a good example of how we should proceed to do root cause analysis. We simply have to continue to ask "Why?" until the pattern completes and the cause of the difficulty in the situation becomes rather obvious.

1.6.7 Example 3

In the tragic accident of Air France Concorde flight 4590 on 25th July 2000, engine failure was suspected. Only a thorough investigation by the Bureau de l'Aviation Civile showed that one of the tyres had been punctured on take off. The runway was not swept as procedure required because of a fire test that day. This one element of the Root Cause could not - and would not - have been discovered without the investigation being undertaken. We are working back from the result Root Cause, through the immediate causes to the crash.

Please note that we have not attempted to detail the events; this is a very brief model of the events that took place.

The basic events that took place in the tragic accident of Concorde

Ref Event Causal Factor or Root Cause

1. Aircraft Crashes.

2. Concorde stalls in flight. Causal Factor

3. Crew fight to gain altitude. Causal Factor

4. Engine No 2 caught fire. Causal Factor

5. Design failure in fuel tank materials. Causal Factor

6. Fuel tank ruptures. Causal Factor

7. One or more pieces of tyre thrown against fuel tank. Causal Factor

8. Cut to tyre on wheel No 2. Causal Factor

9. Concorde runs over strip of metal from a DC 10 that had taken off a few minutes earlier.

Causal Factor

10. Runway not swept as procedure required. Causal Factor

11. Fire Exercise carried out & delays runway inspection. Causal Factor

12. Incorrect repair/material to DC10 ten days earlier. Causal Factor

13. Material not available. Causal Factor

14. Management failed to ensure that correct materials available & used in repair to DC 10 ten days earlier.

Root Cause

The root cause of an accident is the reason why an incident occurred.

1.   ?   False

2.   ?   True

1.7

Recommendations for Remedial Actions We will now consider making recommendations for remedial actions or control measures. It is not enough that the investigation concludes with what went wrong and why. A good investigation will also make recommendations that are designed to prevent such a recurrence.

Initiate preventative action.

Actions should be taken to remedy all of the deficiencies determined in the stages described in the above section, Incident Investigation.

These remedial actions can be divided into two types.

1. Immediate.

For example, the actions that can be taken by local supervision such as replacing a guard on a machine if it is immediately available and safe to do so; arranging for spillages to be cleaned up; erecting temporary barriers, etc.

2. Long term.

There may be a need to raise job orders or purchase requisitions or to submit recommendations for design

and/or process changes which need to be actioned and approved by other departments.

The investigation may identify a training need which is a long-term action. All of these action points need to be considered relative to other areas of the organisation where similar processes or equipment are involved.

Role and function of accident investigation

Please select the correct missing words, in order, for the sentence below.

We _________ accidents to _________ why the accident ___________ and put _________ in place to ensure that the same or similar ________ do not happen again.

Put the parts in order to form a sentence. When you think your answer is correct, click on "Submit" to check your answer. If you get stuck, click on "Hint" to find out the next correct part.

   measures      happened      investigate      ascertain      accidents   

1.7.1

Ensure Actions Are CompleteIt is essential that progress on the identified remedies is

closely monitored to ensure that they do not get unnecessarily delayed or even forgotten. There should be a follow-up review to ensure that the actions taken are effective and do not create other unforeseen hazards.

These objectives may appear to be overkill when the accident only resulted in a minor injury, minor damage or a near-miss. However, every apparent minor accident may be a potentially fatal accident. This first part of the investigation should be to establish the potential severity of injury or damage that could have resulted. The effort and resource devoted to the remainder of the investigation must be in direct proportion to this potential.

1.7.2

Identify Preventive Measures:

Assess/reassess the risk. Question the adequacy of existing physical

safeguards, work methods and discrepancies with those intended.

Reappraise the intended safeguards and work methods.

Do they satisfy the intentions of the company health and safety policy, and do they meet the statutory requirements?

