Investigating accidents and incidents

Transcription

1 Health ad Safety Ivestigatig accidets ad icidets A workbook for employers, uios, safety represetatives ad safety professioals Ivestigatig accidets ad icidets Every year people are killed or ijured at work. Over 40 millio workig days are lost aually through work-related accidets ad illesses. This workbook gives orgaisatios a opportuity to fid out what wet wrog. Learig the lessos ad takig actio may reduce, or eve prevet, accidets i the future. A workbook for employers, uios, safety represetatives ad safety professioals As a step-by-step guide, it will help all orgaisatios, particularly smaller busiesses, to carry out their ow health ad safety ivestigatios. Ivestigatig accidets ad icidets explais why you eed to carry out ivestigatios ad takes you through each step of the process: HSG245, published 2004 Step oe: Gatherig the iformatio Step two: Aalysig the iformatio Step three: Idetifyig risk cotrol measures Step four: The actio pla ad its implemetatio HSE Books Page 1 of 88

2 Health ad Safety Cotets Reducig risks ad protectig people 3 Uderstadig the laguage of ivestigatio 4 The causes of adverse evets 6 Why ivestigate? 7 A step by step guide to health ad safety ivestigatios 12 Gatherig the iformatio 13 Aalysig the iformatio 19 Idetifyig risk cotrol measures 23 The actio pla ad its implemetatio 24 Refereces ad further readig 26 Adverse evet report ad ivestigatio form: Worked examples 28 Adverse evet report ad ivestigatio form: Blak form 56 Adverse evet aalysis: Rootig out risk 66 Adverse evet aalysis: Worked examples 73 Adverse evet aalysis: Blak form 83 Ivestigatig accidets ad icidets Page 2 of 88

3 Health ad Safety Reducig risk ad protectig people Recet figures show that a average of 250 employees ad self-employed people are killed each year as a result of accidets i the workplace. 1 A further sustai major ijuries or ijuries that mea they are abset from work for more tha three days. Over 2.3 millio cases of ill health are caused or made worse by work. 2 Accordig to the Labour Force Survey, 3 over 40 millio workig days are lost through work-related ijuries ad ill health, at a cost to busiess of 2.5 billio. 4 If you thik safety is expesive, try a accidet Chairma of Easy Group Clearly, there are good fiacial reasos for reducig accidets ad ill health. Costigs show that for every 1 a busiess speds o isurace, it ca be losig betwee 8 ad 36 i uisured costs. 4 The same accidets happe agai ad agai, causig sufferig ad distress to a ever-wideig circle of workers ad their families. The ivestigatio ad aalysis of work-related accidets ad icidets forms a essetial part of maagig health ad safety. However, learig the lessos from what you ucover is at the heart of prevetig accidets ad icidets. Idetify what is wrog ad take positive steps to put it right. This guide will show you how. Carryig out your ow health ad safety ivestigatios will provide you with a deeper uderstadig of the risks associated with your work activities. Blamig idividuals is ultimately fruitless ad sustais the myth that accidets ad cases of ill health are uavoidable whe the opposite is true. Well thought-out risk cotrol measures, combied with adequate supervisio, moitorig ad effective maagemet (ie your risk maagemet system) will esure that your work activities are safe. Health ad safety ivestigatios are a importat tool i developig ad refiig your risk maagemet system. A effective ivestigatio requires a methodical, structured approach to iformatio gatherig, collatio ad aalysis. The fidigs of the ivestigatio will form the basis of a actio pla to prevet the accidet or icidet from happeig agai ad for improvig your overall maagemet of risk. Your fidigs will also poit to areas of your risk assessmets that eed to be reviewed. This lik with risk assessmet(s) is a legal duty. 5 This guide will help you to adopt a systematic approach to determiig why a accidet or icidet has occurred ad the steps you eed to take to make sure it does ot happe agai. Ivestigatig accidets ad icidets Page 3 of 88

4 Health ad Safety Uderstadig the laguage of ivestigatio Certai key words ad phrases will be used regularly throughout this guide. Adverse evet icludes: accidet: a evet that results i ijury or ill health; icidet: Figure 1 Accidet ear miss: a evet that, while ot causig harm, has the potetial to cause ijury or ill health. (I this guidace, the term ear miss will be take to iclude dagerous occurreces); udesired circumstace: a set of coditios or circumstaces that have the potetial to cause ijury or ill health, eg utraied urses hadlig heavy patiets. Dagerous occurrece: oe of a umber of specific, reportable adverse evets, as defied i the Reportig of Ijuries, Diseases ad Dagerous Occurreces Regulatios 1995 (RIDDOR). Hazard: the potetial to cause harm, icludig ill health ad ijury; damage to property, plat, products or the eviromet, productio losses or icreased liabilities. Immediate cause: the most obvious reaso why a adverse evet happes, eg the guard is missig; the employee slips etc. There may be several immediate causes idetified i ay oe adverse evet. Figure 2 Near miss Cosequece: fatal: work-related death; major ijury/ill health: (as defied i RIDDOR, Schedule 1), icludig fractures (other tha figers or toes), amputatios, loss of sight, a bur or peetratig ijury to the eye, ay ijury or acute illess resultig i ucosciousess, requirig resuscitatio or requirig admittace to hospital for more tha 24 hours; serious ijury/ill health: where the perso affected is ufit to carry out his or her ormal work for more tha three cosecutive days; mior ijury: all other ijuries, where the ijured perso is ufit for his or her ormal work for less tha three days; damage oly: damage to property, equipmet, the eviromet or productio losses. (This guidace oly deals with evets that have the potetial to cause harm to people.) Figure 3 Udesired circumstace Likelihood that a adverse evet will happe agai: certai: it will happe agai ad soo; likely: it will reoccur, but ot as a everyday evet; possible: it may occur from time to time; ulikely: it is ot expected to happe agai i the foreseeable future; rare: so ulikely that it is ot expected to happe agai. Ivestigatig accidets ad icidets Page 4 of 88

