Investigating accidents and incidents

Health ad Safety Ivestigatig accidets ad icidets A workbook for employers, uios, safety represetatives ad safety professioals Ivestigatig accidets ad icidets This is a free-to-dowload, web-friedly versio of HSG245 (Secod editio, published 2004). This versio has bee adapted for olie use from HSE s curret prited versio. You ca buy the book at www.hsebooks.co.uk ad most bookshops. ISBN 978 0 7176 2827 8 Price Code: B A workbook for employers, uios, safety represetatives ad safety professioals 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. As a ew 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: 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 89

Health ad Safety Crow copyright 2004 First published 2004 Reprited 2005 Reprited with amedmets 2011 ISBN 978 0 7176 2827 8 You may reuse this iformatio (ot icludig logos) free of charge i ay format or medium, uder the terms of the Ope Govermet Licece. To view the licece visit www.atioalarchives.gov.uk/doc/ope-govermet-licece/, write to the Iformatio Policy Team, The Natioal Archives, Kew, Lodo TW9 4DU, or email psi@atioalarchives.gsi.gov.uk. Some images ad illustratios may ot be owed by the Crow so caot be reproduced without permissio of the copyright ower. Equiries should be set to copyright@hse.gsi.gov.uk. This guidace is issued by the Health ad Safety. Followig the guidace is ot compulsory ad you are free to take other actio. But if you do follow the guidace you will ormally be doig eough to comply with the law. Health ad safety ispectors seek to secure compliace with the law ad may refer to this guidace as illustratig good practice. Page 2 of 89

Health ad Safety Cotets Reducig risks ad protectig people 4 Uderstadig the laguage of ivestigatio 5 The causes of adverse evets 7 Why ivestigate? 8 A step by step guide to health ad safety ivestigatios 13 Gatherig the iformatio 14 Aalysig the iformatio 20 Idetifyig risk cotrol measures 24 The actio pla ad its implemetatio 25 Refereces ad further readig 27 Adverse evet report ad ivestigatio form: Worked examples 29 Adverse evet report ad ivestigatio form: Blak form 57 Adverse evet aalysis: Rootig out risk 67 Adverse evet aalysis: Worked examples 74 Adverse evet aalysis: Blak form 84 Ivestigatig accidets ad icidets Page 3 of 89

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 150 000 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 4 of 89

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 5 of 89

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 6 of 89

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 7 of 89

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. 6 Followig the Woolf Report 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 8 of 89

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 9 of 89

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 10 of 89

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 11 of 89

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 12 of 89

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 www.hse.gov.uk/riddor. A telephoe service ca be used to report fatal ad major ijuries oly call the Icidet Cotact Cetre o 0845 300 9923 (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 13 of 89

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 corrupted, eg items moved, guards replaced etc. If ecessary, work must stop ad uauthorised access be preveted. Ivestigatig accidets ad icidets Page 14 of 89

Health ad Safety 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 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 Ivestigatig accidets ad icidets Page 15 of 89

Health ad Safety 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 ambulace, a colleague etc) should also be recorded here. Ivestigatig accidets ad icidets Page 16 of 89

Health ad Safety 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 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 Ivestigatig accidets ad icidets Page 17 of 89

Health ad Safety 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 18 of 89

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 19 of 89

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 20 of 89

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 21 of 89

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 22 of 89

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 23 of 89

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 differet- sized 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 24 of 89

Health ad Safety measures which elimiate the risk, eg use iheretly safe products, such as a water-based product rather tha a hydrocarbo-based solvet; measures which combat the risk at source, eg provisio of guardig; measures which miimise the risk by relyig o huma behaviour, eg safe workig procedures, the use of persoal protective equipmet. I geeral terms, measures that rely o egieerig risk cotrol measures are more reliable tha those that rely o people. 20 Do similar risks exist elsewhere? If so, what ad where? Havig cocluded your ivestigatio of the adverse evet, cosider the wider implicatios: could the same thig happe elsewhere i the orgaisatio, o this site or at aother locatio? What steps ca be take to avoid this? Adverse evets might ot have occurred at other locatios yet, but make a evaluatio as to whether the risks are the same ad the same or similar risk cotrol measures are appropriate. 21 Have similar adverse evets happeed before? Give details. If there have bee similar adverse evets i the past why have they bee allowed to happe agai? The fact that such adverse evets are still occurrig should be a spur to esure that actio is take quickly. You will be particularly ope to criticism if you as a orgaisatio igore a series of similar accidets. Remember that there is value i ivestigatig ear-misses ad udesired circumstaces: it is ofte oly a matter of luck that such icidets do ot result i serious ijuries or loss of life. Step four The actio pla ad its implemetatio 22 Which risk cotrol measures should be implemeted i the short ad log term? The risk cotrol actio pla At this stage i the ivestigatio, seior maagemet, who have the authority to make decisios ad act o the recommedatios of the ivestigatio team, should be ivolved. A actio pla for the implemetatio of additioal risk cotrol measures is the desired outcome of a thorough ivestigatio. The actio pla should have SMART objectives, ie Specific, Measurable, Agreed, ad Realistic, with Timescales. Decidig where to itervee requires a good kowledge of the orgaisatio ad the way it carries out its work. For the risk cotrol measures proposed to be SMART, maagemet, safety professioals, employees ad their represetatives should all cotribute to a costructive discussio o what should be i the actio pla. Not every risk cotrol measure will be implemeted, but the oes accorded the highest priority should be implemeted immediately. I decidig your priorities you should be guided by the magitude of the risk ( risk is the likelihood ad severity of harm). Ask yourself What is essetial to securig the health ad safety of the workforce today? What caot be left util aother day? How high is the risk to employees if this risk cotrol measure is ot implemeted immediately? If the risk is Ivestigatig accidets ad icidets Page 25 of 89

Health ad Safety high, you should act immediately. You will, o doubt, be subject to fiacial costraits, but failig to put i place measures to cotrol serious ad immiet risks is totally uacceptable. You must either reduce the risks to a acceptable level, or stop the work. For those risks that are ot high ad immediate, the risk cotrol measures should be put ito your actio pla i order of priority. Each risk cotrol measure should be assiged a timescale ad a perso made resposible for its implemetatio. It is crucial that a specific perso, preferably a director, parter or seior maager, is made resposible for esurig that the actio pla as a whole is put ito effect. This perso does t ecessarily have to do the work him or herself but he or she should moitor the progress of the risk cotrol actio pla. Progress o the actio pla should be regularly reviewed. Ay sigificat departures from the pla should be explaied ad risk cotrol measure rescheduled, if appropriate. Employees ad their represetatives should be kept fully iformed of the cotets of the risk cotrol actio pla ad progress with its implemetatio. 23 Which risk assessmets ad safe workig procedures eed to be reviewed ad updated? All relevat risk assessmets ad safe workig procedures should be reviewed after a adverse evet. The fidigs of your ivestigatio should idicate areas of your risk assessmets that eed improvig. It is importat that you take a step back ad ask what the fidigs of the ivestigatio tell you about your risk assessmets i geeral. Are they really suitable ad sufficiet? Failig to review relevat risk assessmets after a adverse evet could mea that you are cotraveig the Maagemet of Health ad Safety at Work Regulatios 1999 regulatio 3(3). 5 24 Have the details of adverse evet ad the ivestigatio fidigs bee recorded ad aalysed? Are there ay treds or commo causes which suggest the eed for further ivestigatio? What did the adverse evet cost? I additio to the prompt otificatio of RIDDOR reportable evets to the regulatory authorities you should esure that you keep your ow records of adverse evets, their causes ad the remedial measures take. This will eable you to moitor your health ad safety performace ad detect treds, the commo causes of adverse evets ad so improve your overall uderstadig ad maagemet of risk. It is also useful to estimate the cost of adverse evets to fully appreciate the true cost of accidets ad ill health to your busiess. The step by step approach that is set out i this guide is oly oe of a umber of possible approaches. It is for you to decide which approach suits your busiess best. Ivestigatig accidets ad icidets Page 26 of 89