1.7.3

Establish Whether Initial Management Response Was Adequate

Prompt and appropriate action such as making safe and dealing with any continuing risks, electrical isolation, suitable fire fighting, effective first-aid response and correct spillage procedures.

1.7.4

Identify the Underlying Causes

These might include:

management or supervision failure; lack of competence; inadequate training; shortcomings in original design; inadequate performance standards set by

firm; absence of a system for maintenance.

1.7.5

Determine Action Needed to Prevent a Recurrence

In deciding on the right course of action, employers need to think whether the outcome could have been more serious and what prevented this from happening.

Examples of action are:

improve physical safeguards; provide and use local exhaust ventilation; use mechanical handling aids such as pile

turners and mobile lifts; introduce better test and maintenance

arrangements; improve work methods; provide and use personal protective

equipment; make changes to supervision and training

arrangements; review similar risks in other departments; set up a system to assess the risks from new

plant and substances at the planning stage; review procedures involving contractors; update standards and policies; introduce monitoring and audit systems.

1.7.6

Implement, Analyse and Review

Once the initial action is taken, management need to:

identify underlying causes and corrective action;

implement follow-up action promptly; check that follow-up action has been taken

(standard report forms can help); analyse data systematically to identify

trends and features - safety representatives and company safety committees will find this useful;

question the overall response - did it fully reflect the risks?

review performance periodically.

They can then make sound decisions for the future.

1.7.7

Be SMARTER

Recommendations of remedial actions should be:

SMARTER

SPECIFIC - who will do what and when.

MEASURABLE - the corrective actions must be measurable.

ACCOUNTABLE - the persons responsible for implementing the corrective actions should be clearly defined.

REASONABLE - the corrective action should be practical, i.e. will it work? Can it be implemented?

TIMELY - the due date of the corrective action(s) must be timely; are there any interim actions can be implemented sooner if required?

EFFECTIVE - the corrective actions must prevent or significantly reduce the risk of this problem happening again.

REVIEWABLE - will this corrective action cause any problems? What might be the negative impact if any?

Those involved must:

ADAP

Agree on how to eliminate the immediate hazard.

Develop actionable recommendations for each root cause.

Assign responsibility for each recommendation.

Prioritise recommendations based on the potential for eliminating the incident in the future.

1.8

ILO Recording and Notification of Occupational Accidents and Diseases

The International Programme for the Improvement of Working Conditions and Environment (PIACT) was launched by the International Labour Organisation in 1976 at the request of the International Labour Conference and after extensive consultations with member States.

PIACT is designed to promote or support action by member States to set and attain definite objectives aiming at making work more human. The Programme is thus concerned with improving the quality of working life in all its aspects: for example, the prevention of occupational accidents and diseases, a wider application of the principles of ergonomics, the arrangement of working time, the improvement of the content and organisation of work and of conditions of work in general, a greater concern for the human element in the transfer of technology.

To achieve these aims, PIACT makes use of and coordinates the traditional means of ILO action, including:

the preparation and revision of international labour standards;

operational activities, including the dispatch of multidisciplinary teams to assist member States on request;

tripartite meetings between representatives of governments, employers and workers, including industrial committees to study the problems facing major industries, regional meetings and meetings of experts;

action-oriented studies and research; and clearing-house activities, especially through the International Occupational Safety

and Health Information Centre (CIS) and the Clearing-house for the Dissemination of Information of Conditions of Work.

The below eLearning material is extracted from the publication from the outcome of a PIACT project.

Please follow this linkto view the full publication.

1.8.1.

Arrangements for Recording at National Level

National laws or regulations should require that employers establish and maintain records on occupational accidents, occupational diseases, commuting accidents, dangerous occurrences and incidents as determined by the competent authority.

To ensure that all required data and information are collected systematically, and to provide the methodology for investigating occupational accidents, occupational diseases, dangerous occurrences and incidents, national laws or regulations should prescribe which data and information are to be recorded. Where forms are used for this purpose, they should be standardised.

The information required to be recorded at the level of the enterprise should include at least the information to be notified, as set out in Chapter 6 of the code.

