Investigating accidents and incidents A workbook for employers, unions, safety representatives and safety professionals Every year people are killed or injured at work. Over 40 million working days are Investigating accidents and incidents lost annually through work-related accidents and illnesses.

This workbook gives organisations an opportunity to find out what went wrong. Learning the lessons and taking action may reduce, or even prevent, accidents in the future.

As a step-by-step guide, it will help all organisations, particularly smaller businesses, to carry out their own health and safety investigations. Investigating A workbook for employers, unions, safety representatives and safety professionals accidents and incidents explains why you need to carry out investigations and takes you through each step of the process:

Step one: Gathering the information Step two: Analysing the information HSG245, published 2004 Step three: Identifying risk control measures Step four: The action plan and its implementation

HSE Books Page 1 of 88

Contents Reducing risks and protecting people 3

Understanding the language of investigation 4

The causes of adverse events 6

Why investigate? 7

A step by step guide to health and safety investigations 12

Gathering the information 13 Analysing the information 19 Identifying risk control measures 23 The action plan and its implementation 24

References and further reading 26

Adverse event report and investigation form: Worked examples 28 Adverse event report and investigation form: Blank form 56 Adverse event analysis: Rooting out risk 66 Adverse event analysis: Worked examples 73 Adverse event analysis: Blank form 83

Reducing risk and protecting people Recent figures show that an average of 250 employees and self-employed people are killed each year as a result of accidents in the workplace.1 A further 150 000 sustain major injuries or injuries that mean they are absent from work for more than three days. Over 2.3 million cases of ill health are caused or made worse by work.2

According to the Labour Force Survey,3 over 40 million working days are lost through work-related injuries and ill health, at a cost to business of £2.5 billion.4

“If you think safety is expensive, try an accident” Chairman of Easy Group

Clearly, there are good financial reasons for reducing accidents and ill health. Costings show that for every £1 a business spends on insurance, it can be losing between £8 and £36 in uninsured costs.4

The same accidents happen again and again, causing suffering and distress to an ever-widening circle of workers and their families. The investigation and analysis of work-related accidents and incidents forms an essential part of managing health and safety. However, learning the lessons from what you uncover is at the heart of preventing accidents and incidents. Identify what is wrong and take positive steps to put it right. This guide will show you how.

Carrying out your own health and safety investigations will provide you with a deeper understanding of the risks associated with your work activities. Blaming individuals is ultimately fruitless and sustains the myth that accidents and cases of ill health are unavoidable when the opposite is true. Well thought-out risk control measures, combined with adequate supervision, monitoring and effective management (ie your risk management system) will ensure that your work activities are safe. Health and safety investigations are an important tool in developing and refining your risk management system.

An effective investigation requires a methodical, structured approach to information gathering, collation and analysis. The findings of the investigation will form the basis of an action plan to prevent the accident or incident from happening again and for improving your overall management of risk. Your findings will also point to areas of your risk assessments that need to be reviewed. This link with risk assessment(s) is a legal duty.5

This guide will help you to adopt a systematic approach to determining why an accident or incident has occurred and the steps you need to take to make sure it does not happen again.

Understanding the language of investigation Certain key words and phrases will be used regularly throughout this guide.

‘Adverse event’ includes:

n accident: an event that results in injury or ill health; n incident:

– near miss: an event that, while not causing harm, has the potential to cause injury or ill health. (In this guidance, the term near miss will be taken to include dangerous occurrences); – undesired circumstance: a set of conditions or circumstances that have the potential to cause injury or ill health, eg untrained nurses Figure 1 Accident handling heavy patients.

Dangerous occurrence: one of a number of specific, reportable adverse events, as defined in the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR).

Hazard: the potential to cause harm, including ill health and injury; damage to property, plant, products or the environment, production losses or increased liabilities.

Immediate cause: the most obvious reason why an adverse event happens, eg the guard is missing; the employee slips etc. There may be several immediate causes identified in any one adverse event.

Consequence: Figure 2 Near miss fatal: work-related death;

major injury/ill health: (as defined in RIDDOR, Schedule 1), including fractures (other than fingers or toes), amputations, loss of sight, a burn or penetrating injury to the eye, any injury or acute illness resulting in unconsciousness, requiring resuscitation or requiring admittance to hospital for more than 24 hours;

serious injury/ill health: where the person affected is unfit to carry out his or her normal work for more than three consecutive days;

minor injury: all other injuries, where the injured person is unfit for his or her normal work for less than three days;

damage only: damage to property, equipment, the environment or production losses. (This guidance only deals with events that have the potential to cause harm to people.)