Health ad Safety Refereces ad further readig Refereces 1 Health ad safety statistics 2000/01 Report HSE Books 2001 ISBN 978 0 7176 2110 1 2 Health ad Safety Statistics Highlights 2002/03 Report MISC623 HSE Books 2003 3 Europea Social Statistics: Labour Force Survey Results 2001 ISBN 9289436050 4 The cost to Britai of workplace accidets ad work-related ill health i 1995/96 HSG101 (Secod editio) HSE Books 1999 ISBN 978 0 7176 1709 8 For the latest workplace health ad safety statistics see www.hse.gov.uk/statistics/idex.htm. 5 Maagemet of health ad safety at work. Maagemet of Health ad Safety at Work Regulatios 1999. Approved Code of Practice ad guidace L21 (Secod editio) HSE Books 2000 ISBN 978 0 7176 2488 1 (Regulatios 3(3) ad 5 refer) www.hse.gov.uk/pubs/books/l21.htm 6 Access to Justice: Fial report by the Right Hoourable Lord Woolf, Master of the Rolls July 1996 available o the Lord Chacellor s Departmet website www.lcd.gov.uk/civil/fialfr.htm 7 Safety represetatives ad safety committees L87 (Third editio) HSE Books 1996 ISBN 0 7176 1220 1 (Out of prit. Replaced by Cosultig workers o health ad safety: Safety Represetatives ad Safety Committees Regulatios 1977 (as ameded) ad Health ad Safety (Cosultatio with Employees) Regulatios 1996 (as ameded) L146 HSE Books 2008 ISBN 978 0 7176 6311 8 www.hse.gov.uk/pubs/books/l146.htm) 8 Root causes aalysis: Literature review CRR325 HSE Books 2001 ISBN 978 0 7176 1966 5 9 Evets ad Casual Factors Aalysis is a techique developed for the Uited States Departmet of Eergy. A full descriptio of the techique is available via their Evirometal Health ad Safety iteret iformatio portal at http://tis.eh.doe.gov/ aalysis/trac/14/trac14.htm 10 Reducig error ad ifluecig behaviour HSG48 (Secod editio) HSE Books 1999 ISBN 978 0 7176 2452 2 www.hse.gov.uk/pubs/books/hsg48.htm Further readig Five steps to risk assessmet Leaflet INDG163(rev3) HSE Books 2011 (priced packs of 10 ISBN 978 0 7176 6440 5) www.hse.gov.uk/pubs/books/idg163.pdf Leadig health ad safety at work: Leadership actios for directors ad board members Leaflet INDG417 HSE Books 2007 (priced packs of 5 ISBN 978 0 7176 6267 8) www.hse.gov.uk/pubs/idg417.pdf Ivestigatig accidets ad icidets Page 27 of 89

Health ad Safety Maagemet of health ad safety at work. Maagemet of Health ad Safety at Work Regulatios 1999. Approved Code of Practice ad guidace L21 (Secod editio) HSE Books 2000 ISBN 978 0 7176 2488 1 www.hse.gov.uk/pubs/books/l21.htm A guide to the Reportig of Ijuries, Diseases ad Dagerous Occurreces Regulatios 1995 L73 (Third editio) HSE Books 2008 ISBN 978 0 7176 6290 6 www.hse.gov.uk/pubs/books/l73.htm Successful health ad safety maagemet HSG65 (Secod editio) HSE Books 1997 ISBN 978 0 7176 1276 5 www.hse.gov.uk/pubs/books/hsg65.htm Reducig error ad ifluecig behaviour HSG48 (Secod editio) HSE Books 1999 ISBN 978 0 7176 2452 2 www.hse.gov.uk/pubs/books/hsg48.htm Improvig maiteace: A guide to reducig huma error Guidace HSE Books 2000 ISBN 978 0 7176 1818 7 www.hse.gov.uk/pubs/books/improve-mait.htm Ivestigatig accidets ad icidets Page 28 of 89

Health ad Safety Adverse evet report ad ivestigatio form Part 1 Overview Ref o The purpose of this form is to record all adverse evets. The term accidet is used where ijury or ill health occurs. The term icidet icludes ear-misses ad udesired circumstaces, where there is the potetial for ijury. Part 1 should be filled out immediately by the maager or supervisor for the work activity ivolved. Part 2 should be completed by the perso resposible for health ad safety. Part 3 should be completed, where appropriate, by the ivestigatio team. Part 4 should be completed by the ivestigatig team, together with maagers who have the authority to take decisios. Whe completig Parts 2, 3 ad 4 refer to the guidace uder A step by step guide to health ad safety ivestigatios. Part 1 Overview Reported by: Date/time of adverse evet R Osmud 23.06.03 10.00am Icidet Ill health Mior ijury Serious ijury Major ijury X Brief details (What, where, whe, who ad emergecy measures take) Norma Brow was tryig to fix a problem o the edge gluer whe the machie operated. Norma cut his right had quite badly. He was give first aid ad take to hospital. The fuses have bee take out of the edge gluer ad a sig hug o it. Forwarded to: Richard Wills Date Time 23.06.03 11.00am Ivestigatig accidets ad icidets Page 29 of 89

Health ad Safety Part 2 Iitial assessmet (to be carried out by the perso resposible for health ad safety) Type of evet Actual/potetial for harm Accidet X Fatal or major Ill health Serious X Near-miss Mior Udesired circumstace Damage oly RIDDOR reportable? Etry i accidet book Y/N Y Y/N Y Date/time reported 15.03.03 Date etered/referece 15.03.03 123/03 Ivestigatio level High level Low level Medium level X Basic Iitial assessmet carried out by: Richard Wills Further ivestigatio required? Yes Y/N Date 23.06.03 Priority Immediate For ivestigatio by: Peter Peterso (fitter), Joh Evas (forema) ad Richard Wills Ivestigatig accidets ad icidets Page 30 of 89

Health ad Safety Part 3 Ivestigatio iformatio gatherig 1 Where ad whe did the adverse evet happe? Woodmachie shop Moday 23rd July 2003 at 11.00 am 2 Who was ijured/suffered ill health or was otherwise ivolved with the adverse evet? Norma Brow Ijured perso woodmachiist No witesses 3 How did the adverse evet happe? (Note ay equipmet ivolved). Norma discovered a defect i the edge gluig machie. He opeed the iterlocked lid where the skirtig boards are saw off ad plaed dow. Norma put his pecil ito the iterlock switch, so he could operate the machie with the guard ope, so he could see what was wrog. The cross cut saw operated ad cut Norma s had. Wilmatro 440 edge gluig machie series No 1234/23 1998. Sharpcut Mk1 200mm diameter circular saw blade. 4 What activities were beig carried out at the time? Norma was workig o the edge gluig machie o a batch of alumiium skirtigs. 5 Was there aythig uusual or differet about the workig coditios? Yes. This machie ormally is used with mdf skirtigs, ot alumiium. 6 Were there adequate safe workig procedures ad were they followed? No. Machies should be isolated before carryig out repairs. Ivestigatig accidets ad icidets Page 31 of 89

Health ad Safety Part 3 Ivestigatio iformatio gatherig 7 What ijuries or ill health effects, if ay, were caused? Severe laceratio to the top of the right had at the kuckles resultig i severig of tedos. 8 If there was a ijury, how did it occur ad what caused it? The rotatig blade of the cross cut saw. 9 Was the risk kow? If so, why was t it cotrolled? If ot, why ot? Yes, but Norma thought he would be OK havig a look iside the guard. 10 Did the orgaisatio ad arragemet of the work ifluece the adverse evet? No, but Norma had bee havig trouble with the machie all morig. After the coffee break, he decided to get it fixed. 11 Was maiteace ad cleaig sufficiet? If ot, explai why ot. Yes Ivestigatig accidets ad icidets Page 32 of 89

