Workplace Accident Investigation

Investigating Incidents

• Accidents will happen despite preventive and control measures, and the first response is to care for the victim.
• The employer must investigate to find out what happened and take steps to prevent it from happening again.
• Accident prevention is based on learning from accidents and incidents, and accurate information is necessary to identify causes and take remedial action.

Reasons for Accident Investigation

• Prevent future accidents by identifying and eliminating causes
• Demonstrate concern for people's health and safety and improve employee morale
• Identify weaknesses in management systems
• Prevent business losses
• Comply with ILO, law of land, and Recording and Notification of Occupational Accidents and Diseases
• Conform to occupational health and safety management systems, which require monitoring and reviewing performance

Requirements for Accident Investigation

• Employers must monitor and review performance, including accident investigation
• Risk assessments must be reviewed when there is an accident or ill-health
• Collate (collect) accident and ill-health data and establish trends
• Defend civil claims for compensation by making a full disclosure of the circumstances of an accident
• Defend a criminal case if the accident resulted from a breach of criminal law by the company, accident victim, manufacturers, or suppliers

Consequences of Accident Investigation

• Enforcing Authority may wish to prosecute or issue an improvement/prohibition notice
• Victim may wish to sue for compensation against the company and/or other persons

Roles and Functions of Investigation

• The reasons for investigating accidents are moral, economic, and legal.
• Legal reasons include preventing harm to workers and preventing recurrence of accidents/incidents.

Investigation Objectives

• Establish the causes of an accident, both immediate and underlying, to take preventative action.
• Identify weaknesses in current systems to improve standards.
• Determine economic losses.
• Recommend actions to prevent a recurrence.
• Determine compliance with statutory requirements or company regulations.
• Improve staff relations by demonstrating commitment to health and safety.
• Acquire statistics.
• Prepare for criminal/civil action and provide insurance/worker compensation data.

Role of Investigation

• Prevention of recurrence.
• Identify weaknesses in health and safety systems and procedures and update risk assessments.
• Establish legal liability, prepare a defence, and ensure legal obligations are complied with.
• Determine the economic loss caused by the accident.
• Data gathering.
• Identification of trends.
• Discovery of underlying and root causes.
• Demonstrate commitment by the management to provide a safe place of work.
• Establish if internal disciplinary procedures are necessary.

Investigation Principles

• All accidents should be investigated, including minor injuries and near misses.
• The degree of investigation may vary with the degree of injury or damage.
• Investigation should be based on the worst possible case of injury reasonably foreseeable.
• The investigation should not seek to blame individuals or groups.
• If human error is believed to be a significant cause, the reasons for this must be investigated.
• Management failings, such as lack of knowledge, training, or unsuitability for the job, may be the causes of human error.

Incident Classification

• An incident is an unplanned, uncontrolled event that may include injury, ill-health, dangerous occurrence, near-miss, or property damage.

Types of Incidents

• Accident: an unwanted, unplanned event that results in a loss of some kind (e.g., person tripping over an uneven surface and breaking their leg).
• Injury: physical harm or damage done to or suffered by a person.
• Ill-Health: harm to a person's health caused by their work, including occupational diseases (e.g., asbestosis).
• Occupational Ill-Health: acute or chronic ill-health caused by physical, chemical, or biological agents, including adverse effects on mental health.
• Dangerous Occurrence: an incident that has not caused injury or harm but has potential to do so (e.g., collapse of a scaffold or explosion of a boiler).
• Near Miss: an unwanted, unplanned event that had the potential to result in a loss (e.g., dropping a tool box off a platform onto a walkway below, just missing an employee).
• Damage Only: incidents that could have caused harm to people but only cause damage to property, equipment, the environment, or production losses.

Ratios of Incident Outcomes

• Frank Bird's International Safety Rating System (ISRS) study showed that there is a fixed ratio between losses of different severity and accidents where no loss occurred (near-misses).

Utility and Limitations of Accident Ratios in Accident Prevention

• The accident/incident ratio triangle illustrates that organizations with most accidents/incidents are likely to have the most serious injuries/losses over time.
• Reporting and addressing near-misses can prevent later injuries.

