A5.4 Explain the reasons for loss and near miss investigations and the procedures to be followed.

Question 1

What are the HSE definitions of a near miss and an accident?

Answer 1

Accident = ‘any unplanned event that resulted in injury or ill health of people, or damage or loss to property, plant, materials or the environment or a loss of business opportunity’

Near miss = an unplanned event that did not result in injury, illness or damage but had the potential to do so.

Question 2

What are the reasons for carrying out investigations?

Answer 2

1. Legal reasons

broad duty on employers and employees to take reasonable care of themselves and of others.
Accident investigation enables the employer to also explore and defend if necessary, the adequacy of their duty of care

2. Data gathering

It is important to look for existing and developing trends. Minor accidents could indicate procedural, practical or human issues. If not treated, minor could become major.

3. Establishing root, underlying and immediate causes

There will always be an immediate cause, but we are also interested in finding underlying and root causes, thus we need to consider the chain of events leading to an accident.
Safety practitioners should be interested in ‘cause of accident’ not cause of injury.

Question 3

What are the benefits of carrying out investigations?

Answer 3

1. Prevention of recurrence
2. Improved employee morale

employees will be more co-operative in implementing new safety precautions if they were involved in the decision making and can see that problems are dealt with. Blaming individuals in ineffective.

3. Developing managerial skills

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 reoccurrence of the incident. These skills are transferable.

Question 4

What information should an incident report form contain?

Answer 4

• summary of what happened
• an introductory summary of events before the incident in question
• root/immediate cause
• details of witnesses
• information about injury, ill health or loss sustained
• conclusions
• recommendations
• costings
• support materials
• signature of the person or persons carrying out the investigation
• the date

Incident report forms should be returned to a central point for record-keeping and analysis.

Question 5

What are the steps to an investigation after an accident?

Answer 5

1. GATHERING OF RELEVANT INFORMATION

• be prompt, soon after the accident
• bring necessary equipment eg. camera, measuring equipment, sketchpad, jars, plastic bags
• inspect the scene, report to RIDDOR if necessary, look for immediate signs of a cause of the accident
• interview witnesses (don’t apportion blame)
• three types of witness, primary, secondary and tertiary
• put witness at ease, no blame, make them relaxed
• don’t use why questions, use what, where, when, how or who
• have a non blaming attitude, listen to the witness
• finally, repeat what the witness said to confirm

2. ANALYSIS OF INFORMATION

• assemble data, extract relevant info, identify and fill gaps, discover the immediate, underlying, and root causes
• can use FTA, ETA, may also need a team-based approach

3. IDENTIFY CONTROL MEASURES
   - identify and select most suitable control measure (cost-benefit analysis)
4. PLAN AND IMPLEMENT
   - plan what you have to decided to do and do it. Set timescales.