Health ad Safety Part 3 Ivestigatio iformatio gatherig 12 Were the people ivolved competet ad suitable? Norma was a qualified wood machiist with 9 years experiece. He had worked o the edge gluig machie for 3 years. 13 Did the workplace layout ifluece the adverse evet? Yes access to the edger is difficult. Access to the viewig widow i the guard is difficult. 14 Did the ature or shape of the materials ifluece the adverse evet? Yes the machie was beig used with alumiium rather tha the ormal mdf skirtigs. 15 Did difficulties usig the plat ad equipmet ifluece the adverse evet? Yes, i that the edge gluer was malfuctioig. 16 Was the safety equipmet sufficiet? No the iterlock switch was of a type easily defeated. 17 Did other coditios ifluece the adverse evet? No Ivestigatig accidets ad icidets Page 33 of 89

Health ad Safety Aalysis ad further actio 18 What were the immediate, uderlyig ad root causes? Aalysis (see Aalysis uder Step two ) Why? Norma Brow lacerates his had o the edge gluig machie Because Why? Norma was workig o the machie The saw blade made a stroke Norma s had was i the dager area Because Because Because Why? Norma was ivestigatig a fault The machie was live, uder power The guard was ope A B C Ivestigatig accidets ad icidets Page 34 of 89

Health ad Safety Aalysis ad further actio 18 What were the immediate, uderlyig ad root causes? Aalysis (see Aalysis uder Step two ) A Why? Norma was ivestigatig a fault Because Why? There was a fault o the machie There were o procedures for reportig/repairig faults Because Because Why? The machie was beig used for alumiium There were o arragemets for carryig out maiteace Duties/resposibilities ot clearly set out Ivestigatig accidets ad icidets Page 35 of 89

Health ad Safety Aalysis ad further actio 18 What were the immediate, uderlyig ad root causes? Aalysis (see Aalysis uder Step two ) B Why? The machie was live Because Why? The machie was ot isolated The iterlock had bee defeated Because Because Why? No isolatio procedures Norma ot aware of eed to isolate Iterlock of a type easily defeated Norma decided to defeat safety system Because Because Because Risk assessmet did ot deal with this risk Norma ot competet for maiteace work Risk assessmet did ot aticipate violatios Because Supervisio was poor Poor attitude to health ad safety Ivestigatig accidets ad icidets Page 36 of 89

Health ad Safety Aalysis ad further actio 18 What were the immediate, uderlyig ad root causes? Aalysis (see Aalysis uder Step two ) C Why? The guard was ope Because Norma was ivestigatig a fault Norma wated to see the machie operate uder power Access to the viewig port was obstructed Because Workplace layout was iadequate Ivestigatig accidets ad icidets Page 37 of 89

Health ad Safety Aalysis ad further actio 18 What were the immediate, uderlyig ad root causes? Aalysis (see Aalysis uder Step two ) How/Why 1 Edge gluer was used for alumiium without adjustig to suit 2 The saw blade was tearig the ed of the sectios 3 The operator decided to ivestigate the cause 4 The operator decides that to fid the cause he has to ru the machie 5 The operator is uable to see through the viewig port 6 The operator opes the guards ad defeats the iterlock 7 The machie makes a cuttig stroke 8 The operator s had is cut by the saw blade Immediate causes 1 Not eough room aroud the machie to do the job 2 The saw set up was ot suitable for use o alumiium 3 The iterlocks fitted were of a type easily defeated 4 There were o safe workig procedures for the job 5 Operative ot fully competet Uderlyig causes 6 Poor workplace layout 7 No risk assessmets for use/maiteace of machie 8 Risk assessmets did t address use of other materials 9 Risk assessmets did t address violatios 10 SWPs were ot prepared followig risk assessmets 11 Operators ot traied o machie maiteace ad safety devices 12 Level of supervisio ot adequate should have detected violatios 13 All staff to be remided of their duties ad essetial health ad safety measures Root causes Maagemet commitmet to H&S ot commuicated to employees Health ad safety assistats ot fully competet ad resourced Uclear lies of commuicatio ad resposibilities Ivestigatig accidets ad icidets Page 38 of 89

Health ad Safety Part 3 Ivestigatio iformatio gatherig 19 What risk cotrol measures are eeded/recommeded? 1 2 3 4 5 6 Replace iterlock switch with togue type switch Rearrage machie to allow access to widow Procedures for isolatio of machie Procedures for reportig/repairig defects Clear allocatio of duties Review risk assessmet 20 Do similar risks exist elsewhere? If so, what ad where? Yes there are similar iterlock switches o the multi-headed moulder/plaer 21 Have similar adverse evets happeed before? Give details. No Ivestigatig accidets ad icidets Page 39 of 89

Health ad Safety Part 4 The risk cotrol actio pla 22 Which risk cotrol measures should be implemeted i the log ad short term? Cotrol measure Completio Date Perso resposible 1 Replace iterlocks Before use Peter (fitter) 2 Rearrage workshop Before use Joh (forema) Richard (H&S) 3 Prepare SWPs for isolatio ad reportig ad repair/maiteace 1.12.03 Joh (forema) Richard (H&S) 4 Assess competece ad traiig eeds & deliver traiig 1.12.03 1.3.04 Joh (forema) Richard (H&S) 5 Prepare/review risk assessmets 1.03.03 Richard (H&S) 23 Which risk assessmets ad safe workig procedures eed to be reviewed ad updated? Name of risk assessmet safe workig procedure Completio Date Perso resposible 1 Risk Assess. For workplace 1st week i July Richard (H&S) 2 Risk Assess. For machiery 1st week i July Richard (H&S) 3 4 Ivestigatig accidets ad icidets Page 40 of 89

Health ad Safety Part 4 The risk cotrol actio pla 24 Have the details of the adverse evet ad the ivestigatio fidigs bee recorded ad aalysed? Are there ay treds or commo causes which suggest the eed for further ivestigatio? What did the adverse evet cost? Details have bee recorded o treds or commo causes eed to check quality of risk assessmets. Estimated cost of accidet 3,700 25 Siged o behalf of the ivestigatio team Name Sigature 26 Members of the ivestigatio team Name Positio Richard Wills Joh Evas Peter Peterso H&S Officer Forema Fitter Ivestigatig accidets ad icidets Page 41 of 89

Health ad Safety Part 4 The risk cotrol actio pla 27 The fidigs of this ivestigatio eed to be commuicated to the followig maagers, uio ad employee safety represetatives Perso Sigature Date A. Director W.K.S Maager A. Rep Ivestigatig accidets ad icidets Page 42 of 89

Health ad Safety Adverse evet report ad ivestigatio form Part 1 Overview Ref o The purpose of this form is to record all adverse evets. The term accidet is used where ijury or ill health occurs. The term icidet icludes ear-misses ad udesired circumstaces, where there is the potetial for ijury. Part 1 should be filled out immediately by the maager or supervisor for the work activity ivolved. Part 2 should be completed by the perso resposible for health ad safety. Part 3 should be completed, where appropriate, by the ivestigatio team. Part 4 should be completed by the ivestigatig team, together with maagers who have the authority to take decisios. Whe completig Parts 2, 3 ad 4 refer to the guidace uder A step by step guide to health ad safety ivestigatios. Part 1 Overview Reported by: Adam Joes (Wages Dept) Date/time of adverse evet Ukow Icidet Ill health Mior ijury Serious ijury Major ijury X Brief details (What, where, whe, who ad emergecy measures take) Sick paper received from Joh Smith together with a ote from his GP which states that he is sufferig from occupatioal asthma Forwarded to: Paul Melish Date Time 09.11.03 10.30am Ivestigatig accidets ad icidets Page 43 of 89

