4.2 Investigating Incidents Flashcards
Nebosh Learning Outcome 2016
Explain the purpose of, and procedures for, investigating incidents (accidents, cases of work-related ill-health and other occurrences)
Investigating incidents
*The function of incident investigation as a reactive monitoring measure
*The distinction between different types of incident: ill-health, injury accident, dangerous occurrence, near-miss, damage-only
- Typical ratios of incident outcomes and their relevance in terms of the proportion of non-injury events
- Utility and limitations of accident ratios in accident prevention (Bird’s triangle)
*Basic incident investigation procedures
*Interviews, plans, photographs, relevant records, checklists - Immediate causes (unsafe acts and unsafe conditions) and root causes (management systems failures)
*Remedial actions.
Role and Function of accident Investigation
Accident investigation is considered to be apart of a reactive monitoring system because it is triggered after an event
Accident investigation is based on the logic that:
All accidents have causes, by eliminating the root cause you eliminate any potential future incidents
The direct and indirect causes of an accident can be discovered through accident investigation
Corrective action can target the root cause thereby eliminating future potential incidents
Cross-referencing the information gathered from reactive measure procedures can help investigators to identify any otherwise unreported events
Investigators should cross references
- first aid treatments records
- health records
- maintenance and fire reports
- insurance and liability claims
Contributing to a more accurate investigative report
What information can be gained from carrying out accident investigations
*an understanding of how and why the problems arose
*an understanding of the ways people are exposed to substances or situations which can cause them harm
*a snapshot of what really happens, for example why people take short cuts or ignore safety rules
*helps identify the deficiencies in the safety management system
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Explain the LEGAL reasons for conducting an accident investigation
- to ensure that the organisation is operating in compliance with legal requirements
- MHSW Regulation 5 requirements to plan, organise, control, monitor and review health and safety arrangements
- Full disclosure of the circumstances of an accident has to be made to any the injured parties considering legal action.
- the fact that a thorough investigation was carried out and remedial action taken would demonstrate to a court that a company has a positive attitude to health and safety
- the investigation will also provide essential information for insurers in the event of an employer’s liability claim
What are the BENEFITS from investigating accidents/incidents
- the prevention of similar events occurring again
- the prevention of business losses
- improvement in employee morale and attitudes
- improve management skills and health and safety performance
(Bird’s Triangle)
Accident triangle and some of its limitations
The safety triangle, states that reducing minor injuries or near misses leads to a proportionate reduction in deaths and severe injuries. However statistics have shown that this is not always true.
Explain the limitations of accident ratios in accident prevention:
- Similar injuries may have completely different causes
- Some incidents have the potential for serious injury yet may only result in minor ones. For example falling off of a ladder may only cause a bruise but had the potential to be serious
- Serious injuries have different underlying causes to minor injuries
- Insurance companies may concentrate more on frequent minor injuries because serious injuries, although individually expensive, are very rare
- There are many other potential reasons why this may not be true, look them up.
Describe some,
Basic incident investigation procedures and factors which could potentially influencing events:
- Investigations should be led by people with sufficient knowledge and status
- Also those responsible for the area the event occurred should be involved as they know the situation, employees, have a personal stake in preventing further incidents, can communicate and demonstrate practical concerns to employees
- Don’t forget, in serious cases there will be a lot of confusion and emotionally volatility in the workforce especially from witnesses
- Line managers or supervisors whose recommendations will be respected by the organisation
- Investigations should be carried out as soon as possible
- This allows for the maximum amount of information to be obtained
An immediate investigation is advantageous because: - Factors are fresh in the minds of witnesses;
- Witnesses have had less time to talk and adjust their story to the dominant consensus (view)
- Physical conditions have had less time to change
- Immediate information from the person suffering the accident often proves to be most useful
Explain what is involved in:
Investigation interview techniques
- The aim of interviews is NOT to appropriate blame but to discover the facts
- Witnesses should be given the opportunity to explain what happened in their own way (words)
- Any questions to a witness should be to, elicit more information
- Questions should not be leading but of an open type
- Investigators should then give a summery back to the witness while indicating clearly that they are willing to alter the notes if the witness is not content with them
Some of the questions should start with words like: - What
- Where
- Who
- When
- Why
Explain the importance of: - Plans - Photographs - Relevant records - Checklists In accident investigations:
Investigations have four basic elements to a sound investigation:
- Collect facts about what occurred
- Assemble and analyse the information obtained
- Compare the information with acceptable industry and company standards and practices.
- Use relevant legal requirements to draw conclusions
- Implement the findings and monitor progress
To do this requires information, procedures, inspection records, risk assessments, training records, policies, tests and examinations. To be correlated and examined
Checklists, photographs, plans and relevant records make this a more streamlined process
- Immediate causes:
(unsafe acts and unsafe conditions).
Incidents/Accidents resulting directly from unsafe acts and unsafe conditions in the workplace
List the possible personal and task factors:
Personal factors:
- Behaviour of the people involved (Unsafe acts)
- Suitability of the people doing the work
- Training and competence
Task factors:
- Workplace conditions and precautions or controls (Unsafe conditions)
- Actual method of work adopted at the time
- Ergonomic factors
- Normal working practice either written or customary
- Root causes:
(management system failures)
Underlying causes are the less obvious system or organisational reasons for an accident or incident
List some of the (underlying, and root) causes
Underlying causes:
- The hazard not considered in the risk assessment
- There was no suitable method statement
- Pressures of production
- Employees under personal pressure at the time
- Inadequate supervision, control and coordination of work practices involved
Root causes:
- Quality of the health and safety policy and procedures
- Quality of consultation and cooperation of employees
- The adequacy and quality of communications and information
- Deficiencies in risk assessments, plans and control systems
- Deficiencies in the monitoring and measurement of work activities
- Quality and frequency of reviews and audits