5 Health ad Safety Risk: The level of risk is determied from a combiatio of the likelihood of a specific udesirable evet occurrig ad the severity of the cosequeces (ie how ofte is it likely to happe, how may people could be affected ad how bad would the likely ijuries or ill health effects be?) Risk cotrol measures: are the workplace precautios put i place to reduce the risk to a tolerable level? Root cause: a iitiatig evet or failig from which all other causes or failigs sprig. Root causes are geerally maagemet, plaig or orgaisatioal failigs. Uderlyig cause: the less obvious system or orgaisatioal reaso for a adverse evet happeig, eg pre-start-up machiery checks are ot carried out by supervisors; the hazard has ot bee adequately cosidered via a suitable ad sufficiet risk assessmet; productio pressures are too great etc. Ivestigatig accidets ad icidets Page 5 of 88

6 Health ad Safety The causes of adverse evets Adverse evets have may causes. What may appear to be bad luck (beig i the wrog place at the wrog time) ca, o aalysis, be see as a chai of failures ad errors that lead almost ievitably to the adverse evet. (This is ofte kow as the Domio effect.) These causes ca be classified as: immediate causes: the aget of ijury or ill health (the blade, the substace, the dust etc); uderlyig causes: usafe acts ad usafe coditios (the guard removed, the vetilatio switched off etc); root causes: the failure from which all other failigs grow, ofte remote i time ad space from the adverse evet (eg failure to idetify traiig eeds ad assess competece, low priority give to risk assessmet etc). To prevet adverse evets, you eed to provide effective risk cotrol measures which address the immediate, uderlyig ad root causes. A B Figure 4 Sequece of domioes Note: Each domio represets a failig or error which ca combie with other failigs ad errors to cause a adverse evet. Dealig with the immediate cause (B) will oly prevet his sequece. Dealig with all causes, especially root causes (A) ca prevet a whole series of adverse evets. Ivestigatig accidets ad icidets Page 6 of 88

7 Health ad Safety Why ivestigate? There are hazards i all workplaces; risk cotrol measures are put i place to reduce the risks to a acceptable level to prevet accidets ad cases of ill health. The fact that a adverse evet has occurred suggests that the existig risk cotrol measures were iadequate. Learig lessos from ear misses ca prevet costly accidets. (The Clapham Juctio rail crash ad the Herald of Free Eterprise ferry capsize were both examples of situatios where maagemet had failed to recogise, ad act o, previous failigs i the system.) You eed to ivestigate adverse evets for a umber of reasos. Legal reasos for ivestigatig To esure you are operatig your orgaisatio withi the law. The Maagemet of Health ad Safety at Work Regulatios 1999, regulatio 5, requires employers to pla, orgaise, cotrol, moitor ad review their health ad safety arragemets. Health ad safety ivestigatios form a essetial part of this process. Followig the Woolf Report 6 o civil actio, you are expected to make full disclosure of the circumstaces of a accidet to the ijured parties cosiderig legal actio. The fear of litigatio may make you thik it is better ot to ivestigate, but you ca t make thigs better if you do t kow what wet wrog! The fact that you thoroughly ivestigated a accidet ad took remedial actio to prevet further accidets would demostrate to a court that your compay has a positive attitude to health ad safety. Your ivestigatio fidigs will also provide essetial iformatio for your isurers i the evet of a claim. Iformatio ad isights gaied from a ivestigatio A uderstadig of how ad why thigs wet wrog. A uderstadig of the ways people ca be exposed to substaces or coditios that may affect their health. A true sapshot of what really happes ad how work is really doe. (Workers may fid short cuts to make their work easier or quicker ad may igore rules. You eed to be aware of this.) Idetifyig deficiecies i your risk cotrol maagemet, which will eable you to improve your maagemet of risk i the future ad to lear lessos which will be applicable to other parts of your orgaisatio. Beefits arisig from a ivestigatio The prevetio of further similar adverse evets. If there is a serious accidet, the regulatory authorities will take a firm lie if you have igored previous warigs. The prevetio of busiess losses due to disruptio, stoppage, lost orders ad the costs of crimial ad civil legal actios. A improvemet i employee morale ad attitude towards health ad safety. Employees will be more cooperative i implemetig ew safety precautios if they were ivolved i the decisio ad they ca see that problems are dealt with. Ivestigatig accidets ad icidets Page 7 of 88