Health ad Safety Part 2 Iitial assessmet (to be carried out by the perso resposibile for health ad safety) Type of evet Actual/potetial for harm Ijury Fatal or major Ill health X Serious X Near-miss Mior Udesired circumstace Damage oly RIDDOR reportable? Etry i accidet book Y/N Y Y/N Y Date/time reported 11.30 am Date etered/referece 09.11.03 Ivestigatio level High level Low level Medium level X Basic Iitial assessmet carried out by: Paul Melish Further ivestigatio required? Yes Y/N Date 09.11.03 Priority Immediate For ivestigatio by: P Melish, workshop maager ad forema Ivestigatig accidets ad icidets Page 44 of 89

Health ad Safety Part 3 Ivestigatio iformatio gatherig 1 Where ad whe did the adverse evet happe? Spray shop sometime over last 6 moths? Joh Smith was take o 6 moths ago as a pait sprayer 2 Who was ijured/suffered ill health or was otherwise ivolved with the adverse evet? Joh Smith pait sprayer Also other sprayers Peter Joh ad Roger Wilso 3 How did the adverse evet happe? (Note ay equipmet ivolved). Joh works i the pait spray booth. Booth Widflow Mark 3 serial o 12345/97 Spray gus Paitspraymaster model 2 Gu wash Cleaomax mark 4 serial o 247/99 Half mask Wearmask model 12 with AXP3 filters 4 What activities were beig carried out at the time? Duties carried out would have bee limited to the mixig ad sprayig of isocyaate-based spray pait i the spray booth 5 Was there aythig uusual or differet about the workig coditios? Nothig differet 6 Were there adequate safe workig procedures ad were they followed? As ormal Ivestigatig accidets ad icidets Page 45 of 89

Health ad Safety Part 3 Ivestigatio iformatio gatherig 7 What ijuries or ill health effects, if ay, were caused? Reported Occupatioal Asthma 8 If there was a ijury, how did it occur ad what caused it? Exposure to isocyaate-based pait suspected Also possible poor quality of air fed to mask 9 Was the risk kow? If so, why was t it cotrolled? If ot, why ot? Risks of pait kow existig cotrols assumed to be sufficiet Poor air quality ot kow 10 Did the orgaisatio ad arragemet of the work ifluece the adverse evet? No supervisio or moitorig of pait spray shop air-fed mask ot always used for small jobs half-masks were sometimes used (suitable for workig with isocyaates but NOT suitable for spray paitig) 11 Was maiteace ad cleaig sufficiet? If ot, explai why ot. Spray booth ot examied for 2 years compressed air quality to air-fed masks ot tested. Both subsequetly foud to be iadequate Ivestigatig accidets ad icidets Page 46 of 89

Health ad Safety Part 3 Ivestigatio iformatio gatherig 12 Were the people ivolved competet ad suitable? Joh Smith was a experieced pait sprayer with 2 1 / 2 years experiece with his previous employer 13 Did the workplace layout ifluece the adverse evet? No 14 Did the ature or shape of the materials ifluece the adverse evet? Yes solvet-based isocyaate paits are respiratory sesitisers 15 Did difficulties usig the plat ad equipmet ifluece the adverse evet? No 16 Was the safety equipmet sufficiet? Spray booth air flow was foud to be iadequate Air quality to air-fed masks was poor cotamiated Correct Respiratory Protective Equipmet ot always used. 17 Did other coditios ifluece the adverse evet? No Ivestigatig accidets ad icidets Page 47 of 89

Health ad Safety Aalysis ad further actio 18 What were the immediate, uderlyig ad root causes? Aalysis (see Aalysis uder Step two ) Joh Smith develops occupatioal asthma Because He is exposed to cotamiated air He is exposed to isocyaate pait His deterioratig health is ot detected A B C Ivestigatig accidets ad icidets Page 48 of 89

Health ad Safety Aalysis ad further actio 18 What were the immediate, uderlyig ad root causes? Aalysis (see Aalysis uder Step two ) A Why? He is exposed to cotamiated air Because Why? The compressed air supply to his air-fed mask is cotamiated Because Why? The air supply was ot tested for quality Cotamiatio was beig fed ito the air supply (faulty pump) Because The risk assessmet did ot idetify the risk No-oe had resposibility for maiteace maagemet Ivestigatig accidets ad icidets Page 49 of 89

Health ad Safety Aalysis ad further actio Aalysis (see Aalysis uder Step two ) B Why? Joh Smith exposed to isocyaate pait Because Why? Spray booth extractio iadequate Sprayers sometimes used iadequate RPE Because Because Why? Booth was ot tested No iformatio istructios or procedures for use of RPE Supervisio iadequate Because Because No oe had overall resposibility for maiteace Risk assessmet ad procedures iadequate Ivestigatig accidets ad icidets Page 50 of 89

Health ad Safety Aalysis ad further actio 18 What were the immediate, uderlyig ad root causes? Aalysis (see Aalysis uder Step two ) C Why? Deterioratig health ot detected Because Why? No health screeig o recruitmet No health surveillace icludig lug fuctio test Because Risk assessmet ot adequate Because Ivestigatig accidets ad icidets Page 51 of 89

Health ad Safety Aalysis ad further actio 18 What were the immediate, uderlyig ad root causes? Aalysis (see Aalysis uder Step two ) How/why might he have bee exposed to substaces which caused occupatioal asthma 1 The compressed air supply to the breathig equipmet was cotamiated 2 The spray booth extractio was ot adequate 3 Sprayers sometimes used RPE which was ot adequate Immediate Causes 1 Spray booth performace had deteriorated ot tested/maitaied 2 Air quality to air-fed masks had deteriorated ot tested/maitaied 3 Icorrect RPE sometimes used 4 No safe workig procedures for RPE ad booth Uderlyig Causes 1 Risk assessmets iadequate for sprayig operatios 2 No oe i overall charge of testig/maiteace 3 Supervisio ad moitorig of work practices iadequate 4 Sprayers ot fully competet traiig/istructio o use/choice of RPE 5 Risk assessmet did t recogise risk from previous employmet exposure 6 No arragemets for health screeig Root Causes No seior parter i overall charge of H&S H&S performace to be moitored Resposibilities uclear Ivestigatig accidets ad icidets Page 52 of 89

Health ad Safety Part 3 Ivestigatio iformatio gatherig 19 What risk cotrol measures are eeded/recommeded? 1 2 3 4 5 6 Spray booth & air to be tested Health surveillace & screeig for sprayers Resposibilities for maiteace to be allocated Refresher traiig o hazards ad PPE Icreased supervisio ad moitorig Parter appoited to maage H&S 20 Do similar risks exist elsewhere? If so, what ad where? No 21 Have similar adverse evets happeed before? Give details. No Ivestigatig accidets ad icidets Page 53 of 89

Health ad Safety Part 4 The risk cotrol actio pla 22 Which risk cotrol measures should be implemeted i the log ad short term? Cotrol Measure Completio Date Perso resposible 1 Booth ad air to be tested Immediate Maiteace fitter 2 Health surveillace ad screeig Ja 2003 Peter Riley 3 Maiteace schedule Ja 2003 Maiteace fitter 4 Traiig PPE Ja 2003 Peter Riley 5 Supervisio/moitorig Ja 2003 All forema/peter Riley 6 Parter appoited to review Ja 2003 P Melish 23 Which risk assessmets ad safe workig procedures eed to be reviewed ad updated? Name of risk assessmet safe workig procedure Completio Date Perso resposible 1 Spray paitig Ja 2003 Peter Riley 2 3 Ivestigatig accidets ad icidets Page 54 of 89