Preparing for Accident Investigation

• Determine who should be involved in the investigation team.
• Ensure the accident scene remains undisturbed.
• Collate relevant documents (incident reports, maintenance records, risk assessments, etc.).
• Identify witnesses to be interviewed.
• Check that relatives of injured persons have been notified and legal reporting requirements have been met.

Training for Accident Reporting

• Importance of reporting accidents and incidents for legal, investigative, and monitoring reasons.
• Types of incidents requiring reporting.
• Lines of reporting.
• Completing internal documents and forms.
• Responsibilities for completing the accident book.

Scope and Depth of Investigation

• Ideally, all accidents should be investigated.
• Depth of investigation depends on severity of actual or potential loss.

Types of Investigation

• Supervisory Investigations: logical for supervisors to gather information on all accidents in their area of responsibility.
• Formal Investigations: convened for more serious incidents, involving a senior manager, health and safety practitioner, engineer/technical expert, and worker health and safety representative.

Investigation Guidelines

• When conducting accident investigations, consider the following factors:
  • The scene of the accident may still be hazardous, so take care to avoid becoming a victim.
  • Begin the investigation as soon as possible after the accident.
  • Keep the objective in mind to discover causes and initiate remedial action, not to find someone to blame.
  • Interview witnesses one at a time and avoid influencing subsequent statements.
  • Identify root causes, not just immediate ones.
  • Avoid making early unqualified assumptions.
  • Approach witnesses without bias or pre-conceptions.
  • Take notes to avoid relying on memory.

Steps to Take Following an Incident/Accident

• Emergency Response:
  • Make the area safe.
  • Initiate an emergency plan.
  • Contact emergency services.
  • Administer first aid to preserve life.
  • Preserve the scene.
• Initial Report:
  • Note the names of witnesses.
  • Report the event internally to the company Health and Safety Adviser, senior management, and relatives of the injured person.
  • Record the event in the accident book.
• Initial Assessment and Investigation:
  • Report the event to regulatory authorities, if applicable.
  • Report the event to insurers, lawyers, etc.
  • Decide on the depth of the investigation and select the investigation team.
  • Gather evidence at the scene.
  • Interview witnesses.
• Gathering Further Information:
  • Inspect documents.
  • Appoint specialists, if applicable.
• Analysing the Information:
  • Draw conclusions.
  • Implement action.
  • Monitor progress.
  • Review effectiveness.

The Different Levels of Investigations

• The level of investigation should be proportionate to the risk associated with the incident.
• Risk estimation should be based on the foreseeable and possible severity of harm or loss.
• Consider the likelihood of occurrence and foreseeable severity of harm or loss to determine the level of investigation.
• Levels of investigation:
  • Minimal: immediate line manager with minimal time and effort.
  • Low: line manager with some support and moderate time and effort.
  • Medium: middle manager with support and significant time and effort.
  • High: senior management oversight with a team-based approach and significant time and effort.

Basic Incident Investigation Steps

• The ILO Code of Practice for Recording and Notifying of Occupational Accidents and Diseases (COP-RNOAD) sets out requirements for employers to investigate reported occupational accidents.
• The Code of Practice proposes that employers should call upon the services of a person with expertise to conduct an investigation, if necessary.
• Incident/accident/ill-health investigations comprise four basic steps:
  1. Gather the information.
  2. Analyse the information.
  3. Identify the risk control measures.
  4. Take action.
• Step 1: Gathering the Information:
  • Keep an open mind and avoid dismissing any evidence.
  • Use a pre-prepared questionnaire to gather information.
  • Consider the following aspects:
    • Materials: Did the event involve the use or handling of materials or substances?
    • Equipment: Were tools, vehicles, machinery, etc. involved?
    • Environment: Did lighting, temperature, noise, poor ventilation, etc. contribute to the event?
    • People: Were those involved authorised, competent, and adhering to procedures?
  • Documentary evidence may also help to confirm witness statements.