8 Health ad Safety The developmet of maagerial skills which ca be readily applied to other areas of the orgaisatio. While the argumet for ivestigatig accidets is fairly clear, the eed to ivestigate ear misses ad udesired circumstaces may ot be so obvious. However, ivestigatig ear misses ad udesired circumstaces is as useful, ad very much easier tha ivestigatig accidets. Adverse evets where o oe has bee harmed ca be ivestigated without havig to deal with ijured people, their families ad a demoralised workforce, ad without the threat of crimial ad civil actio hagig over the whole proceedigs. Witesses will be more likely to be helpful ad tell the truth. (Cosider the followig: I mistakely tured the wrog valve which released the boilig water because the valves all look the same or I do t kow how Joh was scalded. Which is the likely respose to a ear miss ad which to a accidet? More importatly, which is the most useful?) It is ofte pure luck that determies whether a udesired circumstace traslates ito a ear miss or accidet. The value of ivestigatig each adverse evet is the same. A ivestigatio is ot a ed i itself, but the first step i prevetig future adverse evets. A good ivestigatio will eable you to lear geeral lessos, which ca be applied across your orgaisatio. The ivestigatio should idetify why the existig risk cotrol measures failed ad what improvemets or additioal measures are eeded. More geeral lessos o why the risk cotrol measures were iadequate must also be leared. Which evets should be ivestigated? Havig bee otified of a adverse evet ad bee give basic iformatio o what happeed, you must decide whether it should be ivestigated ad if so, i what depth. It is the potetial cosequeces ad the likelihood of the adverse evet recurrig that should determie the level of ivestigatio, ot simply the ijury or ill health suffered o this occasio. For example: Is the harm likely to be serious? Is this likely to happe ofte? Similarly, the causes of a ear miss ca have great potetial for causig ijury ad ill health. Whe makig your decisio, you must also cosider the potetial for learig lessos. For example if you have had a umber of similar adverse evets, it may be worth ivestigatig, eve if each sigle evet is ot worth ivestigatig i isolatio. It is best practice to ivestigate all adverse evets which may affect the public. Who should carry out the ivestigatio? For a ivestigatio to be worthwhile, it is essetial that the maagemet ad the workforce are fully ivolved. Depedig o the level of the ivestigatio (ad the size of the busiess), supervisors, lie maagers, health ad safety professioals, uio safety represetatives, employee represetatives ad seior maagemet/ directors may all be ivolved. As well as beig a legal duty, it has bee foud that where there is full cooperatio ad cosultatio with uio represetatives ad employees, the umber of accidets is half that of workplaces where there is o such employee ivolvemet. 7 Ivestigatig accidets ad icidets Page 8 of 88

9 Health ad Safety This joit approach will esure that a wide rage of practical kowledge ad experiece will be brought to bear ad employees ad their represetatives will feel empowered ad supportive of ay remedial measures that are ecessary. A joit approach also reiforces the message that the ivestigatio is for the beefit of everyoe. I additio to detailed kowledge of the work activities ivolved, members of the team should be familiar with health ad safety good practice, stadards ad legal requiremets. The ivestigatio team must iclude people who have the ecessary ivestigative skills (eg iformatio gatherig, iterviewig, evaluatig ad aalysig). Provide the team with sufficiet time ad resources to eable them to carry out the ivestigatio efficietly. It is essetial that the ivestigatio team is either led by, or reports directly to someoe with the authority to make decisios ad act o their recommedatios. Whe should it start? The urgecy of a ivestigatio will deped o the magitude ad immediacy of the risk ivolved (eg a major accidet ivolvig a everyday job will eed to be ivestigated quickly). I geeral, adverse evets should be ivestigated ad aalysed as soo as possible. This is ot simply good practice; it is commo sese memory is best ad motivatio greatest immediately after a adverse evet. What does it ivolve? A ivestigatio will ivolve a aalysis of all the iformatio available, physical (the scee of the icidet), verbal (the accouts of witesses) ad writte (risk assessmets, procedures, istructios, job guides etc), to idetify what wet wrog ad determie what steps must be take to prevet the adverse evet from happeig agai. It is importat to be ope, hoest ad objective throughout the ivestigatio process. Pre-coceived ideas about the process, the equipmet or the people ivolved i a adverse evet may blid you to the real causes. Questio everythig. Be wary of blamig idividuals. What makes a good ivestigatio? To get rid of weeds you must dig up the root. If you oly cut off the foliage, the weed will grow agai. Similarly it is oly by carryig out ivestigatios which idetify root causes that orgaisatios ca lear from their past failures ad prevet future failures. Simply dealig with the immediate causes of a adverse evet may provide a shortterm fix. But, i time, the uderlyig/root causes that were ot addressed will allow coditios to develop where further adverse evets are likely, possibly with more serious cosequeces. It is essetial that the immediate, uderlyig causes ad root causes are all idetified ad remedied. Ivestigatios should be coducted with accidet prevetio i mid, ot placig blame. Attemptig to apportio blame before the ivestigatio has started is Ivestigatig accidets ad icidets Page 9 of 88

10 Health ad Safety couterproductive, because people become defesive ad ucooperative. Oly after the ivestigatio has bee completed is it appropriate to cosider whether ay idividuals acted iappropriately. Ivestigatios that coclude that operator error was the sole cause are rarely acceptable. Uderpiig the huma error there will be a umber of uderlyig causes that created the eviromet i which huma errors were ievitable. For example iadequate traiig ad supervisio, poor equipmet desig, lack of maagemet commitmet, poor attitude to health ad safety. The objective is to establish ot oly how the adverse evet happeed, but more importatly, what allowed it to happe. The root causes of adverse evets are almost ievitably maagemet, orgaisatioal or plaig failures. Ma slippig o a patch of oil Iadequate maiteace Iadequate housekeepig Maagemet ot beig committed to health ad safety Iadequate health ad safety maagemet Lack of supervisio ad moitorig Look carefully at your health ad safety policy ad how it is reflected i the workplace. Do staff uderstad the health ad safety message i geeral ad i particular those parts that relate to their work? Is somethig missig from the policy? Is it implemeted, or is maagemet failig to esure that health ad safety measures remai i place ad are effective at all times? If ot, your health ad safety policy eeds to be chaged. The ivestigatio should be thorough ad structured to avoid bias ad leapig to coclusios. Do t assume you kow the aswer ad start fidig solutios before you complete the ivestigatio. A good ivestigatio ivolves a systematic ad structured approach. Iformatio gatherig: explores all reasoable lies of equiry; is timely; is structured, settig out clearly what is kow, what is ot kow ad records the ivestigative process. Aalysis: is objective ad ubiased; idetifies the sequece of evets ad coditios that led up to the adverse evet; idetifies the immediate causes; idetifies uderlyig causes, ie actios i the past that have allowed or caused udetected usafe coditios/practices; idetifies root causes, (ie orgaisatioal ad maagemet health ad safety arragemets supervisio, moitorig, traiig, resources allocated to health ad safety etc). Ivestigatig accidets ad icidets Page 10 of 88