Health ad Safety Part 4 The risk cotrol actio pla 24 Have the details of the adverse evet ad the ivestigatio fidigs bee recorded ad aalysed? Are there ay treds or commo causes which suggest the eed for further ivestigatio? What did the adverse evet cost? No treds Estimated total cost 2,700 25 Siged o behalf of the ivestigatio team Name Sigature Paul Melish 26 Members of the ivestigatio team Name Positio Paul Melish A Coome P Berry T Roberts Parter Work Maager Forema Employee rep Ivestigatig accidets ad icidets Page 55 of 89

Health ad Safety Part 4 The risk cotrol actio pla 27 The fidigs of this ivestigatio eed to be commuicated to the followig maagers, uio ad employee safety represetatives Perso Sigature Date A. Maager A. Supervisor A. Represetative Ivestigatig accidets ad icidets Page 56 of 89

Health ad Safety Adverse evet report ad ivestigatio form Part 1 Overview Ref o The purpose of this form is to record all adverse evets. The term accidet is used where ijury or ill health occurs. The term icidet icludes ear-misses ad udesired circumstaces, where there is the potetial for ijury. Part 1 should be filled out immediately by the maager or supervisor for the work activity ivolved. Part 2 should be completed by the perso resposible for health ad safety. Part 3 should be completed, where appropriate, by the ivestigatio team. Part 4 should be completed by the ivestigatig team, together with maagers who have the authority to take decisios. Whe completig Parts 2, 3 ad 4 refer to the guidace uder A step by step guide to health ad safety ivestigatios. Part 1 Overview Reported by: Date/time of adverse evet Icidet Ill health Mior ijury Serious ijury Major ijury Brief details (What, where, whe, who ad emergecy measures take) Forwarded to: Date Time Ivestigatig accidets ad icidets Page 57 of 89

Health ad Safety Part 2 Iitial assessmet (to be carried out by the perso resposible for health ad safety) Type of evet Actual/potetial for harm Accidet Fatal or major Ill health Serious Near-miss Mior Udesired circumstace Damage oly RIDDOR reportable? Y/N Date/time reported Etry i accidet book Y/N Date etered/referece Ivestigatio level High level Low level Medium level X Basic Iitial assessmet carried out by: Date Further ivestigatio required? Y/N Priority For ivestigatio by: Ivestigatig accidets ad icidets Page 58 of 89

Health ad Safety Part 3 Ivestigatio iformatio gatherig 1 Where ad whe did the adverse evet happe? 2 Who was ijured/suffered ill health or was otherwise ivolved with the adverse evet? 3 How did the adverse evet happe? (Note ay equipmet ivolved.) 4 What activities were beig carried out at the time? 5 Was there aythig uusual or differet about the workig coditios? 6 Were there adequate safe workig procedures ad were they followed? Ivestigatig accidets ad icidets Page 59 of 89

Health ad Safety Part 3 Ivestigatio iformatio gatherig 7 What ijuries or ill health effects, if ay, were caused? 8 If there was a ijury, how did it occur ad what caused it? 9 Was the risk kow? If so, why was t it cotrolled? If ot, why ot? 10 Did the orgaisatio ad arragemet of the work ifluece the adverse evet? 11 Was maiteace ad cleaig sufficiet? If ot, explai why ot. Ivestigatig accidets ad icidets Page 60 of 89

Health ad Safety Part 3 Ivestigatio iformatio gatherig 12 Were the people ivolved competet ad suitable? 13 Did the workplace layout ifluece the adverse evet? 14 Did the ature or shape of the materials ifluece the adverse evet? 15 Did difficulties usig the plat ad equipmet ifluece the adverse evet? 16 Was the safety equipmet sufficiet? 17 Did other coditios ifluece the adverse evet? Ivestigatig accidets ad icidets Page 61 of 89

Health ad Safety Aalysis ad further actio 18 What were the immediate, uderlyig ad root causes? Aalysis (see Aalysis uder Step two ) Ivestigatig accidets ad icidets Page 62 of 89

Health ad Safety Part 3 Ivestigatio iformatio gatherig 19 What risk cotrol measures are eeded/recommeded? 1 2 3 4 5 6 20 Do similar risks exist elsewhere? If so, what ad where? 21 Have similar adverse evets happeed before? Give details. Ivestigatig accidets ad icidets Page 63 of 89

Health ad Safety Part 4 The risk cotrol actio pla 22 Which risk cotrol measures should be implemeted i the log ad short term? Cotrol measure Completio date Perso resposible 1 2 3 4 5 23 Which risk assessmets ad safe workig procedures eed to be reviewed ad updated? Name of risk assessmet safe workig procedure Completio date Perso resposible 1 2 3 4 Ivestigatig accidets ad icidets Page 64 of 89

Health ad Safety Part 4 The risk cotrol actio pla 24 Have the details of the adverse evet ad the ivestigatio fidigs bee recorded ad aalysed? Are there ay treds or commo causes which suggest the eed for further ivestigatio? What did the adverse evet cost? 25 Siged o behalf of the ivestigatio team Name Sigature 26 Members of the ivestigatio team Name Positio Ivestigatig accidets ad icidets Page 65 of 89

Health ad Safety Part 4 The risk cotrol actio pla 27 The fidigs of this ivestigatio eed to be commuicated to the followig maagers, uio ad employee safety represetatives Perso Sigature Date Ivestigatig accidets ad icidets Page 66 of 89

Health ad Safety Adverse evet aalysis: Rootig out risk Usig the iformatio gathered durig your ivestigatio, go through each of the four sectios o the immediate causes (the Place, the Plat, the Process ad the People). If the aswer to ay of the questios is o, the this is a immediate cause of the adverse evet uder ivestigatio. After idetifyig the immediate causes, direct your attetio to the potetial uderlyig causes (which are set out to the right of the immediate causes idetified) ad cosider the questios uder the relevat headigs. For example if the aswer to the first questio below Were the access ad egress adequate? is o, you should cosider whether the desig of the workplace ad the risk assessmet for workplace access/egress were adequate. Immediate causes 1 The place or premises where the icidet happeed The place or premises where the icidet happeed. If there was aythig about the coditio of the workplace that cotributed to the adverse evet, aswer the followig questio, which will suggest other areas to cosider. If ot, go to Plat, equipmet ad substaces. Cotrol Co-operatio Commuicatio Competece Desig Implemetatio Risk assessmet 1 Were the access ad egress adequate? 2 Were the access ad egress poits beig used? 3 Was the workplace suitable for the task i had? 4 Was there sufficiet space for the task i had? 5 Was the workplace beig used as iteded? 6 Were people segregated from hazardous areas/processes/machiery? 7 Was the work eviromet (lightig, temperature ad vetilatio) suitable? 8 Did the ergoomics of the workstatio suit the perso usig it? 9 Was the work area clea ad tidy? (Routie cleaig programme ad dealig with spills.) 10 Were weather coditios a factor? 11 Were the oise levels withi acceptable levels? 12 Were the appropriate warig sigs i place? 13 Were cotractors provided with adequate iformatio o access/egress ad the hazards withi the premises? Immediate causes Ivestigatig accidets ad icidets Page 67 of 89

