Incident and accident investigation and reporting
8.4 Investigations and causes of incidents
➤ investigate all incidents and accidents reported
➤ analyse the events routinely to check for trends in performance and the prevalence of types of incident or injury
➤ monitor the system to make sure that it is working satisfactorily.
8.3 Which incidents/accidents should be investigated?
8.3.1 Injury accident
Should every accident be investigated or only those that lead to serious injury? In fact the main determinant is the potential of the accident to cause harm rather than the actual harm resulting. For example, a slip can result in an embarrassing fl ailing of arms or, just as easily, a broken leg. The frequency of occurrence of the accident type is also important – a stream of minor cuts from paper needs looking into.
As it is not possible to determine the potential for harm simply from the resulting injury, the only really sensible solution is to investigate all accidents. The amount of time and effort spent on the investigation should, however, vary depending on the level of risk (severity of potential harm, frequency of occurrence).
The most effort should be focused on signifi cant events involving serious injury, ill-health or losses and events which have the potential for multiple or serious harm to people or substantial losses. These factors should become clear during the accident investigation and be used to guide how much time should be taken.
The following table has been developed by the HSE to help to determine the level of investigation which is appropriate. The worst case scenario for the consequences should be considered in using the table. A particular incident like a scaffold collapse may not have caused an injury but had the potential to cause major or fatal injuries.
➤ In a minimal level investigation, the relevant super- visor will look into the circumstances of the accident/
incident and try to learn any lessons which will pre- vent future incidents
➤ A low level investigation will involve a short investi- gation by the relevant supervisor or line manager into the circumstances and immediate underlying and root causes of the accident/incident, to try to pre- vent a recurrence and to learn any general lessons
➤ A medium level investigation will involve a more detailed investigation by the relevant supervisor or line manager, the health and safety adviser and employee representatives and will look for the imme- diate, underlying and root causes
➤ A high level investigation will involve a team-based investigation, involving supervisors or line managers, health and safety advisers and employee represen- tatives. It will be carried out under the supervision of senior management or directors and will look for the immediate, underlying and root causes.
8.4 Investigations and causes of incidents
8.4.1 Who should investigate?
Investigations should be led by supervisors, line man- agers or other people with suffi cient status and know- ledge to make recommendations that will be respected by the organization. The person to lead many investigations
Likelihood of recurrence
Potential worst injury consequences of accident / incident
Minor Serious Major Fatal Certain
Likely Possible Unlikely Rare
Risk Minimal Low Medium High
Investi- gation level
Minimal level
Low level
Medium level
High level
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Incident and accident investigation and reporting
119 will be the department manager or supervisor of the per-
son/area involved because they:
➤ know about the situation
➤ know most about the employees
➤ have a personal interest in preventing further incidents/
accidents affecting ‘their’ people, equipment, area, materials
➤ can take immediate action to prevent a similar incident
➤ can communicate most effectively with the other employees concerned
➤ can demonstrate practical concern for employees and control over the immediate work situation.
8.4.2 When should the investigation be conducted?
The investigation should be carried out as soon as pos- sible after the incident to allow the maximum amount of information to be obtained. There may be diffi culties which should be considered in setting up the investiga- tion quickly – if, for example, the victim is removed from the site of the accident, or if there is a lack of a particu- lar expert. An immediate investigation is advantageous because:
➤ factors are fresh in the minds of witnesses
➤ witnesses have had less time to talk (there is an almost automatic tendency for people to adjust their story of the events to bring it into line with a consen- sus view)
➤ physical conditions have had less time to change
➤ more people are likely to be available, for example, delivery drivers, contractors and visitors who will quickly disperse following an incident making con- tact very diffi cult
➤ there will probably be the opportunity to take imme- diate action to prevent a recurrence and to demon- strate management commitment to improvement
➤ immediate information from the person suffering the accident often proves to be most useful.
Consideration should be given to asking the person to return to site for the accident investigation if they are physically able, rather than wait for them to return to work. A second option, although not as valuable, would be to visit the injured person at home or even in hospital (with their permission) to discuss the accident.
8.4.3 Investigation method
There are four basic elements to a sound investigation:
1. collect facts about what has occurred
2. assemble, and analyse the information obtained
3. compare the information with acceptable industry and company standards and legal requirements to draw conclusions
4. implement the fi ndings and monitor progress.
Information should be gathered from all available sources, for example, witnesses, supervisors, physical conditions, hazard data sheets, written systems of work, training records, etc. The amount of time spent should not, however, be disproportionate to the risk. The aim of the investigation should be to explore the situation for possible underlying factors, in addition to the imme- diately obvious causes of the accident. For example, in a machinery accident it would not be suffi cient to con- clude that an accident occurred because a machine was inadequately guarded. It is necessary to look into the pos- sible underlying system failure that may have occurred.
Investigations have three facets, which are particu- larly valuable and can be used to check against each other:
➤ direct observation of the scene, premises, work- place, relationship of components, materials and substances being used, possible reconstruction Figure 8.2 Near miss event likely – accident waiting to happen.