National laws or regulations should specify which additional information must be recorded by employers, although it is not required to be notified. This should apply to:

(a) all incidents where no immediate personal injury is recognised;

(b) specified categories of dangerous occurrences;

(c) commuting accidents, if applicable.

National laws or regulations should specify, in particular:

(a) the content and format of such records;

(b) the period of time within which records are to be established;

(c) the period of time for which records are to be retained;

(d) that such records are to be obtained and maintained in such a way that respects the confidentiality of personal and medical data in accordance with national laws and regulations, conditions and practice, and are consistent with paragraph 6 of the Occupational Health Services Recommendation, 1985 (No. 171);

(e) that the employer should identify a competent person at the level of the enterprise to prepare and keep records; and

(f) the cooperation in recording procedures where two or more employers engage in activities simultaneously at one worksite.

1.8.2 At the Level of the Enterprise

The employer should set up arrangements, in accordance with national laws or regulations, to record occupational accidents, occupational diseases, commuting accidents, dangerous occurrences and incidents.

These arrangements should include:

(a) the identification of a competent person to prepare and keep records of all occupational accidents, occupational diseases, commuting accidents, dangerous occurrences and incidents, as required by national laws and regulations; and

(b) cooperation in recording procedures where two or more employers engage in activities simultaneously at one worksite, as required by national laws and regulations.

The employer should ensure that records of occupational accidents, occupational diseases, commuting accidents, dangerous occurrences and incidents are available and readily retrievable at all reasonable times.

In cases in which more than one worker is injured in a single occupational accident, a record should be made for each of the injured workers.

Workers' compensation insurance reports and accident reports to be submitted for notification are acceptable as records if they contain all the facts required for recording or are supplemented in an appropriate manner.

For inspection purposes and as information for workers' representatives and health services, employers should prepare records within a period of time to be determined by the competent authority, but preferably within no more than six days after reporting has occurred.

Workers in the course of performing their work should cooperate with the employer in carrying out the arrangements within the enterprise for recording and notification of occupational accidents, occupational diseases and dangerous occurrences.

The employer should give appropriate information to workers and their representatives concerning:

(a) the arrangements for recording; and

(b) the competent person identified by the employer to receive and record information on occupational accidents, occupational diseases, commuting accidents, dangerous occurrences and incidents.

The employer should provide appropriate information to workers or their representatives on all occupational accidents, occupational diseases, dangerous occurrences and incidents in the enterprise, as well as commuting accidents, to assist workers and employers to reduce the risk of exposure to similar events.

1.8.3 Arrangements For Notification

At national level.

The competent authority should, through national laws or regulations or by any other method consistent with national conditions and practice, establish and apply procedures for the notification of occupational accidents, occupational diseases, dangerous occurrences and commuting accidents, as appropriate.

Close cooperation should be ensured between the competent authority or authorities, public authorities, and representative organisations of employers and workers, as well as other bodies concerned in the formulation and application of the procedures referred to above.

National laws or regulations should specify that occupational accidents, occupational diseases, commuting accidents and dangerous occurrences be notified, as appropriate, to:

(a) the relevant enforcement body (e.g. labour inspectorate);

(b) the appropriate insurance institution;

(c) the statistics-producing body; or

(d) any other body.

National laws or regulations should specify:

(a) the respective information on occupational accidents, occupational diseases, dangerous occurrences and commuting accidents, as appropriate, to be notified to the competent authority, labour inspectorate, insurance institution or other bodies;

(b) the timing of the notification, which should preferably be made by the employer:

(i) by the quickest possible means immediately after reporting of an occupational accident causing loss of life;

(ii) within a prescribed time for other occupational accidents and occupational diseases;

(c) the prescribed standardised form of notification to be used for submission of notifications to the competent authority, labour inspectorate, insurance institution or other bodies;

(d) that the employer identify a competent person at the level of the enterprise for notification;

(e) the responsibilities, appropriate arrangements and procedures enabling employers to cooperate in the notification procedure where two or more enterprises engage in activities simultaneously at one workplace; and

(f) the systems for the classification of information to be used (see section 3.2 of the code).

