A2 LOSS CAUSATION AND INCIDENT INVESTIGATION Flashcards
A2.1 ACCIDENT/INCIDENT RATION STUDIES, THEIR USE AND LIMITATIONS
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A2.1 DOMINO AND MULTI-CAUSALITY THEORIES, IMMEDIATE AND UNDERLYING CAUSES
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A2.1 LATENET AND ACTIVE FAILURES - REASONS MODEL OF ACCIDENT CAUSATION
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A2.2 METHODS OF CALCULATING LOSS RATES FROM RAW DATA, ACCIDENT/INCIDENT FREQUENCY RATE, ACCIDENT INCIDENT RATE, ACCIDENT SEVERITY RATE, ILL HEALTH PREVALENCE RATE
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A2.2 THE APPLICATION AND LIMITATION OF SIMPLE STATISTICAL AND EPIDEMIOLOGICAL ANALYSIS IN THE IDENTIFICATION OF PATTERNS AND TRENDS
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A2.2 PRESENTING AND INTERPRETING LOSS EVENT DATA IN GRAOHICAL AND NUMERICAL FORMAT, USING EXAMPLESOF HISTOGRAMS, PIE CHARDS AND LINE GRAPHS
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A2.2 PRINCIPLES OF STATISTICAL VARIABILITY, VALIDITY AND THE USE OF DISTRIBUTIONS (EG SAMPLING A POPULATION, ERRORS IN DATA)
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A2.3 RIDDOR
STATUTORY REPORTING REQUIREMENTS AND PROCEDURES
REPORTING OF INJURIES, DISEASES AND DANGEROUS OCCURANCES REGLUATION 1995
A2.3 INTERNAL REPORTING AND RECORDING SYSTEMS
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A2.4 LOSS INVESTIGATIONS
IMPLIED LEGAL REQUIREMENTS
Outline of purposes of loss investigation to include discovery of underlying causes, root cause analysis, prevention of recurrence, legal liability, data gathering and identification of trends with models such as the UK Health and Safety Executive HSG245.
A2.4 PURPOSES OF INVESTIGATION INCLUDING DISCOVERY OF UNDERLYING CAUSES PREVENTION OF RECURRENCE LEGAL LIABILITY DATA GATHERING INDENTIFICATION OF TRENDS
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A2.4 INVESTIGATION PROCEDURES AND METHODOLOGIES TO INCLUDE
ACCIDENT/ INCDENT REPORT FORMS
GATHERING OF RELEVANT INFORMATION
INTERVIEWING WITNESSES
ANALYSIS OF INFORMATION
INVOLVEMENT OF MANAGER, SUPERVISORS, EMPLOYEES’ REPRESENTATIVES AND OTHER IN THE INVESTIGATION PROCESS
Description of investigation procedures and methodologies to include incident report forms, gathering of relevant information, interviewing witnesses, analysis of information, and the involvement of managers, supervisors, workers’ representatives and others in the investigation process.
A2.4 COMMUNICATIONS WITH A PARTICULAR FOCUS ON REMIDIAL ACTIONS AND LESSONS LEARNT
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A2.4 ROOT CASUE ANALYSIS METHODS SUCH AS FAULT TREE ANLYSIS AS INVESTGATIVE TOOLS
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Why are accident investigations carried out
Accident investigations are carried out to.
To identify the immediate root causes of the incident - incidents are usually caused by unsafe acts and unsafe conditions in the workplace, but these often arise from underlying root causes.
To identify corrective actions that will prevent a recurrence - The main reason for investigating.
What are the four steps in the investigation process
The four steps in the investigation process are.
Step 1:
Gather factual information about the event.
Step 2:
Analyse that information and draw conclusions about the immediate and root causes.
Step 3:
Identify suitable corrective measures.
Step 4:
Plan the remedial actions.
Identify the categories of staff who might be considered useful members of an internal accident investigation team
A simple investigation might be carried out by the line manager of the area; a more detailed investigation often involves a team of investigators that might include
- A safety specialist
- Senior managers
- A technical specialist
- A worker representative
Offshore investigating teams may also include installation specialists from services such as drilling, well services, maintenance, process, and deck crews.
List the types of documentation which might be consulted during an accident investigation
Various documents may be examined during an accident investigation, such as:
Company policy
Risk assessments
Training records
Safe systems of work
Permits-to-work
Maintenance records
Disciplinary records
Internal incident report forms
Log book entries
Computer printouts relevant to the situation
What are the two categories of immediate cause of accidents/incidents
Immediate causes are the unsafe acts and unsafe conditions that gave rise to the event itself.
These will be the things that occurred at the time and place of the accident.
For example a worker slips on a patch of oil spilt on the floor
Immediate causes:
The slip hazard = unsafe condition
The worker walking through it = unsafe act
A worker has been hit by a reversing vehicle in a loading bay.
List possible immediate causes and root causes
Immediate causes for such an accident might be:
• Failure to secure the load on the pallet
• Poor road positioning of the truck close to a pedestrian exit
• Aggressive breaking by the truck driver
• An inattentive pedestrian stepping out in front of the truck
On investigation each of these immediate causes might have their own separate root causes such as:
- No training for the driver, who is new to the workplace, has not worked with this type of load before and is unaware of the load securing techniques required
- Lack of segregation of pedestrian and traffic routes; no barriers and no markings to separate the two
- Lack of proper driver induction into the new workplace so they are unaware of the layout and position of pedestrian exits, etc.
- Poor maintenance of the truck
- No refresher training for existing staff, meaning that experienced staff become complacent
POWERS OF INSPECTORS
Powers of inspectors
Require Statements
Authorise Others (Police etc)
Inspect a Copy
Samples (Take)
Enter Premises
Direct Leave Undisturbed
Take Possession of Anything
Examine and Investigate
Any Other Power Necessary
Provide Assistance, Records, Information or Facilities
Order Testing
Take Photos/Measurements/Recordings
Serve Notices - Improvement or Prohibition
Identify the categories of staff who might be considered useful members of an internal accident investigation team
A simple investigation might be carried out by the line manager of the area; a more detailed investigation often involves a team of investigators that might include
- A safety specialist
- Senior managers
- A technical specialist
- A worker representative
Offshore investigating teams may also include installation specialists from services such as drilling, well services, maintenance, process, and deck crews.
What are the two categories of immediate cause of accidents/incidents
Immediate causes are the unsafe acts and unsafe conditions that gave rise to the event itself.
These will be the things that occurred at the time and place of the accident.
For example a worker slips on a patch of oil spilt on the floor
Immediate causes:
The slip hazard = unsafe condition
The worker walking through it = unsafe act
A worker has been hit by a reversing vehicle in a loading bay.
List possible immediate causes and root causes
Immediate causes for such an accident might be:
- Failure to secure the load on the pallet
- Poor road positioning of the truck close to a pedestrian exit
- Aggressive breaking by the truck driver
- An inattentive pedestrian stepping out in front of the truck
On investigation each of these immediate causes might have their own separate root causes such as:
- No training for the driver, who is new to the workplace, has not worked with this type of load before and is unaware of the load securing techniques required
- Lack of segregation of pedestrian and traffic routes; no barriers and no markings to separate the two
- Lack of proper driver induction into the new workplace so they are unaware of the layout and position of pedestrian exits, etc.
- Poor maintenance of the truck
- No refresher training for existing staff, meaning that experienced staff become complacent