Figure 3 Undesired Likelihood that an adverse event will happen again: circumstance certain: it will happen again and soon; likely: it will reoccur, but not as an everyday event; possible: it may occur from time to time; unlikely: it is not expected to happen again in the foreseeable future; rare: so unlikely that it is not expected to happen again.

Risk: The level of risk is determined from a combination of the likelihood of a specific undesirable event occurring and the severity of the consequences (ie how often is it likely to happen, how many people could be affected and how bad would the likely injuries or ill health effects be?)

Risk control measures: are the workplace precautions put in place to reduce the risk to a tolerable level?

Root cause: an initiating event or failing from which all other causes or failings spring. Root causes are generally management, planning or organisational failings.

Underlying cause: the less obvious ‘system’ or ’organisational’ reason for an adverse event happening, eg pre-start-up machinery checks are not carried out by supervisors; the hazard has not been adequately considered via a suitable and sufficient risk assessment; production pressures are too great etc.

The causes of adverse events Adverse events have many causes. What may appear to be bad luck (being in the wrong place at the wrong time) can, on analysis, be seen as a chain of failures and errors that lead almost inevitably to the adverse event. (This is often known as the Domino effect.)

These causes can be classified as:

n immediate causes: the agent of injury or ill health (the blade, the substance, the dust etc); n underlying causes: unsafe acts and unsafe conditions (the guard removed, the ventilation switched off etc); n root causes: the failure from which all other failings grow, often remote in time and space from the adverse event (eg failure to identify training needs and assess competence, low priority given to risk assessment etc).

To prevent adverse events, you need to provide effective risk control measures which address the immediate, underlying and root causes.

A B

Figure 4 Sequence of dominoes

Note: Each domino represents a failing or error which can combine with other failings and errors to cause an adverse event. Dealing with the immediate cause (B) will only prevent his sequence. Dealing with all causes, especially root causes (A) can prevent a whole series of adverse events.

Why investigate? There are hazards in all workplaces; risk control measures are put in place to reduce the risks to an acceptable level to prevent accidents and cases of ill health.

The fact that an adverse event has occurred suggests that the existing risk control measures were inadequate.

Learning lessons from near misses can prevent costly accidents. (The Clapham Junction rail crash and the Herald of Free Enterprise ferry capsize were both examples of situations where management had failed to recognise, and act on, previous failings in the system.) You need to investigate adverse events for a number of reasons.

Legal reasons for investigating

n To ensure you are operating your organisation within the law. n The Management of Health and Safety at Work Regulations 1999, regulation 5, requires employers to plan, organise, control, monitor and review their health and safety arrangements. Health and safety investigations form an essential part of this process. n Following the Woolf Report6 on civil action, you are expected to make full disclosure of the circumstances of an accident to the injured parties considering legal action. The fear of litigation may make you think it is better not to investigate, but you can’t make things better if you don’t know what went wrong! The fact that you thoroughly investigated an accident and took remedial action to prevent further accidents would demonstrate to a court that your company has a positive attitude to health and safety. Your investigation findings will also provide essential information for your insurers in the event of a claim.

Information and insights gained from an investigation

n An understanding of how and why things went wrong. n An understanding of the ways people can be exposed to substances or conditions that may affect their health. n A true snapshot of what really happens and how work is really done. (Workers may find short cuts to make their work easier or quicker and may ignore rules. You need to be aware of this.) n Identifying deficiencies in your risk control management, which will enable you to improve your management of risk in the future and to learn lessons which will be applicable to other parts of your organisation.

Benefits arising from an investigation

n The prevention of further similar adverse events. If there is a serious accident, the regulatory authorities will take a firm line if you have ignored previous warnings. n The prevention of business losses due to disruption, stoppage, lost orders and the costs of criminal and civil legal actions. n An improvement in employee morale and attitude towards health and safety. Employees will be more cooperative in implementing new safety precautions if they were involved in the decision and they can see that problems are dealt with.

n The development of managerial skills which can be readily applied to other areas of the organisation.

While the argument for investigating accidents is fairly clear, the need to investigate near misses and undesired circumstances may not be so obvious. However, investigating near misses and undesired circumstances is as useful, and very much easier than investigating accidents.

Adverse events where no one has been harmed can be investigated without having to deal with injured people, their families and a demoralised workforce, and without the threat of criminal and civil action hanging over the whole proceedings. Witnesses will be more likely to be helpful and tell the truth. (Consider the following: ‘I mistakenly turned the wrong valve which released the boiling water because the valves all look the same’ or ‘I don’t know how John was scalded.’ Which is the likely response to a near miss and which to an accident? More importantly, which is the most useful?)