National laws or regulations should specify that notification of an occupational disease by an employer is mandatory, at least whenever the employer receives a medical certificate to the effect that one of his or her workers is suffering from an occupational disease.

If more detailed information is needed beyond that required for notification, national laws or regulations should specify:

(a) the content and format of the returns to the competent authority containing supplementary information;

(b) the frequency and manner in which such returns are to be made by employers to the competent authority.

The competent authority should register notifications in such a way as to enable them to be used for compiling appropriate statistics, using classification systems as referred to in the code, and for making analyses.

At the level of the enterprise.

The employer, after consultation with the workers and their representatives, should set up arrangements within the enterprise, in accordance with national laws or regulations, to notify occupational accidents, occupational diseases, dangerous occurrences and commuting accidents, as appropriate.

The arrangements within the enterprise should include:

(a) the identification of a competent person to prepare the appropriate notification for submission by the employer;

(b) the determination of responsibility for notification, where two or more employers engage in activities simultaneously at one

worksite, as required by national law and regulations.

1.8.4

Notification of Occupational Accidents

General.

All occupational accidents should be notified, as required by national laws or regulations, to the competent authority, the labour inspectorate, the appropriate insurance institution or any other body:

(a) immediately after reporting of an occupational accident causing loss of life;

(b) within a prescribed time for other occupational accidents.

Notification should be made within such time as may be specified, and in prescribed specific forms, such as:

(a) an accident report for the labour inspectorate;

(b) a compensation report for the insurance institution;

(c) a report for the statistics-producing body; or

(d) a single form which contains all essential data for all bodies.

Minimum information.

With a view to meeting the requirements of labour inspectorates, insurance institutions and the statistics-producing body, the forms prescribed in either a specific or single format should include at least the following information:

(a) enterprise, establishment and employer:

(i) name and address of the employer, and his or her telephone and fax numbers (if available);

(ii) name and address of the enterprise;

(iii) name and address of the establishment (if different);

(iv) economic activity of the establishment; 1 and

(v) number of workers (size of the establishment);

(b) injured person:

(i) name, address, sex and age;

(ii) employment status; 2

(iii) occupation; 3

(c) injury:

(i) fatal accident;

(ii) non-fatal accident;

(iii) nature of the injury (e.g. fracture, etc.); 4

(iv) location of the injury (e.g. leg, etc.); 5

(d) accident and its sequence:

(i) geographical location of the place of the accident (usual workplace, another workplace within the establishment or outside the establishment);

(ii) date and time;

(iii) action leading to injury type of accident (e.g. fall, etc.); 6

1 See paragraph 3.2.1(a) and Annex C.2 See paragraph 3.2.1(c) and Annex E.

3 See paragraph 3.2.1(b) and Annex D.4 See Annex F.

5 See Annex G.6 See Annex H.

Recording and notification.

(iv) agency related to the accident (e.g. ladder, etc.). 1

For commuting accidents, the relevant necessary information to be notified should be specified.

More detailed information.

National laws or regulations should provide for the specification of more detailed information, which should include the following:

(a) enterprise, establishment and employer:

(i) name and address of the employer, and his or her telephone and fax numbers (if available);

(ii) name and address of the enterprise;

(iii) name and address of the establishment (if different);

(iv) economic activity of the establishment; 2 and

(v) number of workers (size of the establishment);

(b) injured person:

(i) name, address, sex and date of birth;

(ii) employment status; 3

(iii) occupation; 4

(iv) length of service for present employer;

(c) injury:

(i) fatal accident;

(ii) non-fatal accident;

(iii) nature of the injury (e.g. fracture, etc.); 5

(iv) location of the injury (e.g. leg, etc.); 6

(v) incapacity for work in calendar days;

(d) accident and its sequence:

(i) geographical location of the place of the accident (usual workplace, another workplace within the establishment or outside the establishment);