11 Health ad Safety Risk cotrol measures: idetify the risk cotrol measures which were missig, iadequate or uused; compare coditios/practices as they were with that required by curret legal requiremets, codes of practice ad guidace; idetify additioal measures eeded to address the immediate, uderlyig ad root causes; provide meaigful recommedatios which ca be implemeted. But woolly recommedatios such as operators must take care ot to touch the cutters durig ru-dow show that the ivestigatio has ot delved deep eough i search of the root causes. Actio pla ad implemetatio: provide a actio pla with SMART objectives (Specific, Measurable, Agreed, Realistic ad Timescaled); esure that the actio pla deals effectively ot oly with the immediate ad uderlyig causes but also the root causes; iclude lessos that may be applied to prevet other adverse evets, eg assessmets of skill ad traiig i competecies may be eeded for other areas of the orgaisatio; provide feedback to all parties ivolved to esure the fidigs ad recommedatios are correct, address the issues ad are realistic; should be fed back ito a review of the risk assessmet. The Approved Code of Practice 5 attached to the Maagemet of Health ad Safety at Work Regulatios 1999 regulatio 3 (paragraph 26), states that adverse evets should be a trigger for reviewig risk assessmets); commuicate the results of the ivestigatio ad the actio pla to everyoe who eeds to kow; iclude arragemets to esure the actio pla is implemeted ad progress moitored. The last three steps, though essetial, are ofte overlooked. But, without them, the full beefits of the ivestigatio will ot be realised ad i the log term othig will chage. Techiques for aalysig adverse evets There are may tools ad techiques for structurig the ivestigatio, aalysig adverse evets, ad idetifyig root causes. 8 HSE does ot edorse ay oe method it is for you to choose which techiques suit your compay. These techiques are simply tools, ot a ed i themselves. For large, complex or techically demadig ivestigatios, these techiques may be essetial i determiig ot oly how the adverse evet happeed, but also what were the root causes. However, provided a methodical approach with full employee participatio is adopted, a less complicated approach, such as that set out i this publicatio, will be appropriate. Ivestigatig accidets ad icidets Page 11 of 88

12 Health ad Safety A step by step guide to health ad safety ivestigatios Steps to take followig a adverse evet Emergecy respose: take prompt emergecy actio (eg first aid); make the area safe (i some cases this may eed to be doe first). Iitial report: preserve the scee; ote the ames of the people, equipmet ivolved ad the ames of the witesses; report the adverse evet to the perso resposible for health ad safety who will decide what further actio (if ay) is eeded. Iitial assessmet ad ivestigatio respose: report the adverse evet to the regulatory authority if appropriate. RIDDOR For those accidets ad dagerous occurreces that are reportable uder the provisios of RIDDOR (the Reportig of Ijuries, Diseases ad Dagerous Occurreces Regulatios 1995), this iformatio must be otified to the eforcig authority. Whether you are HSE or LA-eforced, to make a report, go to A telephoe service ca be used to report fatal ad major ijuries oly call the Icidet Cotact Cetre o (opeig hours Moday to Friday 8.30 am to 5 pm). You must also keep a record of the reports you make that are required uder RIDDOR. You ca do this by: keepig a copy of the form; recordig the icidet i the accidet book; recordig the icidet electroically. You also eed to eter details of the accidet i a accidet book. Ad, you eed to decide o the scale of the ivestigatio. Where appropriate, decide who will carry out the ivestigatio, the resources required ad brief the ivestigatio team. Note: The prompt otificatio of RIDDOR reportable evets is a legal requiremet. Do ot wait util you have carried out a thorough ivestigatio before you report it. Fatalities ad major ijuries (as defied i RIDDOR) must be reported immediately. Those accidets where employees have bee abset from work (or moved to other duties as a result of the accidet) for greater tha three days must be reported withi te days of the accidet date. Where a death has occurred the police may take charge ad they should be otified immediately. Ivestigatig accidets ad icidets Page 12 of 88

13 Health ad Safety The decisio to ivestigate The table below will assist you i determiig the level of ivestigatio which is appropriate for the adverse evet. Remember you must cosider the worst potetial cosequeces of the adverse evet (eg a scaffold collapse may ot have caused ay ijuries, but had the potetial to cause major or fatal ijuries). Likelihood of recurrece Certai Likely Possible Ulikely Rare Potetial worst cosequece of adverse evet Mior Serious Major Fatal (The defiitios of cosequece ad likelihood are set out i the sectio o Uderstadig the laguage of ivestigatio ) Risk Miimal Low Medium High Ivestigatio level Miimal level Low level Medium level High level I a miimal level ivestigatio, the relevat supervisor will look ito the circumstaces of the evet ad try to lear ay lessos which will prevet future occurreces. A low level ivestigatio will ivolve a short ivestigatio by the relevat supervisor or lie maager ito the circumstaces ad immediate, uderlyig ad root causes of the adverse evet, to try to prevet a recurrece ad to lear ay geeral lessos. A medium level ivestigatio will ivolve a more detailed ivestigatio by the relevat supervisor or lie maager, the health ad safety adviser ad employee represetatives ad will look for the immediate, uderlyig ad root causes. A high level ivestigatio will ivolve a team-based ivestigatio, ivolvig supervisors or lie maagers, health ad safety advisers ad employee represetatives. It will be carried out uder the supervisio of seior maagemet or directors ad will look for the immediate, uderlyig, ad root causes. The ivestigatio The four steps iclude a series of umbered questios. These set out i detail the iformatio that should be etered oto the adverse evet ivestigatio form. The questio umbers correspod to those o the form. Step oe Gatherig the iformatio Fid out what happeed ad what coditios ad actios iflueced the adverse evet. Begi straight away, or as soo as practicable. It is importat to capture iformatio as soo as possible. This stops it beig Ivestigatig accidets ad icidets Page 13 of 88