It is often pure luck that determines whether an undesired circumstance translates into a near miss or accident. The value of investigating each adverse event is the same.

An investigation is not an end in itself, but the first step in preventing future adverse events. A good investigation will enable you to learn general lessons, which can be applied across your organisation.

The investigation should identify why the existing risk control measures failed and what improvements or additional measures are needed. More general lessons on why the risk control measures were inadequate must also be learned.

Which events should be investigated?

Having been notified of an adverse event and been given basic information on what happened, you must decide whether it should be investigated and if so, in what depth.

It is the potential consequences and the likelihood of the adverse event recurring that should determine the level of investigation, not simply the injury or ill health suffered on this occasion. For example: Is the harm likely to be serious? Is this likely to happen often? Similarly, the causes of a near miss can have great potential for causing injury and ill health. When making your decision, you must also consider the potential for learning lessons. For example if you have had a number of similar adverse events, it may be worth investigating, even if each single event is not worth investigating in isolation. It is best practice to investigate all adverse events which may affect the public.

Who should carry out the investigation?

For an investigation to be worthwhile, it is essential that the management and the workforce are fully involved. Depending on the level of the investigation (and the size of the business), supervisors, line managers, health and safety professionals, union safety representatives, employee representatives and senior management/ directors may all be involved.

As well as being a legal duty, it has been found that where there is full cooperation and consultation with union representatives and employees, the number of accidents is half that of workplaces where there is no such employee involvement.7

This joint approach will ensure that a wide range of practical knowledge and experience will be brought to bear and employees and their representatives will feel empowered and supportive of any remedial measures that are necessary. A joint approach also reinforces the message that the investigation is for the benefit of everyone.

In addition to detailed knowledge of the work activities involved, members of the team should be familiar with health and safety good practice, standards and legal requirements. The investigation team must include people who have the necessary investigative skills (eg information gathering, interviewing, evaluating and analysing). Provide the team with sufficient time and resources to enable them to carry out the investigation efficiently.

It is essential that the investigation team is either led by, or reports directly to someone with the authority to make decisions and act on their recommendations.

When should it start?

The urgency of an investigation will depend on the magnitude and immediacy of the risk involved (eg a major accident involving an everyday job will need to be investigated quickly).

In general, adverse events should be investigated and analysed as soon as possible. This is not simply good practice; it is common sense – memory is best and motivation greatest immediately after an adverse event.

What does it involve?

An investigation will involve an analysis of all the information available, physical (the scene of the incident), verbal (the accounts of witnesses) and written (risk assessments, procedures, instructions, job guides etc), to identify what went wrong and determine what steps must be taken to prevent the adverse event from happening again.

It is important to be open, honest and objective throughout the investigation process. Pre-conceived ideas about the process, the equipment or the people involved in an adverse event may blind you to the real causes. Question everything. Be wary of blaming individuals.

What makes a good investigation?

To get rid of weeds you must dig up the root. If you only cut off the foliage, the weed will grow again.

Similarly it is only by carrying out investigations which identify root causes that organisations can learn from their past failures and prevent future failures.

Simply dealing with the immediate causes of an adverse event may provide a short- term fix. But, in time, the underlying/root causes that were not addressed will allow conditions to develop where further adverse events are likely, possibly with more serious consequences. It is essential that the immediate, underlying causes and root causes are all identified and remedied.

Investigations should be conducted with accident prevention in mind, not placing blame. Attempting to apportion blame before the investigation has started is

counterproductive, because people become defensive and uncooperative. Only after the investigation has been completed is it appropriate to consider whether any individuals acted inappropriately.

Investigations that conclude that operator error was the sole cause are rarely acceptable. Underpinning the ‘human error’ there will be a number of underlying causes that created the environment in which human errors were inevitable. For example inadequate training and supervision, poor equipment design, lack of management commitment, poor attitude to health and safety.

The objective is to establish not only how the adverse event happened, but more importantly, what allowed it to happen.

The root causes of adverse events are almost inevitably management, organisational or planning failures.

Man slipping Inadequate Inadequate on a patch maintenance housekeeping of oil

Management Inadequate not being Lack of health committed supervision and safety to health and monitoring management and safety

Look carefully at your health and safety policy and how it is reflected in the workplace. Do staff understand the health and safety message in general and in particular those parts that relate to their work? Is something missing from the policy? Is it implemented, or is management failing to ensure that health and safety measures remain in place and are effective at all times? If not, your health and safety policy needs to be changed.

The investigation should be thorough and structured to avoid bias and leaping to conclusions. Don’t assume you know the answer and start finding solutions before you complete the investigation. A good