(ii) date and time;

1 See Annex I.2 See paragraph 3.2.1(a) and Annex C.3 See paragraph 3.2.1(c) and Annex E.

4 See paragraph 3.2.1(b) and Annex D.5 See Annex F.

6 See Annex G.

(iii) shift, start time of work of the injured person and hours worked in the activity in which the accident occurred;

(iv) work environment (e.g. workshop area, office, road, etc.);

(v) work process (e.g. welding, maintenance, manual transport, etc.);

(vi) activity of the injured person at time of the accident (e.g. welding, maintaining press, operating machine, driving, walking, etc.);

(vii) item or items associated with activity of the injured person (e.g. machine, tool, power press, vehicle, etc.);

(viii) action leading to injury type of accident (e.g. fall, etc.); 1

(ix) agency related to injury (e.g. ladder, etc.). 2

For commuting accidents, the relevant necessary information to be notified should be specified.

1.8.5

Notification of Occupational Diseases

National laws or regulations should specify that notification of occupational diseases include at least the following information:

(a) enterprise, establishment and employer;

(i) name and address of the employer, and his or her telephone and fax numbers (if available);

(ii) name and address of the enterprise;

(iii) name and address of the establishment (if different);

(iv) economic activity of the establishment; 3 and

(v) number of workers (size of the establishment);

(b) person affected by the occupational disease:

(i) name, address, sex and date of birth;

(ii) employment status; 4

(iii) occupation at the time when the disease was diagnosed; and

(iv) length of service with present employer;

(c) occupational disease:

(i) name and nature of occupational disease;

(ii) harmful agents, processes or exposure to which the occupational disease is attributable;

1 See Annex H.2 See Annex I.

3 See paragraph 3.2.1(a) and Annex C.4 See paragraph 3.2.1(c) and Annex E.

(iii) description of work which gave rise to the condition;

(iv) length of exposure to harmful agents and processes;

(v) date of diagnosis of the occupational disease.

1.8.6

Notification of Dangerous Occurrences

National laws or regulations should specify that notification of a dangerous occurrence arising in connection with work activities, and which is required to be notified to the competent authorities, include at least the following information:

(a) enterprise, establishment and employer;

(i) name and address of the employer, and his or her telephone and fax numbers (if available);

(ii) name and address of the enterprise;

(iii) name and address of the establishment (if different);

(iv) economic activity of the establishment; 1 and

(v) number of workers (size of the establishment); 2

(b) Dangerous occurrence:

(i) date, time and location;

(ii) type of dangerous occurrence;

(iii) circumstances leading up to the dangerous occurrence.

1 See paragraph 3.2.1(a) and Annex C. 2 See paragraph 3.2.1(c) and Annex E.

1.9

Extension of Recording and Notification Systems

To Self-Employed Persons

At national level.

National laws or regulations on the reporting, recording and notification of occupational accidents, occupational diseases, dangerous occurrences and incidents should also apply to self-employed persons, 1 as specified by the competent authority.

National laws or regulations should specify that notification to the competent authorities of occupational accidents, occupational diseases and dangerous occurrences involving self-employed persons in their own enterprise should be submitted as follows:

(a) in the case of death or a non-fatal occupational accident, occupational disease or dangerous occurrence rendering the self-employed person incapable of submitting notification, the notification should be submitted by the person in control of the establishment, or as prescribed by the competent authority;

(b) in other cases, the notification should be submitted by the self-employed persons themselves.

National laws or regulations should specify that notification to the competent authority of occupational accidents of self-employed persons in other than their own enterprises should be:

(a) recorded and notified by the employer of the enterprise in which the self-employed person was required to work;

(b) notified by the self-employed person to his or her insurance institution, with a record as requested in above.

1.9.1

At the Level of the Enterprise

The person in control of the establishment where the self-employed person is contracted to work should make arrangements for the reporting, recording and notification of occupational accidents, occupational diseases, commuting accidents, dangerous occurrences and incidents which can be applied to self-employed persons.