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of events, and injuries or condition of the person concerned
➤ documents including written instructions, training records, procedures, safe operating systems, risk assessments, policies, records of inspections or test and examinations carried out
➤ interviews (including written statements) with persons injured, witnesses, people who have carried out simi- lar functions or examinations and tests on the equip- ment involved and people with specialist knowledge.
Immediate causes
A detailed investigation should look at the following factors as they can provide useful information about immediate causes that have been manifested in the incident/accident.
➤ Personal factors:
➤ behaviour of the people involved
➤ suitability of people doing the work
➤ training and competence
➤ Task factors:
➤ workplace conditions and precautions or controls
➤ actual method of work adopted at the time
➤ ergonomic factors
➤ normal working practice either written or customary.
Underlying and root causes
A thorough investigation should also look at the follow- ing factors as they can provide useful information about underlying and root causes that have been manifested in the incident/accident:
Underlying causes are the less obvious system or organ- izational reasons for an accident or incident such as:
➤ pre-start-up machinery checks were not made by supervisors
➤ the hazard had not been considered in the risk assessment
➤ there was no suitable method statement
➤ pressures of production had been more important
➤ the employee was under a lot of personal pressure at the time
➤ have there been previous similar incidents?
➤ was there adequate supervision, control and coord- ination of the work involved?
Root causes involve an initiating event or failing from which all other causes or failings arise. Root causes are generally management, planning or organizational fail- ings including:
➤ quality of the health and safety policy and procedures
➤ quality of consultation and cooperation of employees
➤ the adequacy and quality of communications and information
➤ defi ciencies in risk assessments, plans and control systems
➤ defi ciencies in monitoring and measurement of work activities
➤ quality and frequency of reviews and audits.
8.4.4 Investigation interview techniques
It must be made clear at the outset and during the course of the interview that the aim is not to apportion blame but to discover the facts and use them to prevent similar accidents in the future.
A witness should be given the opportunity to explain what happened in their own way without too much interruption and suggestion. Questions should then be asked to elicit more information. These should be of the open type, which do not suggest the answer. Questions starting with the words in Figure 8.3 are useful.
‘Why’ should not be used at this stage. The facts should be gathered fi rst, with notes being taken at the end of the explanation. The investigator should then read them or give a summary back to the witness, indicating clearly that they are prepared to alter the notes, if the witness is not content with them.
If possible, indication should be given to the witness about immediate actions that will be taken to prevent a similar occurrence and that there could be further improvements depending on the outcome of the investigation.
Accidents can often be very upsetting for witnesses, which should be borne in mind. This does not mean they will not be prepared to talk about what has happened.
They may in fact wish to help, but questions should be sensitive; upsetting the witness further should be avoided.
Figure 8.3 Questions to be asked in an investigation.
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Incident and accident investigation and reporting
121 8.4.5 Comparison with relevant standards
There are usually suitable and relevant standards which may come from the HSE, industry or the organization itself. These should be carefully considered to see if:
➤ suitable standards are available to cover legal standards and the controls required by the risk assessments
➤ the standards are suffi cient and available to the organization
➤ the standards were implemented in practice
➤ the standards were implemented, why was there a failure?
➤ changes should be made to the standards.
8.4.6 Recommendations
The investigation should have highlighted both immedi- ate causes and underlying causes. Recommendations, both for immediate action and for longer-term improve- ments, should come out of this, but it may be necessary to ensure that the report goes further up the management chain if the improvements recommended require author- ization, which cannot be given by the investigating team.
8.4.7 Follow-up
It is essential that a follow-up is made to check on the implementation of the recommendations. It is also neces- sary to review the effect of the recommendations to check whether they have achieved the desired result and whether they have had unforeseen ‘knock-on’ effects, creating additional risks and problems.
8.4.8 Use of information
The accident investigation should be used to generate recommendations but should also be used to generate safety awareness. The investigation report or a summary should therefore be circulated locally to relevant people and, when appropriate, summaries circulated throughout the organization. The accident does not need to have resulted in a three-day lost time injury for this system to be used.
8.4.9 Training
A number of people will potentially be involved in acci- dent investigation. For most of these people it will only be necessary on very few occasions. Training guidance and help will therefore be required. Training can be provided in accident investigation in courses run on site and also in numerous off-site venues. Computer-based training
courses are also available. These are intended to provide refresher training on an individual basis or complete train- ing at offi ce sites, for example, where it may not be feas- ible to provide practical training.
8.4.10 Investigation form
Headings which could be used to compile an accident/
incident investigation form are given below:
➤ date and location of accident
➤ circumstances of accident
➤ immediate cause of accident
➤ underlying cause of accident
➤ immediate action taken
➤ recommendation for further improvement
➤ report circulation list
➤ date of investigation
➤ signature of investigation team leader
➤ names of investigating team.
Follow-up
➤ were the recommendations implemented?
➤ were the recommendations effective?
An example of an investigation form using 16 different causes of accidents for analysis purposes is shown in Appendix 8.1.