Interviews, Plans, Photographs, Relevant Records, and Checklists

• Interviews:
  • Are critical to the investigation.
  • Put the witness at ease and state the purpose of the interview.
  • Conduct the interview in private with no interruptions.
  • Avoid interviewing more than one person at a time.
  • Protect the reputation of the people interviewed.
  • Ask probing questions and record the details of the interview.
• Plans:
  • Provide a clear indication of the accident scene.
  • Use sketch plans to assist in determining root causes.
• Photographs:
  • Record and preserve images of the accident scene or resulting injuries.
  • Use cameras to capture evidence.
• Relevant Records:
  • Include all available and relevant information, such as opinions, experiences, observations, measurements, check sheets, work permits, risk assessments, and method statements.
• Checklists:
  • Use investigation report forms to guide the investigation.
  • Determine the level of investigation required based on the incident.

Step 2: Analysing the Information

• Analyse the facts and information to determine what happened and why.
• Consider the 'domino theory' to identify immediate and underlying causes.
• Identify root causes, including factors relating to Materials, Equipment, Environment, People, Organisation, and Management.
• Immediate Causes:
  • Identify the causes of the incident.
  • Injuries/ill-health are caused by unsafe acts or conditions.
• Root and Underlying Causes:
  • Identify the underlying causes of the incident.
  • Typical root causes result from management system failures.
  • Research by Frank Bird and others has led to the development of an incident causation model based on the 'domino theory'.
• Domino Theory:
  • The events leading up to an accident are like a row of dominoes.
  • The 'domino theory' helps to explain accident causation.
  • Concentrate on the management system to identify and solve problems.

Risk Control Measures

• A systematic approach is necessary to identify possible solutions and evaluate risk control measures.
• Evaluation criteria for control measures include:
  • Ability to prevent recurrences
  • Practicality
  • Likelihood of use
  • Effectiveness
• Control measures should be prioritized in the following order:
  • Measures that eliminate risk
  • Measures that combat risks at source
  • Measures that minimize risk through human behavior

Identifying Control Measures

• Consider whether similar risks exist elsewhere in the premises or on another site
• Circulate information from the event to other areas to prevent similar accidents

Action Plan and Implementation

• Senior management should be involved in the decision-making process
• Recommendations should be SMART (Specific, Measurable, Achievable, and Time-framed)
• Consult with health and safety representatives to decide on action
• Implement highest priority risk control measures first
• Assign a senior person responsible for ensuring the action plan is implemented

Reports and Follow-up

• The report should include:
  • A summarized version of the facts and recommendations
  • Discussion of controversial points
  • Appendices containing specialist reports, photographs, and diagrams
• Management is responsible for implementing and monitoring remedial actions
• The line manager, health and safety practitioner, and health and safety committee-members should monitor remedial actions

Investigation Objective

• The objective of the investigation is to prevent a recurrence of the accident, not to apportion blame
• Identify the true causes of the accident, not superficial ones
• Commitment and assistance from witnesses and other persons are necessary for a successful investigation
• Recommendations must be put into action, regardless of time, trouble, and cost

Importance of Recording and Notifying Occupational Accidents and Diseases

• Recording and reporting of occupational accidents and diseases is crucial for identifying and implementing corrective and preventive measures to avoid reoccurrence.
• It provides an opportunity for investigation, analysis, and gathering of statistical evidence to benchmark health and safety performance.

Types of Report Forms

• Initial record of incident (e.g., accident book)
• Event (incident/accident) reports
• Event (near miss) reports
• First-aid treatment reports
• Maintenance/repair reports
• Medical treatment reports
• Insurance reports
• Medical (doctor) reports of ill health
• Reports of incidents to competent authority
• Sickness absence reports

ILO Code of Practice for Recording and Notifying of Occupational Accidents and Diseases (RNOAD)

• Employers should make arrangements to record occupational accidents, commuting accidents, occupational disease, and dangerous occurrences.
• Records should be prepared in accordance with national requirements and be available and retrievable at any reasonable time.

Reporting Routes

• Person receiving harm
• Person causing loss
• Person discovering loss

Analysing and Communicating Data

• Reports from first-line managers may be copied to the next line manager, health and safety practitioner, and worker health and safety representative.
• The originator retains a copy until action to prevent is complete.
• The copy passed to the next line manager is usually seen as the primary document.

Reporting of Events to External Agencies

• National practices vary considerably regarding the terms and definitions used for incidents.