Health ad Safety 2 The plat, equipmet ad substaces (used or geerated) The plat, equipmet ad substaces (used or geerated). If the equipmet beig used, or the substaces/materials used or geerated, cotributed to the adverse evet, aswer the followig questios, which will suggest other areas to cosider. If ot, go to Process/procedures. Cotrol Co-operatio Commuicatio Competece Implemetatio Risk assessmet 1 Were the most suitable plat ad equipmet available for the job? 2 Were the plat ad equipmet used suitable for the perso usig them? 3 Were the plat ad equipmet used suitable for the job? 4 Had the plat ad equipmet bee chose, or modified, so that its health ad safety efficiecy could ot be improved? 5 Were plat ad equipmet i workig order ad adequately maitaied? Was there a routie maiteace programme? Was there a procedure for repair whe a defect was discovered? 6 Were the plat ad equipmet beig properly used? 7 Were there adequate cotrols or guards for the safe use of the equipmet? 8 Were the cotrols or guards fitted, maitaied ad properly used? 9 Were the cotrols well laid out ad easy to uderstad? 10 Were the most suitable materials or substaces available for the job? 11 Were the correct materials beig used? 12 Were the materials as specified? 13 Were the materials or substaces used suitable for the job ad perso? 14 Were the materials or substaces beig properly used? 15 Was exposure to hazardous materials ad by-products adequately cotrolled? 16 If the eed for persoal protective equipmet (PPE) had ot bee idetified, was it safe to do the job without PPE? 17 If ecessary, was suitable PPE available? 18 If ecessary, was the correct PPE used? 19 If the correct PPE was used, was it used correctly? Ivestigatig accidets ad icidets Page 68 of 89

Health ad Safety Immediate causes 3 The process/procedures The process/procedures. If the procedures, istructios or iformatio (or the lack of them), cotributed to the adverse evet, aswer the followig questios, which will suggest other areas to cosider. If ot, go to People. Cotrol Commuicatio Competece Desig Implemetatio Risk assessmet 1 Were there safe workig procedures ad istructios for the tasks uder cosideratio? 2 If there were safe workig procedures ad istructios, were they up to date? 3 If there were safe workig procedures ad istructios, were they realistic, accurate ad adequate? 4 If there were safe workig procedures ad istructios, did they deal with the circumstaces of the adverse evet? 5 If there were safe workig procedures ad istructios, were the correct oes followed? 6 If there were safe workig procedures ad istructios, were they provided or readily available to those carryig out the work? Iclude cotractors. 7 If there were safe workig procedures, were they policed? 8 Was the level of supervisio adequate? Iclude cotractors. 9 Were the traiig eeds for this activity idetified? 10 If there were safe workig procedures ad istructios, were they used as part of traiig? 11 Were cotractors workig i accordace with agreed method statemets ad safe systems of work? 12 Were cotractors iformed of the safe workig procedures they should adopt? Ivestigatig accidets ad icidets Page 69 of 89

Health ad Safety Immediate causes 3 The people ivolved The people ivolved. If there was aythig about the people ivolved that cotributed to the adverse evet, aswer the followig questios which will suggest other areas to cosider. Cotrol Co-operatio Commuicatio Competece Desig Implemetatio Risk assessmet 1 Were the people ivolved suited for their job? physically ad emotioally (youg people eed special cosideratio)? competece (skilled, kowledgeable ad experieced)? 2 Was the health of people who could be affected moitored? 3 Were the people performig their work as expected? 4 Were workers employed by cotractors suitable ad competet? 5 Was the evet free of huma failigs? Was it a mistake? If it was a mistake cosider: Was it a slip or lapse caused by: fatigue ot eough rest breaks, workig excessive hours, already tired? lack of motivatio or boredom? beig distracted? beig preoccupied, eg agry, or excited? beig uder too much pressure, ie too much or too may thigs to do? too little time? takig substaces, such as alcohol, medicies or drugs? If it was a violatio, ie breakig the rules or takig short cuts, cosider: Ivestigatig accidets ad icidets Page 70 of 89

Health ad Safety Uderlyig ad Root Causes If your aswers to the Place, Plat, Procedures ad People sectios idetified ay immediate cause, cosider the relevat Uderlyig ad Root Causes sectio. ORGANISATION how we do thigs ad how we make sure they are doe correctly Cotrol 1 Were the workplace ad work activities adequately supervised ad moitored i order to esure that risk cotrol measures were effective ad implemeted as iteded? 2 Did the supervisors have adequate resources to carry out their duties? 3 Were people held accoutable for their performace i carryig out their duties with regard to Health ad Safety? 4 Were there adequate arragemets for overseeig ad cotrollig cotractors? Co-operatio 1 Were trade uios, employees ad their represetatives ivolved i determiig workplace arragemets, preparig risk assessmets ad safe workig procedures? 2 Did the idividuals ivolved i the icidet share iformatio? 3 Were there arragemets for cooperatio with, ad co-ordiatio of, cotractors? Commuicatio 1 Were resposibilities ad duties clearly set out? 2 Were they clearly uderstood by those ivolved? 3 Did everyoe ivolved kow who they report to ad who reports to them? 4 Was there sufficiet, up-to-date iformatio to eable good decisios to be made? 5 Were there adequate arragemets for passig o iformatio at shift chages? 6 Were writte istructios, safe workig procedures ad product iformatio sheets practical ad clear? 7 Were the istructios ad procedures available to all who eeded them? 8 Was commuicatio betwee workers ad supervisors effective? 9 Was the commuicatio betwee differet departmets effective? 10 Were there effective commuicatios with cotractors? Competece: Traiig ad suitability 1 Were the people ivolved assessed as suitable for the work i terms of health ad physical ability? 2 Were the health ad safety traiig eeds of people idetified? o recruitmet; o chagig jobs; whe chages i the work are proposed; periodically as part of refresher traiig? 3 Were the traiig requiremets for particular jobs idetified? 4 Was the traiig effectively delivered? Ivestigatig accidets ad icidets Page 71 of 89

Health ad Safety with adequate resources? effectively? ad assessed? were traiig records kept? 5 Was the competece of cotractors, employees ad agecy workers checked? Plaig ad Implemetatio: How we prepare to do thigs effectively ad efficietly Desig 1 Were the workplace ad equipmet layouts desiged cosiderig health ad safety? 2 Were the cotrols, displays etc of plat ad equipmet desiged to reduce the risk of, or prevet, huma error? For example mis-readig dials or operatig the wrog switch Implemetatio 1 Were there arragemets for esurig that sufficiet, ad suitable, plat, equipmet ad materials were available? 2 Were there arragemets for esurig that sufficiet ad suitable labour was available? 3 Was there adequate cover for leave or sickess absece? 4 Were suitable cotractors appoited? 5 Were there adequate arragemets for cleaig? 6 Were there adequate arragemets for reportig defects i plat ad equipmet? 7 Were there adequate arragemets for carryig out maiteace work? 8 Were there adequate arragemets for reportig health ad safety cocers? 9 Were there adequate arragemets for reportig ear-misses ad udesired circumstaces? 10 Were there adequate arragemets for carryig out health surveillace? 11 Were there adequate arragemets for carryig out air moitorig/samplig? (If required) 12 Did productio targets take accout of health ad safety? 13 Were there adequate arragemets for appoitig ad cotrollig cotractors? Risk assessmet Risk assessmets ivolve idetifyig the hazards, idetifyig who may be affected ad puttig i place suitable arragemets to elimiate or reduce the risks to a acceptable level. 1 Were there risk assessmets for the work i questio? 2 Were they adequate? did they correctly idetify the risks? were they up-to-date ad reviewed as ecessary? were correct techical stadards used? were adequate risk cotrol measures idetified? were safe workig procedures developed? were there clear coclusios ad recommedatios? were employees ivolved i preparig them? Ivestigatig accidets ad icidets Page 72 of 89