1.9.2 The Self-Employed Person

The self-employed person should cooperate with the person in control of the establishment where he or she is contracted to work, to enable notification of occupational accidents, occupational diseases, commuting accidents and dangerous occurrences.

The self-employed person should, in accordance with national laws or regulations, submit notification to the competent authorities of non-fatal occupational accidents, occupational diseases, commuting accidents and dangerous occurrences. If he or she is not in a position to do so, the self-employed person should make suitable alternative arrangements.

1.10.

Statistics of Occupational Accidents, Occupational Diseases, Commuting Accidents and Dangerous Occurrences: Compilation and Publication

At national level

The competent authority should arrange for the compilation and publication, at least once a year, of statistics of occupational accidents, occupational diseases, commuting accidents and dangerous occurrences, on the basis of the information notified to it.

Where practicable, the statistics should be compiled by the competent authority from notifications of occupational accidents, occupational diseases, commuting accidents and dangerous occurrences without recourse to additional returns.

The unit to be recorded should be:

(a) the person killed or injured as a result of an occupational accident or commuting accident;

(b) the person affected as a result of an occupational disease; or

(c) the dangerous occurrence.

Where one person has suffered more than one separate occupational accident or disease during the

period covered by the statistics, he or she should be counted separately with respect to each accident or disease.

The period covered by the statistics should be clearly defined, and ideally should not exceed one calendar year.

Information on occupational accidents and occupational diseases relating to self-employed persons, as well as commuting accidents, should be included in the statistics; however, such information should be shown separately so that appropriate comparisons may be made with countries which do not include such information in their national statistics.

In presenting statistics on occupational accidents, occupational diseases, commuting accidents and dangerous occurrences, the competent authority should ensure that information is provided on:

(a) the nature of the sources of the statistics; e.g. direct reporting by employers or by various bodies, such as insurance institutions or labour inspectorates;

(b) the scope of the statistics, particularly in respect of categories of persons, branches of economic activity, occupations, size of the enterprise, constituent states of a country or regions;

(c) the definitions used;

(d) the methods used for recording and notifying occupational accidents, occupational diseases, commuting accidents and dangerous occurrences, and for compiling the statistics;

(e) the quality of the statistics;

(f) the prior statistics, where available.

In designing or revising the concepts, definitions and methodology used in the collection, compilation and publication of such statistics, the competent authority should take into account the latest standards and

guidelines established under the auspices of the ILO or other relevant international organisations.

In designing or revising the concepts, definitions and methodology used in the compilation and publication of such statistics, the competent authority should consult the most representative organisations of employers and workers.

When publishing statistical data on occupational accidents, occupational diseases and dangerous occurrences, the competent authority should arrange for the frequency rate, incidence rate and severity rate, where appropriate, to be computed for major divisions of economic activity (see classification in paragraph 3.2.1(a) of the code), occupation (see classification in paragraph 3.2.1(b) of the code), age group, sex and other groups to be specified.

Recording and notification of more detailed information in a progressive manner.

National laws or regulations should provide for the specification of progressively more detailed information to be included in records and the notification of occupational accidents, occupational diseases, commuting accidents and dangerous occurrences.

Before specifying requirements for more detailed information, the competent authority should consult the most representative organisations of employers and workers.

The competent authority should allow a reasonable time, as specified by national laws or regulations, for employers to be able to provide the more detailed information required for records and notifications of occupational accidents, occupational diseases and dangerous occurrences.

1.11

Statistics of Occupational Accidents, Occupational Diseases and Dangerous Occurrences: Classifications

General.

The statistics of occupational accidents, occupational diseases and dangerous occurrences should be classified at least according to branch of economic activity and, as far as possible, according to:

(a) significant characteristics of workers, such as status in employment, sex, age or age group; and

(b) significant characteristics of the enterprise.

1.11.1

Occupational Diseases

Statistics of occupational diseases published by the competent authority should give the total number of cases reported for each of the diseases included in the list of occupational diseases prescribed by the competent authorities.