Definitions of Occupational Accidents, Commuting Accidents, Occupational Diseases, and Dangerous Occurrences

• Occupational accident: an occurrence arising out of, or in the course of, work that results in fatal or non-fatal occupational injury.
• Commuting accident: an accident occurring on the direct way between the place of work and the worker's principal or secondary residence, meal, or remuneration location.
• Occupational disease: a disease contracted as a result of an exposure to risk factors arising from work activity.
• Dangerous occurrence: a readily identifiable event with the potential to cause injury or disease to persons at work or the public.

Major Injuries

• Examples of major injuries that might be reportable:
• Any fracture, other than finger or thumbs or toes
• Any amputation
• Dislocation of the shoulder, hip, knee, or spine
• Permanent or temporary loss of sight
• Chemical, hot metal, or penetrating eye injury
• Electrical shock, electrical burn leading to unconsciousness or resuscitation or admittance to hospital for more than 24 hours

Diseases

• The ILO List of Occupational Diseases Recommendation R194, updated in 2010, provides a clear statement of diseases or disorders that can and should be prevented.
• Examples of occupational diseases include:
• Diseases by agent (physical, chemical, biological)
• Respiratory diseases (e.g., chronic obstructive pulmonary diseases, pneumoconioses, bronchopulmonary diseases)
• Skin diseases (e.g., irritant contact dermatoses, allergic contact dermatoses, occupational vitiligo)
• Musculoskeletal disorders (e.g., tenosynovitis, epicondylitis, carpal tunnel syndrome, bursitis)
• Mental and behavioural disorders (e.g., post-traumatic stress disorder)
• Occupational cancer (e.g., caused by asbestos, benzene, mineral oil, wood dust)

Dangerous Occurrences

• Incidents that have the potential to cause death or serious injury, even if no one is injured, should be reported.
• Examples of dangerous occurrences that may be required to be reported under national laws include: • Collapse or failure of lifting equipment • Explosion • Failure of a pressurised closed vessel • Fire

Incident Statistics

• Many organisations track health and safety performance based on incidents, including accidents, dangerous occurrences, near misses, ill-health, complaints, and enforcement actions.
• Incident data has limitations, as it reflects efforts to prevent a recurrence rather than action to prevent the event.
• A more complete approach to monitoring includes 'before the event' (active) actions, such as audits and inspections, to indicate what is being done to prevent accidents.

Limitations of Incident Data

• A low injury accident rate is not a guarantee that risks are being effectively controlled.
• It may be a matter of good fortune or underreporting rather than effective management.

Effective Management

• Waiting for an event to occur before determining where health and safety effort is required is an undesirable way of learning.
• The more mature organisation seeks to learn from activities before the event or from near misses.

Incident Data Analysis

• Incident data can identify specific problem areas and general trends.
• Analysis can help identify common root causes and compare with others to learn from successes.
• Incident data can raise awareness of health and safety among managers and workers.
• Data can also help calculate costs, increasing the likelihood of resources being allocated.

Presenting Incident Data

• Incident data can be presented using incidence and frequency rates.
• Methods of presenting data should not be mixed, and figures should only be used to compare like with like.
• Multipliers used in calculating indices vary depending on the level of analysis (international, national, or workplace organisation).
• The main purpose of the multiplier is to bring the numbers to a manageable size.

Accident and Ill-Health Incident Rates

• Accident incident rate: calculated by multiplying the number of accidents by 100,000 and dividing by the number of people who worked during the period.
• Ill health incident rate: calculated by multiplying the number of ill health cases by 100,000 and dividing by the number of people who worked during the period.

Accident and Ill-Health Frequency Rates

• Accident frequency rate: calculated by multiplying the number of accidents in the period by 1,000,000 and dividing by the total hours worked during the period.
• Ill health frequency rate: calculated by multiplying the number of ill health cases in the period by 1,000,000 and dividing by the total hours worked during the period.

Accident and Ill-Health Severity Rates

• Accident severity rate: calculated by multiplying the total number of days lost by 1,000 and dividing by the total hours worked.
• Ill health severity rate: calculated by multiplying the total number of days lost by 1,000 and dividing by the total hours worked.

Mean Duration Rates and Duration Rates

• Mean duration rate: calculated by dividing the total number of days lost by the total number of accidents/ill health.
• Duration rate: calculated by dividing the number of hours worked by the total number of accidents/ill health.