Health ad Safety 3 Did the risk assessmets result i a risk cotrol actio pla with SMART (Specific, Measurable, Agreed, Realistic ad Timescaled) objectives? 4 Were resposibilities for implemetig the risk cotrol actio pla set out? 5 Had the risk cotrol actio pla bee implemeted? 6 If there had bee similar adverse evets i the past, had they bee ivestigated? 7 Were adverse evets recorded, ivestigated ad the fidigs fed back ito the risk assessmets? 8 Did the risk assessmets iclude the risks from work carried out by cotractors? A o aswer to ay of the questios i the uderlyig or root cause sectio idetifies a uderlyig or root cause. These uderlyig or root causes i tur poit to failigs i the health ad safety maagemet system. Seior maagemet should cosider all the questios i the followig Maagemet sectio to idetify weakesses i the overall risk cotrol maagemet of the orgaisatio. Maagemet: How we create the eviromet ad set the stadards uder which all other health ad safety activities take place Was there a writte health ad safety policy statemet? Did all employees kow ad uderstad the health ad safety policy statemet? Were amed parters, directors ad seior maagers made resposible for health ad safety arragemets? Was there a adequate commitmet to health ad safety at a seior level? Was this commitmet reflected i the actios of directors, parters ad maagers? Were sufficiet people appoited to assist with health ad safety measures? Were the people appoited to assist with health ad safety measures adequately traied ad competet? Did the health ad safety assistats have sufficiet authority to carry out their duties? Were the tasks of carryig out risk assessmets ad preparig safe workig practices give to competet persos? Was the carryig out of risk assessmets a high priority? Were adequate resources allocated to health ad safety? Was it your policy to lear from adverse evet ivestigatios ad improve your health ad safety performace? Were the recommedatios ad fidigs of the health ad safety team acted o? Was the work of the health ad safety team (icludig maagers, safety officers, safety assistats, supervisors ad safety represetatives) moitored? Were the health ad safety team held to accout for their performace? Were there clear ad itegrated lies of commuicatio ad cotrol? Was there a coflict betwee productio ad health ad safety? Was health ad safety performace measured ad moitored? Did you seek to improve your health ad safety performace as a result of your dealigs with the regulatory authorities ad other health ad safety professioals? Ivestigatig accidets ad icidets Page 73 of 89

Health ad Safety Adverse evet Ref o Adverse evet aalysis Usig the Adverse evet aalysis: Rootig out risk checklist, cosider the questios i the immediate cause sectios. Eter each of the immediate causes idetified i the table ad eter the risk cotrol measures required. For each immediate cause the checklist suggests possible uderlyig/root causes. Cosider each of these potetial uderlyig/root causes ad eter those that are relevat. Fially eter the remedial measures required to remedy the uderlyig/root cause. 1 Place or premises Immediate cause: Poit Risk cotrol measure required Uderlyig/root causes Measures to remedy uderlyig/ root cause Ivestigatig accidets ad icidets Page 74 of 89

Health ad Safety Adverse evet Ref o Adverse evet aalysis Usig the Adverse evet aalysis: Rootig out risk checklist, cosider the questios i the immediate cause sectios. Eter each of the immediate causes idetified i the table ad eter the risk cotrol measures required. For each immediate cause the checklist suggests possible uderlyig/root causes. Cosider each of these potetial uderlyig/root causes ad eter those that are relevat. Fially eter the remedial measures required to remedy the uderlyig/root cause. 2 Plat equipmet ad substaces Immediate cause: Poit Risk cotrol measure required Uderlyig/root causes Measures to remedy uderlyig/root cause Poit 5 Equipmet ot beig routiely maitaied Spray booth to be examied immediately ad air quality to sprayers masks to be checked Risk assessmet iadequate - did ot recogise risks where booth extractio ad air quality had deteriorated Review risk assessmets where deterioratio i safety equipmet will lead to icreased risks Poit 15 Exposure to hazardous materials ot cotrolled Spray booth ad air quality to be tested immediately to esure safe Cotrol - No clear resposibilities for esurig equipmet workig effectively Maiteace fitter to be made resposible for testig of spray booth ad air quality Poit 18 Correct PPE ot used Esure oly air-fed masks are used for all spray paitig Supervisio ad moitorig iadequate Esure supervisors check that correct PPE is used - itroduce moitorig of actual use Competece - sprayers ot fully aware of risks ad limitatios of RPE Istructios ad traiig of sprayers o risks ad limitatios of RPE Ivestigatig accidets ad icidets Page 75 of 89

Health ad Safety Adverse evet Ref o Adverse evet aalysis Usig the Adverse evet aalysis: Rootig out risk checklist, cosider the questios i the immediate cause sectios. Eter each of the immediate causes idetified i the table ad eter the risk cotrol measures required. For each immediate cause the checklist suggests possible uderlyig/root causes. Cosider each of these potetial uderlyig/root causes ad eter those that are relevat. Fially eter the remedial measures required to remedy the uderlyig/root cause. 3 Processes ad procedures Immediate cause: Poit Risk cotrol measure required Uderlyig/root causes Measures to remedy uderlyig/root cause Poit 1 No safe workig procedures (SWPs) or istructios Prepare SWPs ad istructios for the safe use of the spray booth ad the RPE required Risk Assessmets ad SWPs iadequate Review risk assessmet ad prepare SWPs for the maiteace ad use of the spray booth ad air-fed masks Ivestigatig accidets ad icidets Page 76 of 89

Health ad Safety Adverse evet Ref o Adverse evet aalysis Usig the Adverse evet aalysis: Rootig out risk checklist, cosider the questios i the immediate cause sectios. Eter each of the immediate causes idetified i the table ad eter the risk cotrol measures required. For each immediate cause the checklist suggests possible uderlyig/root causes. Cosider each of these potetial uderlyig/root causes ad eter those that are relevat. Fially eter the remedial measures required to remedy the uderlyig/root cause. 4 People Immediate cause: Poit Risk cotrol measure required Uderlyig/root causes Measures to remedy uderlyig/ root cause Poit 1 People ot suited for the job Esure that recruitmet of sprayers icludes health checks Risk assessmet iadequate ad o health screeig o recruitmet Esure risk assessmets recogise eed to scree people for ill health which may be made worse by their work Poit 2 No health moitorig Spray paiters to have aual lug fuctio tests as a part of their health moitorig Risk Assessmets iadequate Esure that risk assessmets recogise where health moitorig ca detect the oset of ill health ad set up the ecessary arragemets Ivestigatig accidets ad icidets Page 77 of 89

Health ad Safety Adverse evet Ref o Adverse evet aalysis Health ad safety maagemet issues This sectio should be completed by maagers/directors/parters with the authority to make decisios o the maagemet of health ad safety. It should be completed usig the maagemet sectio of the rootig out risk checklist ad with referece to the immediate, uderlyig/root causes idetified earlier i the aalysis. What weakesses i the overall maagemet of health ad safety allowed the uderlyig/root causes of the adverse evet to exist? Remedial actio No oe i overall charge of health ad safety at seior level Appoit parter to take overall charge of maagig Health ad Safety The work of the people resposible for day-to-day health ad safety arragemets was ot moitored Parter to moitor health ad safety performace No clear lies of commuicatio ad cotrol Resposibilities ad lies of commuicatio o health ad safety matter to be established Ivestigatig accidets ad icidets Page 78 of 89

Health ad Safety Adverse evet Ref o Adverse evet aalysis Usig the Adverse evet aalysis: Rootig out risk checklist, cosider the questios i the immediate cause sectios. Eter each of the immediate causes idetified i the table ad eter the risk cotrol measures required. For each immediate cause the checklist suggests possible uderlyig/root causes. Cosider each of these potetial uderlyig/root causes ad eter those that are relevat. Fially eter the remedial measures required to remedy the uderlyig/root cause. 1 Place or premises Immediate cause: Poit Risk cotrol measure required Uderlyig/root causes Measures to remedy uderlyig/root cause Poit 4 Not eough room for the job Re-arrage machiery to allow access to viewig port Plaig - desig of layouts Risk assessmets - ot adequate Review risk assessmets - look at safe workig access to all areas of machiery for operatio ad maiteace Ivestigatig accidets ad icidets Page 79 of 89