14 Health ad Safety corrupted, eg items moved, guards replaced etc. If ecessary, work must stop ad uauthorised access be preveted. Talk to everyoe who was close by whe the adverse evet happeed, especially those who saw what happeed or kow aythig about the coditios that led to it. The amout of time ad effort spet o iformatio gatherig should be proportioate to the level of ivestigatio. Collect all available ad relevat iformatio. That icludes opiios, experieces, observatios, sketches, measuremets, photographs, check sheets, permits-to-work ad details of the evirometal coditios at the time etc. This iformatio ca be recorded iitially i ote form, with a formal report beig completed later. These otes should be kept at least util the ivestigatio is complete. Where, whe ad who? 1 Where ad whe did the adverse evet happe? 2 Who was ijured/suffered ill health or was otherwise ivolved with the adverse evet? Gatherig detailed iformatio: How ad what? Discoverig what happeed ca ivolve quite a bit of detective work. Be precise ad establish the facts as best you ca. There may be a lack of iformatio ad may ucertaities, but you must keep a ope mid ad cosider everythig that might have cotributed to the adverse evet. Hard work ow will pay off later i the ivestigatio. May importat thigs may emerge at this stage of the process, but ot all of them will be directly related to the adverse evet. Some of the iformatio gathered may appear to have o direct bearig o the evet uder ivestigatio. However, this iformatio may provide you with a greater isight ito the hazards ad risks i your workplace. This may eable you to make your workplace safer i ways you may ot have previously cosidered. 3 How did the adverse evet happe? Note ay equipmet ivolved. Describe the chai of evets leadig up to, ad immediately after, the adverse evet. Very ofte, a umber of chace occurreces ad coicideces combie to create the circumstaces i which a adverse evet ca happe. All these factors should be recorded here i chroological order, if possible. Work out the chai of evets by talkig to the ijured perso, eye witesses, lie maagers, health ad safety represetatives ad fellow workers to fid out what happeed ad who did what. I particular, ote the positio of those ijured, both immediately before ad after the adverse evet. Be objective ad, as far as possible, avoid apportioig guilt, assigig resposibility or makig sap judgemets o the probable causes. Plat ad equipmet that had a direct bearig o the adverse evet must be idetified clearly. This iformatio ca usually be obtaied from a ameplate attached to the equipmet. Note all the details available, the maufacturer, model type, model umber, machie umber ad year of maufacture ad ay modificatios made to the equipmet. Note the positio of the machiery cotrols immediately after the adverse evet. This iformatio may help you to spot treds ad idetify risk cotrol measures. You should cosider approachig the supplier if the same machie has bee implicated i a umber of adverse evets. Be Ivestigatig accidets ad icidets Page 14 of 88

15 Health ad Safety precise. Shop floor process ad layout chages are a regular occurrece. Uless you precisely idetify plat ad equipmet, you will ot detect, eg that a machie or particular piece of equipmet has bee moved aroud ad caused ijuries o separate occasios, i differet locatios. 4 What activities were beig carried out at the time? The work that was beig doe just before the adverse evet happeed ca ofte cast light o the coditios ad circumstaces that caused somethig to go wrog. Provide a good descriptio, icludig all the relevat details, eg the surroudigs, the equipmet/materials beig used, the umber of employees egaged i the various activities, the way they were positioed ad ay details about the way they were behavig etc. 5 Was there aythig uusual or differet about the workig coditios? Adverse evets ofte happe whe somethig is differet. Whe faced with a ew situatio, employees may fid it difficult to adapt, particularly if the sources of dager are ukow to them, or if they have ot bee adequately prepared to deal with the ew situatio. If workig coditios or processes were sigificatly differet to ormal, why was this? Describe what was ew or differet i the situatio. Was there a safe workig method i place for this situatio, were operatives aware of it, ad was it beig followed? If ot, why ot? Learig how people deal with ufamiliar situatios will eable similar situatios to be better hadled i the future. Was the way the chages, temporary or otherwise, were itroduced a factor? Were the workers ad supervisors aware that thigs were differet? Were workers ad supervisors sufficietly traied/experieced to recogise ad adapt to chagig circumstaces? 6 Were there adequate safe workig procedures ad were they followed? Adverse evets ofte happe whe there are o safe workig procedures or where procedures are iadequate or are ot followed. Commets such as we ve bee doig it that way for years ad othig has ever goe wrog before or he has bee workig o that machie for years ad kows what to do ofte lead to the ijured perso gettig the blame, irrespective of what part procedures, traiig ad supervisio or the lack of them had to play i the adverse evet. What was it about ormal practice that proved iadequate? Was a safe workig method i place ad beig followed? If ot, why ot? Was there adequate supervisio ad were the supervisors themselves sufficietly traied ad experieced? Agai, it is importat to pose these questios without attemptig to apportio blame, assig resposibility or stipulate cause. 7 What ijuries or ill health effects, if ay, were caused? It is importat to ote which parts of the body have bee ijured ad the ature of the ijury - ie bruisig, crushig, a bur, a cut, a broke boe etc. Be as precise as you are able. If the site of the ijury is the right upper arm, midway betwee the elbow ad the shoulder joit, say so. Precise descriptios will eable you to spot treds ad take prompt remedial actio. For example it could be that what appears to be a safe piece of equipmet, due to the stadard of its guardig, is actually causig a umber of iadvertet cut ijuries due to the sharp edges o the guards themselves. Facts such as whether the ijured perso was give first aid or take to hospital (by Ivestigatig accidets ad icidets Page 15 of 88