Absence Data

• Analysing absence data is important for identifying work-related absence problems and understanding the causes of absenteeism.
• Days lost per worker: calculated by dividing the total days lost by the number of workers.
• Percentage lost time: calculated by dividing the number of days lost through absence by the number of workers and the number of working days, and multiplying by 100.

Limitations of Incident Statistics

• Incident statistics have limitations, including differences in work methods, hours of work, hazard controls, and management systems.
• These statistics are best suited for comparing performance within the same organisation over time.
• Comparisons between organisations should be made with caution, considering differences in definitions of accidents, hours worked, and multipliers used.

Importance of Sharing Lessons Learned

• Sharing lessons learned from incidents is crucial to maximize the benefits and minimize the risks of adverse events.
• The lessons learned should be shared with as many relevant people as possible, including different departments within an organization.

Benefits of Sharing Lessons Learned

• Examining the root causes of incidents can reveal areas for improvement that may be relevant to other departments.
• Improved job induction processes, for instance, can benefit all departments of an organization.
• Sharing lessons learned with other locations of the same organization can also identify common hazards and underlying causes.

Industry-Wide Sharing of Lessons Learned

• Some industries share lessons learned across the entire industry, especially where practices or equipment are similar.
• Trade associations play a key role in collecting and sharing non-attributable data on incidents, enabling the identification of common problems and hazards.
• The collective experience of lessons learned helps to identify underlying causes, including human, organizational, and technical factors.

Integrating Lessons Learned into Organizational Performance

• Lessons learned from incidents should be considered as part of the regular review of an organization's health and safety performance.
• Incidents can influence an organization's policy, objectives, and management system, and should be considered by senior management.

Investigating and Evaluating Health and Safety Incidents and Complaints

• Health and safety in the workplace is governed by a framework of legislation designed to protect employees, employers, and the public from harm.
• As an investigator of health and safety incidents and complaints, your role involves:
  • Identifying potential hazards and risks in the workplace
  • Assessing compliance with health and safety legislation
  • Conducting thorough investigations of incidents and complaints
  • Recommending corrective actions and improvements
  • Ensuring that all findings are documented and reported accurately
• Your capabilities include:
  • Knowledge of health and safety legislation
  • Skills in hazard identification and risk assessment
  • Proficiency in investigation techniques and report writing
  • Ability to communicate findings effectively to management and employees

Relevant Legislation

• UK Health and Safety at Work Act 1974:
  • General duties of employers and employees
  • Employers must ensure, as far as is reasonably practicable, the health, safety, and welfare of their employees
  • Employees must take reasonable care for their own health and safety and that of others who may be affected by their actions
• RIDDOR Regulations (Reporting of Injuries, Diseases, and Dangerous Occurrences Regulations 2013):
  • Employers, self-employed individuals, and those in control of premises must report specified workplace incidents, diseases, and dangerous occurrences
• Other relevant regulations:
  • COSHH Regulations (Control of Substances Hazardous to Health): Applicable in industries dealing with hazardous substances
  • CDM Regulations (Construction (Design and Management) Regulations): Specific to the construction industry
  • PUWER Regulations (Provision and Use of Work Equipment Regulations): Relevant for workplaces using machinery and equipment

Industry-Specific Legislation

• Construction industry: CDM Regulations require specific duties for managing the health, safety, and welfare of construction projects
• Healthcare industry: Health and Social Care Act 2008 imposes duties related to infection control and patient safety

Level of Risk and Safeguards

• The level of risk associated with your role as an investigator depends on the industry and work areas involved
• Typical hazards may include:
  • Exposure to hazardous substances
  • Physical hazards such as machinery or construction activities
  • Biological hazards in healthcare settings
• Safeguards to protect investigators include:
  • Providing appropriate personal protective equipment (PPE)
  • Implementing safety protocols and procedures
  • Ensuring proper training and awareness of hazards
  • Conducting regular risk assessments and safety audits

Conducting and Reporting Investigations

• Conducting and reporting health and safety investigations in the workplace requires a comprehensive understanding of the relevant regulations and local laws
• Compliance with these regulations ensures that investigations are conducted effectively, risks are managed appropriately, and the safety and well-being of employees are maintained
• Employers and employees must work together to adhere to these legal requirements, fostering a culture of safety and continuous improvement in the workplace