e5.4 - Loss and near miss investigations

Question 1

Implied legal requirement to investigate

Answer 1

No specific requirement to investigate incidents. However, health and safety law does imply that it is required.

Section 2 of HASWA implies that should an accident occur, the employer should prevent recurrence

Reg 5 of MHSWR requires effective arrangements to be in place with accompanying guidance starting with remedial action following an accident

Question 2

Why investigate?

Answer 2

Identify ROOT cause

Prevent RECURRENCE

Identify TRENDS

Improve CONTROL

Establish LEGAL LIABILITY

Calculate COSTS

Gather DATA

Question 3

HSG245

Answer 3

Investigation Procedure

Emergency response -

Take prompt emergency action (e.g. first aid)

Make the area safe

Initial Actions -

Preserve the scene

Inform next of kin

Inform internal personnel

Report to enforcing authority if required

Report to insurance company

Decide on further action

Question 4

Formal team required for serious accidents

Answer 4

Health and Safety practitioner

Safety rep

Member of senior management

Supervisor

Subject expert

Occupational nurse/physician

Question 5

4 steps in accident investigation

Answer 5

Step 1 Gathering the Information

Step 2 Analysing the information

Step 3 Identifying risk control measures

Step 4 Action plan and its implementation

Question 6

STEP 1 - Gathering the information

Answer 6

Three main sources of info -

The scene

Witnesses

Documents

Question 7

STEP 1 - The scene

Answer 7

Using photographs and videos to document the scene

Notepads to sketch the scene showing positions of people and equipment

Taking measurements of light, temperature

Finding out speeds of vehicles by looking at tyre marks (if involved)

Obtaining CCTV footage (if available)

Investigating the state of equipment (guards missing, worn parts)

Question 8

STEP 1 - Interview technique

Answer 8

Interview as soon as possible after the event

Select suitable location for interview

Interview witnesses individually

Explain reasons for interview

Be polite, put witness at ease

Avoid leading questions

Ask open questions - where, when, what, who, how

Dont interrupt the witness

Record the interview

Repeat account to witness to ensure accuracy

Question 9

STEP 1 - Documents

Answer 9

Gathering relevant information such as -

Risk assessments

Safe system of work

Training records

Maintenance records

Inspection records

Manufacturers data relating to equipment or substance

Question 10

STEP 2 - Analysing causes

Answer 10

Immediate causes lead to - unsafe acts and/or unsafe conditions

Question 11

STEP 2 - Unsafe acts

Answer 11

Operating without permission

Working at unsafe speed

Turning off safety devices

Using unsafe equipment

Failure to wear PPE

Horseplay between workers

Question 12

STEP 2 - Unsafe conditions

Answer 12

Inadequate guarding on machines

Unsafe work processes

Hot, cold environments

Inadequate lighting

Holes in floor

Poor housekeeping

Question 13

Underlying/ root causes…

Answer 13

Management failures

Question 14

STEP 2 - Typical underlying/root causes

Answer 14

Failure to provide training

Failure to carry out risk assessments

Failure to allocate roles and responsibilities

Failure to carry out regular monitoring

Failure to provide adequate resources

Failure to select competent people

Failure to supervise staff

Failure to carry out maintenance at suitable intervals

Failure to regularly consult workers

Question 15

STEP 3 - Identifying risk control measures

Answer 15

Based on analysis of underlying/root causes

Temporary, short term remedial action may be required

Permanent, long term remedial action should then be considered

Various controls should be assessed for reasonable practicability before a decision made as to which controls to implement

New controls should follow principles of prevention

Question 16

STEP 4 - Action plan and implementation

Answer 16

Involves setting timescales for implementation of new controls

Prioritizing which controls should be implemented first

Senior management to provide necessary resources

Allocating required actions to specific individuals

Setting up monitoring systems to ensure plan is completed within timescales set

Question 17

Communicating remedial action/lessons learnt

Answer 17

Findings should be discussed/consulted with employees

Raises awareness of accident causes

Staff involved in same task need to be briefed on changes to working practices

Method of communication depends on size of business