Health ad Safety Adverse evet Ref o Adverse evet aalysis Usig the Adverse evet aalysis: Rootig out risk checklist, cosider the questios i the immediate cause sectios. Eter each of the immediate causes idetified i the table ad eter the risk cotrol measures required. For each immediate cause the checklist suggests possible uderlyig/root causes. Cosider each of these potetial uderlyig/root causes ad eter those that are relevat. Fially eter the remedial measures required to remedy the uderlyig/root cause. 2 Plat equipmet ad substaces Immediate cause: Poit Risk cotrol measure required Uderlyig/root causes Measures to remedy uderlyig/root cause Poit 3 Equipmet ot suitable for the job Machie ot to be used o alumiium util maufacturer s literature checked ad adjustmets made Risk assessmet did t deal with use for other materials Risk assess machie for use with alumiium Procedures for use with alumiium to be produced ad istructios/traiig give Poit 4 Equipmet ot most effective - iterlocks of a type easily defeated Arrage for iterlocks to be chaged for better desig All employees to be remided of eed for iterlocks Risk assessmets ot adequate - did t aticipate violatios Review how tamperproof safety equipmet is Remid workforce of the importace of safety measures ad procedures ad the importace the busiess places o H&S Ivestigatig accidets ad icidets Page 80 of 89

Health ad Safety Adverse evet Ref o Adverse evet aalysis Usig the Adverse evet aalysis: Rootig out risk checklist, cosider the questios i the immediate cause sectios. Eter each of the immediate causes idetified i the table ad eter the risk cotrol measures required. For each immediate cause the checklist suggests possible uderlyig/root causes. Cosider each of these potetial uderlyig/root causes ad eter those that are relevat. Fially eter the remedial measures required to remedy the uderlyig/root cause. 3 Processes ad procedures Immediate cause: Poit Risk cotrol measure required Uderlyig/root causes Measures to remedy uderlyig/root cause Poit 1 No safe workig procedures (SWP) for job Prepare SWP for workig for repairs, lockig off ad isolatio procedures Traiig Risk assessmets ad procedures Update risk assessmets ad prepare ad commuicate procedures for reportig of defects, repairs, lockig off ad isolatio - traiig Moitor Ivestigatig accidets ad icidets Page 81 of 89

Health ad Safety Adverse evet Ref o Adverse evet aalysis Usig the Adverse evet aalysis: Rootig out risk checklist, cosider the questios i the immediate cause sectios. Eter each of the immediate causes idetified i the table ad eter the risk cotrol measures required. For each immediate cause the checklist suggests possible uderlyig/root causes. Cosider each of these potetial uderlyig/root causes ad eter those that are relevat. Fially eter the remedial measures required to remedy the uderlyig/root cause. 4 People Immediate cause: Poit Risk cotrol measure required Uderlyig/root causes Measures to remedy uderlyig/ root cause Poit 1 Competece - use of equipmet ad hazards of job durig maiteace Traiig i eed for iterlocks ad isolatio/lockig off. Traiig o hazards ad accepted use of machie Competece - traiig requiremets ot assessed or delivered Esure all ecessary iformatio o machiery is available ad traiig eeds are idetified ad suitable traiig give Poit 4 Violatio - defeatig of iterlock guards Fit less easily defeated switches Istructio to all operatives Cotrol ad commuicatio Staff to be remided of eed for ad cosequeces of iterferig with safety equipmet Levels of supervisio ad moitorig to be icreased Ivestigatig accidets ad icidets Page 82 of 89

Health ad Safety Adverse evet Ref o Adverse evet aalysis Health ad safety maagemet issues This sectio should be completed by maagers/directors/parters with the authority to make decisios o the maagemet of health ad safety. It should be completed usig the maagemet sectio of the rootig out risk checklist ad with referece to the immediate, uderlyig/root causes idetified earlier i the aalysis. What weakesses i the overall maagemet of health ad safety allowed the uderlyig/root causes of the adverse evet to exist? Remedial actio Employees ot fully aware of maagemet commitmet to health ad safety Esure all employees are aware of maagemet commitmet to health ad safety - as set out i our policy statemet Health ad safety assistats ot fully competet ad resourced Esure those resposible for preparig risk assessmets/swps ad i charge of maiteace are adequately traied ad have time to carry out their duties No clear lies of commuicatio ad cotrol ad uclear resposibilities Esure all staff aware of their ow duties ad how they fit ito the orgaisatio Ivestigatig accidets ad icidets Page 83 of 89

Health ad Safety Adverse evet Ref o Adverse evet aalysis Usig the Adverse evet aalysis: Rootig out risk checklist, cosider the questios i the immediate cause sectios. Eter each of the immediate causes idetified i the table ad eter the risk cotrol measures required. For each immediate cause the checklist suggests possible uderlyig/root causes. Cosider each of these potetial uderlyig/root causes ad eter those that are relevat. Fially eter the remedial measures required to remedy the uderlyig/root cause. 1 Place or premises Immediate cause: Poit Risk cotrol measure required Uderlyig/root causes Measures to remedy uderlyig/root cause Ivestigatig accidets ad icidets Page 84 of 89

Health ad Safety Adverse evet Ref o Adverse evet aalysis Usig the Adverse evet aalysis: Rootig out risk checklist, cosider the questios i the immediate cause sectios. Eter each of the immediate causes idetified i the table ad eter the risk cotrol measures required. For each immediate cause the checklist suggests possible uderlyig/root causes. Cosider each of these potetial uderlyig/root causes ad eter those that are relevat. Fially eter the remedial measures required to remedy the uderlyig/root cause. 2 Plat equipmet ad substaces Immediate cause: Poit Risk cotrol measure required Uderlyig/root causes Measures to remedy uderlyig/root cause Ivestigatig accidets ad icidets Page 85 of 89

Health ad Safety Adverse evet Ref o Adverse evet aalysis Usig the Adverse evet aalysis: Rootig out risk checklist, cosider the questios i the immediate cause sectios. Eter each of the immediate causes idetified i the table ad eter the risk cotrol measures required. For each immediate cause the checklist suggests possible uderlyig/root causes. Cosider each of these potetial uderlyig/root causes ad eter those that are relevat. Fially eter the remedial measures required to remedy the uderlyig/root cause. 3 Processes ad procedures Immediate cause: Poit Risk cotrol measure required Uderlyig/root causes Measures to remedy uderlyig/root cause Ivestigatig accidets ad icidets Page 86 of 89

Health ad Safety Adverse evet Ref o Adverse evet aalysis Usig the Adverse evet aalysis: Rootig out risk checklist, cosider the questios i the immediate cause sectios. Eter each of the immediate causes idetified i the table ad eter the risk cotrol measures required. For each immediate cause the checklist suggests possible uderlyig/root causes. Cosider each of these potetial uderlyig/root causes ad eter those that are relevat. Fially eter the remedial measures required to remedy the uderlyig/root cause. 4 People Immediate cause: Poit Risk cotrol measure required Uderlyig/root causes Measures to remedy uderlyig/root cause Ivestigatig accidets ad icidets Page 87 of 89

Health ad Safety Adverse evet Ref o Adverse evet aalysis Health ad safety maagemet issues This sectio should be completed by maagers/directors/parters with the authority to make decisios o the maagemet of health ad safety. It should be completed usig the maagemet sectio of the rootig out risk checklist ad with referece to the immediate, uderlyig/root causes idetified earlier i the aalysis. What weakesses i the overall maagemet of health ad safety allowed the uderlyig/root causes of the adverse evet to exist? Remedial actio Ivestigatig accidets ad icidets Page 88 of 89

Health ad Safety Further iformatio For iformatio about health ad safety, or to report icosistecies or iaccuracies i this guidace, visit www.hse.gov.uk/. You ca view HSE guidace olie ad order priced publicatios from the website. HSE priced publicatios are also available from bookshops. Published by the Health ad Safety 10/11 Page 89 of 89