16 Health ad Safety ambulace, a colleague etc) should also be recorded here. 8 If there was a ijury, how did it occur ad what caused it? Where a accidet is relatively straightforward, it may seem artificial to differetiate betwee the accidet itself (questio 3) ad the mode of ijury, but whe the accidet is more complicated the differeces betwee the two aspects become clearer ad therefore precise descriptios are vital. The mode of ijury cocers two differet aspects: the harmful object (kow as the aget ) that iflicted the ijury; ad the way i which the ijury was actually sustaied. The object that iflicted the ijury may be a had-held tool like a kife, or a chemical, a machie, or a vehicle etc. The way i which it happeed might, eg, be that the employee cut themselves or spilt chemicals o their ski. 9 Was the risk kow? If so, why was t it cotrolled? If ot, why ot? You eed to fid out whether the source of the dager ad its potetial cosequeces were kow, ad whether this iformatio was commuicated to those who eeded to kow. You should ote what is said ad who said it, so that potetial gaps i the commuicatio flow may be idetified ad remedied. The aim is to fid out why the sources of dager may have bee igored, ot fully appreciated or ot uderstood. Remember you are ivestigatig the processes ad systems, ot the perso. The existece of a writte risk assessmet for the process or task that led to the adverse evet will help to reveal what was kow of the associated risks. A judgemet ca be made as to whether the risk assessmet was suitable ad sufficiet, as required by law 5 ad whether the risk cotrol measures idetified as beig ecessary were ever adequately put i place. 10 Did the orgaisatio ad arragemet of the work ifluece the adverse evet? The orgaisatioal arragemet sets the framework withi which the work is doe. Here are some examples; there are may more: stadards of supervisio ad o-site moitorig of workig practices may be less tha adequate; lack of skills or kowledge may mea that obody itervees i the evet of procedural errors; iappropriate workig procedures may mea certai steps i the procedures are omitted, because they are too difficult ad time-cosumig; lack of plaig may mea that some tasks are ot doe, are doe too late or are doe i the wrog order; employees actios ad priorities may be a cosequece of the way i which they are paid or otherwise rewarded; high productio targets ad piecework may result i safety measures beig degraded ad employees workig at too fast a pace. 11 Was maiteace ad cleaig sufficiet? If ot, explai why ot. Lack of maiteace ad poor housekeepig are commo causes of adverse evets. Was the state of repair ad coditio of the workplace, plat ad equipmet such that they cotributed to or caused the adverse evet? Were Ivestigatig accidets ad icidets Page 16 of 88

17 Health ad Safety the brakes o the forklift truck i good workig order? Were spills dealt with immediately? Was the site so cluttered ad utidy that it created a slippig or trippig hazard? Was there a programme of prevetative maiteace? What are the istructios cocerig good housekeepig i the workplace? You should observe the locatio of the adverse evet as soo as possible ad judge whether the geeral coditio or state of repair of the premises, plat or equipmet was adequate. Those workig i the area, together with witesses, ad ay ijured parties, should also be asked for their opiio. Workig i the area, they will have a good idea of what is acceptable ad whether coditios had deteriorated over time. Cosider the role the followig factors may play: a badly maitaied machie or tool may mea a employee is exposed to excessive vibratio or oise ad has to use icreased force, or tamper with the machie to get the work doe; a oisy eviromet may prevet employees hearig istructios correctly as well as beig a possible cause of oise-iduced hearig loss; ueve floors may make movemet aroud the workplace, especially vehicle movemets, hazardous; badly maitaied lightig may make carryig out the task more difficult; poorly stored materials o the floor i ad aroud the work area will icrease the risk of trippig; ice, dirt ad other cotamiats o stairs or walkways make it easier to slip ad fall; tools ot i immediate use should be stored appropriately ad ot left lyig aroud the work area. 12 Were the people ivolved competet ad suitable? Traiig should provide workers with the ecessary kowledge, skills ad hads-o work experiece to carry out their work efficietly ad safely. The fact that someoe has bee doig the same job for a log time does ot ecessarily mea that they have the ecessary skills or experiece to do it safely. This is particularly the case whe the ormal routie is chaged, whe ay lack of uderstadig ca become apparet.there is o substitute for adequate health ad safety traiig. Some of the problems that might arise follow: a lack of istructio ad traiig may mea that tasks are ot doe properly; misuderstadigs, which arise more easily whe employees lack uderstadig of the usual routies ad procedures i the orgaisatio; a lack of respect for the risks ivolved, due to igorace of the potetial cosequeces; problems due to the immaturity, iexperiece ad lack of awareess of existig or potetial risks amog youg people (uder18).you must assess the risks to youg people before they start work; poor hadlig of dagerous materials or tools, due to employees ot beig properly iformed about how thigs should be doe correctly. People should also be matched to their work i terms of health, stregth, metal ability ad physical stature. 13 Did the workplace layout ifluece the adverse evet? The physical layout ad surroudigs of the workplace ca affect health ad safety. Ijuries may be caused by sharp table edges. Hazardous or highly iflammable fumes may be produced i areas where operatives work or where there are aked lights. Or, the workplace may be orgaised i such a way that there is ot eough circulatio space. Or, it may be impossible to see or hear warig sigals, eg durig fork lift truck movemets. Ivestigatig accidets ad icidets Page 17 of 88