The period covered by the statistics of occupational diseases should not exceed a calendar year.

Statistics on occupational diseases for self-employed persons should be shown separately.

1.11.2

Dangerous Occurrences

The competent authority should publish statistics of the numbers and types of dangerous occurrences that have been notified.

1.12

Investigation of Occupational Accidents, Occupational Diseases, Commuting Accidents, Dangerous Occurrences and Incidents

At national level.

In furtherance of national policies on occupational safety, occupational health and the working environment, and of national policy on the prevention of occupational accidents and diseases, the competent authority should arrange for the investigation of a sufficient number and variety of types of occupational accidents, occupational diseases, commuting accidents and dangerous occurrences in order to be able to:

(a) verify the effectiveness of those policies;

(b) determine whether changes are necessary to those policies, or to national laws or regulations; and

(c) verify the effectiveness, at both national and enterprise levels, of the arrangements for recording and notification of occupational accidents, occupational diseases, commuting accidents and dangerous occurrences.

National laws or regulations concerning occupational safety and health - and the working environment - should specify that the competent authority must establish adequate arrangements and appropriate systems of investigation of occupational accidents, occupational diseases, commuting accidents and dangerous occurrences.

The competent authority should arrange for investigations to be carried out by labour inspectorates or by other authorised agencies. Representatives of the employers, and of the workers of the enterprise, should have the opportunity to accompany the investigators, unless the latter consider, in the light of the general instructions of the competent authority, that this may be prejudicial to the performance of their duties.

Where the investigation is not entrusted to an institution authorised by the competent authority or to a government department responsible to the legislature, national laws or regulations should specify arrangements for the participation of the most representative organisations of employers and workers - and of public authorities - in the planning of the investigation, and for the participation in the investigations of the representatives of the employers and of the workers affected, as specified in the paragraph above.

The competent authority should hold inquiries - and publish reports on those inquiries - into cases of occupational accidents, occupational diseases, commuting accidents, dangerous occurrences and incidents which appear to reflect serious situations in terms of actual or potential risk to workers or the public.

The competent authority should require employers to carry out investigations of specific occupational accidents, occupational diseases, commuting accidents, dangerous occurrences and incidents, and to report on the action taken to prevent a recurrence.

The competent authority should require employers to assist them in carrying out investigations and holding inquiries.

At the level of the enterprise.

The employer should investigate all reported occupational accidents, occupational diseases, dangerous occurrences and incidents.

The employer should ensure that a competent person, as specified by the competent authority, is identified within the enterprise to carry out thorough investigations of occupational accidents, occupational diseases and dangerous occurrences.

Where the employer lacks the necessary expertise within the enterprise to carry out a thorough investigation, he or she should call upon the assistance of a person with appropriate expertise, if necessary from outside the enterprise.

The employer should arrange for the site of an occupational accident or a dangerous occurrence to be left undisturbed before the start of the investigation, apart from the requirements for first aid or to prevent further risk to persons.

Where for reasons of first aid, or to prevent further risk to persons, it is necessary to disturb the site before the start of the investigation, the employer should arrange for a competent person to make a record of the site, including where necessary photographs, drawings and the identities of eyewitnesses prior to any intervention.

The employer should ensure that the investigations of occupational accidents, occupational diseases and dangerous occurrences should, as far as possible:

(a) establish what happened;

(b) determine the causes of what happened; and

(c) identify measures necessary to prevent a recurrence.

The employer should ensure that arrangements are in place at the enterprise for an immediate investigation of reported occupational accidents, occupational diseases, dangerous occurrences and incidents.

The employer should ensure that the report required under paragraph 10.1.6 of the code is sent to

the competent authority by the quickest practicable means.

The employer should make the results of investigations available to workers and their representatives with a view to preventing similar occurrences and so that they may assist the employer in the more effective implementation of his or her policy on occupational safety and health.

Workers and the investigation of occupational accidents, occupational diseases, dangerous occurrences and incidents.