18 Health ad Safety Employees should be able to see the whole of their work area ad see what their immediate colleagues are doig. The workplace should be orgaised i such a way that safe practices are ecouraged. I other words, workplace arragemets should discourage employees from ruig risks, eg providig a clear walkway aroud machiery will discourage people from crawlig uder or climbig over it. 14 Did the ature or shape of the materials ifluece the adverse evet? As well as beig itrisically hazardous, materials ca pose a hazard simply by their desig, weight, quality or packagig, eg heavy ad awkward materials, materials with sharp edges, spliters, poisoous chemicals etc. The choice of materials also iflueces work processes, eg a particularly hazardous material may be required. Poor quality may also result i materials or equipmet failig durig ormal processig, causig malfuctios ad accidets. 15 Did difficulties usig the plat ad equipmet ifluece the adverse evet? Plat ad equipmet icludes all the machiery, plat ad tools used to orgaise ad carry out the work. All of these items should be desiged to suit the people usig them. This is referred to as ergoomic desig, where the focus is o the idividual as well as the work task the item is specifically desiged to carry out. If the equipmet meets the eeds of the idividual user, it is more likely to be used as it is iteded - ie safely. Cosider user istructios here. A machie that requires its operator to follow a complicated user maual is a source of risk i itself. 16 Was the safety equipmet sufficiet? You should satisfy yourself that ay safety equipmet ad safety procedures are both sufficiet ad curret for all coditios i which work takes place, icludig the provisio ad use of ay extra equipmet eeded for employees safety. For example: extra techical safety equipmet at machies; power supply isolatio equipmet ad procedures; persoal protective equipmet (PPE); buildig safety systems, eg a extract vetilatio system. Make a ote of whether the safety equipmet was used, whether it was used correctly, whether or ot it was i good coditio ad was workig properly etc. 17 Did other coditios ifluece the adverse evet? Other coditios is iteded to cover everythig else that has ot bee reported yet, but which might have iflueced the adverse evet. For example: disagreemets or misuderstadigs betwee people; the weather; uauthorised iterferece i a process or job task; defective supplies or equipmet; deliberate acts, such as trespass or sabotage. Ivestigatig accidets ad icidets Page 18 of 88

19 Health ad Safety Step two Aalysig the iformatio A aalysis ivolves examiig all the facts, determiig what happeed ad why. All the detailed iformatio gathered should be assembled ad examied to idetify what iformatio is relevat ad what iformatio is missig. The iformatio gatherig ad aalysis are actually carried out side by side. As the aalysis progresses, further lies of equiry requirig additioal iformatio will develop. To be thorough ad free from bias, the aalysis must be carried out i a systematic way, so all the possible causes ad cosequeces of the adverse evet are fully cosidered. A umber of formal methods have bee developed to aid this approach. 8 Oe useful method for orgaisig your iformatio, idetifyig gaps ad begiig the aalysis is Evets ad Causal Factor Aalysis (ECFA), 9 which is beyod the scope of this guidace. The aalysis should be coducted with employee or trade uio health ad safety represetatives ad other experts or specialists, as appropriate. This team approach ca ofte be highly productive i eablig all the relevat causal factors to emerge. 18 What were the immediate, uderlyig ad root causes? It is oly by idetifyig all causes, ad the root causes i particular, that you ca lear from past failures ad prevet future repetitios. The causes of adverse evets ofte relate to oe aother i a complex way, sometimes oly ifluecig evets ad at other times havig a overwhelmig impact, due to their timig or the way they iteract. The aalysis must cosider all possible causes. Keep a ope mid. Do ot reject a possible cause util you have give it serious cosideratio.the emphasis is o a thorough, systematic ad objective look at the evidece. Aalysis There are may methods of aalysig the iformatio gathered i a ivestigatio to fid the immediate, uderlyig ad root causes ad it is for you to choose whichever method suits you best. Ivestigatig accidets ad icidets Page 19 of 88

20 Health ad Safety Joh breaks his leg Joh is o ladder Fallig due to gravity Joh falls off Access to the roof The ladder slips The ladder is ot tied Figure 5 What happeed ad why? The first step i uderstadig what happeed ad why is to orgaise the iformatio you have gathered. This guidace uses the simple techique of askig Why over ad over, util the aswer is o loger meaigful (see Figure 5). The startig poit is the evet, eg Joh has broke his leg. O the lie below, set out the reasos why this happeed. This first lie should idetify: the vulerable perso, eg Joh o a ladder; the hazard, eg fallig due to gravity; the circumstaces that brought them together, eg Joh fell off the ladder. For each of the reasos idetified ask Why? ad set dow the aswers. Cotiue dow the page askig Why util the aswers are o loger meaigful. Do ot be cocered at the umber of times you ask the questio, Why? because by doig so you will arrive at the real causes of the adverse evet. Some lies of equiry will quickly ed, eg Why was the hazard of fallig preset? Aswer: Gravity. Havig collected the relevat iformatio ad determied what happeed ad why, you ca ow determie the causes of the adverse evet systematically. Checklist/questio aalysis of the causes Usig the adverse evet aalysis work sheets ad checklist (i the Adverse Evet ad Ivestigatio Form), work through the questios about the possible immediate causes of the adverse evet (the place, the plat, the people ad the process) ad idetify which are relevat. Record all the immediate causes idetified ad the ecessary risk cotrol measures. For each immediate cause, the aalysis suggests uderlyig causes which may have allowed the immediate causes to exist. Cosider the uderlyig/root cause questios suggested by the immediate causes. Record those that are relevat ad ote the measures eeded to remedy them. The fial step of your aalysis is to cosider the eviromet i which the Ivestigatig accidets ad icidets Page 20 of 88

21 Health ad Safety orgaisatio ad plaig of health ad safety was carried out. This Maagemet sectio of the aalysis must be carried out by people withi the orgaisatio who have both the overall resposibility for health ad safety, ad the authority to make chages to the maagemet system. Record the uderlyig failigs i the overall maagemet system (ie the root causes of the adverse evet) ad the remedial actio required at maagemet level. The root causes of almost all adverse evets are failigs at maagerial level. Worked examples of the Adverse Evet Report ad Ivestigatio Form are o page 29. What if huma failigs (errors ad violatios) 10 are idetified as a cotributory factor? If your ivestigatio cocludes that errors or violatios cotributed to the adverse evet, cosider carefully how to hadle this iformatio. Not addressig the huma factors greatly reduces the value of the ivestigatio. The objective of a ivestigatio is to lear the lessos ad to act to prevet recurreces, through suitable risk cotrol measures. You will ot be able to do that uless your workforce trusts you eough to co-operate with you. Layig all the blame o oe or more idividuals is couter-productive ad rus the risk of alieatig the workforce ad udermiig the safety culture, crucial to creatig ad maitaiig a safer workig eviromet. Speak to those ivolved ad explai how you believe their actio(s) cotributed to the adverse evet. Ivite them to explai why they did what they did. This may ot oly help you better uderstad the reasos behid the immediate causes of the adverse evet, but may offer more poiters to the uderlyig causes: perhaps the productio deadlie was short, ad removig the guards saved valuable time; maybe the workload is too great for oe perso etc. Uless you discover a deliberate ad malicious violatio or sabotage of workplace safety precautios, it may be couter-productive to take discipliary actio agaist those ivolved. Will ayoe be ope ad hoest with you the ext time a adverse evet occurs? What you should aim for is a fair ad just system where people are held to accout for their behaviour, without beig uduly blamed. I ay evet, your regime of supervisio ad moitorig of performace should have detected ad corrected these usafe behaviours. Huma failigs ca be divided ito three broad types ad the actio eeded to prevet further failigs will deped o which type of huma failig is ivolved. See Figure 6. Ivestigatig accidets ad icidets Page 21 of 88

22 Health ad Safety Huma failigs Skill-based errors Slip Lapse Mistake Violatio Rule-based Kowledge-based Figure 6 Skill-based errors: a slip or lapse of memory: slips happe whe a perso is carryig out familiar tasks automatically, without thikig, ad that perso s actio is ot as plaed, eg operatig the wrog switch o a cotrol pael; lapses happe whe a actio is performed out of sequece or a step i a sequece is missed, eg a road taker driver had completed fillig his taker ad was about to discoect the hose whe he was called away to aswer the phoe. O his retur he forgot that he had t discoected the hose ad drove off. These types of error ca be foresee ad measures ca be take to prevet or reduce their likelihood, eg colour codig, a checklist, a iterlock etc. Mistakes: errors of judgemet (rule-based or kowledge-based): rule-based mistakes happe whe a perso has a set of rules about what to do i certai situatios ad applies the wrog rule; kowledge-based mistakes happe whe a perso is faced with a ufamiliar situatio for which he or she has o rules, uses his or her kowledge ad works from first priciples, but comes to a wrog coclusio. For example whe the warig light comes o idicatig that the coolig system pump is overheatig, is there a rule for what to do? If ot, do you leave the pump o, tur it off, or shut dow the whole uit? Traiig, comprehesive safe workig procedures ad equipmet desig are most importat i prevetig mistakes. Violatio (rule breakig): deliberate failure to follow the rules, cuttig corers to save time or effort, based o the belief that the rules are too restrictive ad are ot eforced ayway, eg operatig a circular saw bech with the guard removed. This type of behaviour ca be foresee. The provisio of traiig, simple practical rules, ad routie supervisio ad moitorig of performace will reduce this type of behaviour. Whe cosiderig how to avoid huma failigs, bear i mid the fact they do ot happe i isolatio. If huma failigs are idetified as a cause of a adverse evet, cosider the followig factors that ca ifluece huma behaviour. Ivestigatig accidets ad icidets Page 22 of 88

23 Health ad Safety Job factors: how much attetio is eeded for the task (both too little ad too much ca lead to higher error rates)? divided attetio or distractios are preset; iadequate procedures; time available. Huma factors: physical ability (size ad stregth); competece (kowledge, skill ad experiece); fatigue, stress, morale, alcohol or drugs. Orgaisatioal factors: work pressure, log hours; availability of sufficiet resources; quality of supervisio; maagemet beliefs i health ad safety (the safety culture). Plat ad equipmet factors: how clear ad simple to read ad uderstad are the cotrols? is the equipmet desiged to detect or prevet errors? (For example differetsized coectors are used for oxyge ad acetylee bottles to prevet errors i coectig the hoses); is the workplace layout user-friedly? Step three Idetifyig suitable risk cotrol measures The methodical approach adopted i the aalysis stage will eable failigs ad possible solutios to be idetified. These solutios eed to be systematically evaluated ad oly the optimum solutio(s) should be cosidered for implemetatio. If several risk cotrol measures are idetified, they should be carefully prioritised as a risk cotrol actio pla, which sets out what eeds to be doe, whe ad by whom. Assig resposibility for this to esure the timetable for implemetatio is moitored. 19 What risk cotrol measures are eeded/recommeded? Your aalysis of the adverse evet will have idetified a umber of risk cotrol measures that either failed or that could have iterrupted the chai of evets leadig to the adverse evet, if they had bee i place. You should ow draw up a list of all the alterative measures to prevet this, or similar, adverse evets. Some of these measures will be more difficult to implemet tha others, but this must ot ifluece their listig as possible risk cotrol measures. The time to cosider these limitatios is later whe choosig ad prioritisig which measures to implemet. Evaluate each of the possible risk cotrol measures o the basis of their ability to prevet recurreces ad whether or ot they ca be successfully implemeted. I decidig which risk cotrol measures to recommed ad their priority, you should choose measures i the followig order, where possible: Ivestigatig accidets ad icidets Page 23 of 88