Whenever an employer investigates under the code an occupational accident, an occupational disease, a commuting accident or a dangerous occurrence, workers' representatives should have the right, the facilities and the necessary time, without loss of pay, to participate in such investigations.

Workers in the course of their work should assist the employer and persons acting on his or her behalf in the investigation of occupational accidents, occupational diseases, dangerous occurrences and incidents.

2.0

SummaryThis summary will now refer you back to the learning outcomes for this lesson and give a summary of the information.

Explain the purpose of and procedures for investigating accidents at work

Why do we investigate accidents and incidents?

The simple answer is to ascertain why the accident happened and put measures in place to ensure that the same - or similar - accidents do not happen again.

It is, however, much more complicated than that. Finding the root cause of an accident and ensuring that measures are put in place to ensure that it cannot happen again is a vital part of any investigation.Basic accident investigation procedures:

interviews; plans; photographs; relevant records; checklists; identifying immediate causes (unsafe acts and conditions)

and root or underlying causes (management system failures);

Identifying remedial actions.

Describe the requirements for the statutory reporting of fatalities and specified injuries, diseases/ ill-health conditions and dangerous occurrences

What is RIDDOR

It stands for the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995. Sometimes referred to as RIDDOR 95, or RIDDOR for short, these Regulations came into force on 1 April 1996 .

It is important that you make reference to the full title: Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995, when answering a question that refers to RIDDOR in your NEBOSH examination.

Persons who are employers, the self-employed or are in control of work premises have duties under RIDDOR. The regulations apply to all work activities.

There is little to do when reporting incidents and accidents under RIDDOR. For most businesses, a reportable accident, dangerous occurrence or case of disease is a comparatively rare event.

Why should I report?

Reporting accidents and ill-health at work is a legal requirement.

When to Report In the event of a death or major injury. If there is an accident connected with work. An employee, or a self-employed person working is killed or

suffers a major injury (including as a result of physical violence).

A member of the public is killed or taken to hospital.

Those with responsibilities to report under the regulations must notify the enforcing authority without delay (e.g. by telephone). Brief details are required such as:

Name and address. The injured person's details. About the accident.

Within ten days of making the telephone call, this must be followed up with a completed accident report form (F2508). Again, you will see that the form asks for basic information.

Over-Three-Day Injury

If there is an accident connected with work (including an act of physical violence) and an employee, or a self-employed person working on the premises, suffers an over-three day injury, form F2508 must be completed and sent to the enforcing authority within ten days.

An over-three-day injury is one which is not major but results in the injured person being away from work, or unable to do the full range of their normal duties, for more than three days (including any days they would not normally be expected to work such as weekends, rest days or holidays), not counting the day of the injury itself.

So in simple terms, if someone suffers a major injury, including death or a major incident occurs, then the enforcing authority must be notified immediately, normally by telephone. This must be followed on within 10 days of the telephone call by completing the F2508 form.

Major injury or Incident

Amputation. Acute illness requiring medical treatment. Injury resulting from an electric shock or burn. Loss of sight (temporary or permanent), and so

on. Failure of industrial radiography equipment. Plant in contact with overhead power lines. Explosion or fire causing suspension of normal

work for over 24 hours. Failure of load-bearing parts of lifting

equipment. Reportable diseases. Some skin diseases, infections such as

legionellosis. Lung diseases such as occupational asthma.

Disease

If a doctor notifies an employee that they are suffering from a reportable work-related disease, the employer must send a completed disease report form (F2508A) to the enforcing authority.

A full list of these reportable diseases is included in 'the guide to the Regulations'. It is also possible to contact the H.S.E Information Line to check whether a disease is reportable.

Dangerous Occurrence

If something happens which does not result in a reportable injury but which clearly could have done, it may be a dangerous occurrence which must be reported immediately (e.g. by telephone) to the enforcing authority.

Again, within ten days of reporting the incident by telephone, this must be followed up with a completed accident report form F2508.

Incident Investigation

Congratulations - end of lesson reached