Loss and Near-Miss Investigations Flashcards
Where is the legal requirement for Employers to investigate loss events?
The Social Security (Claims & Payments) Regulations 1979
What is the purpose of the legal requirement to investigate loss events?
This is solely for the purpose of awarding Industrial Injuries Disablement Benefit
List the steps provided in the official guidance on accident investigation as found within the HSE publication HSG245 Investigating Accidents and Incidents.
Step 1 - Gathering the information
Step 2 - Analyzing the information
Step 3 - Identifying risk control measures
Step 4 - The action plan & its implementation
Explain what is meant by an ‘Immediate Cause’ and provide an example
The most obvious reason why an adverse event happens
Example: Guard is missing, employee slips etc.
Explain what is meant by an ‘Underlying Cause’ and provide an example
The less obvious system or organisational reason for an adverse event happening.
Example: Pre-Start up machinery checks are not carried out by supervisors, hazard has not been adequately considered in a risk assessment, production pressures are too great etc.
Explain what is meant by ‘Root Cause’ and provide an example
An initiating event or failing from which all other failings spring. Root causes are generally management, planning or organisational failings.
What are the benefits of carrying out an investigation?
Prevention of Recurrence
The purpose is to establish whether a recurrence can be prevented by the introduction of safeguards, procedures, training and information, or any combination of these.
Improved Employee Morale
Employees will be more co-operative in implementing new safety precautions if they were involved in the decision and can see that problems are dealt with. Effective control measures, combined with adequate supervision, monitoring and management control will ensure that work activities are safe.
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 incident from happening again and for improving your overall management of risk. The managerial skills developed in investigating accidents and incidents are fully transferable and can be readily applied to other areas of the organisation.
List the 4 steps to take following an adverse event
EMERGENCY RESPONSE
Take prompt emergency action such as first aid and making the area safe
INITIAL REPORT
The scene must be preserved as far as possible to safeguard any evidence and the names of the people, equipment involved and witnesses need to be recorded. The incident should be reported to a responsible person who will decide what further action is required.
INITIAL ASSESSMENT & INVESTIGATION RESPONSE
For accidents and dangerous occurrences that are reportable under RIDDOR, this information must be notified to the enforcing authority.
Details of the accident should be entered in an accident book and a decision taken on the scale of the investigation. If possible decide who will carry out the investigation, resources required and brief the investigation team.
DECISION TO INVESTIGATE
The level of any investigation will be determined by the worst potential consequences of the adverse event and the likelihood of a recurrence.
Explain the four types of investigation
MINIMAL LEVEL INVESTIGATION
Supervisor looks into the circumstances to learn any lessons which will prevent future occurrences
LOW LEVEL INVESTIGATION
A short investigation by the line manager into the immediate, underlying and root causes to prevent a recurrence and to learn any general lessons.
MEDIUM LEVEL INVESTIGATION
Detailed investigation by the relevant supervisor or line manager, the H&S adviser and employee representatives who looks for the immediate, underlying and root causes.
HIGH LEVEL INVESTIGATION
A team based investigation, involving supervisors or line managers, H&S advisers and employee representatives. It will be carried out under the supervision of senior management or directors and will look for the immediate, underlying and root causes.
Explain the the 1st step of an accident investigation
STEP 1 - GATHERING RELEVANT INFORMATION
Promptness - Begin an investigation as soon as possible after the event. Facts will be easier to determine and more details will be remembered by those involved.
Equipment - Photographs, portable lights for poorly lit areas such as a manhole, Sketchpad and pencils and measuring equipment, Record keeping equipment such as a notebook, Sample collection equipment such as jars or other containers which can be sealed to prevent loss, evaporation or contamination. Paper bags and plastic bags and envelopes and cartons may also be required. Tools for cleaning debris or spillages. Where explosive or flammable vapors and gases may be involved portable gas/vapor detection equipment should be available.
INSPECTION OF THE SCENE
Help injured people.
Report the incident under RIDDOR.
Site to be made safe or left undisturbed.
Investigator to be present during clean-up
Supervisor to collect evidence
In event of a fire, the investigator should be present during the fire or as soon as possible after the fire. The exact area of the fires origin may be more obvious. The investigator may watch the activities of fire fighters and photograph the course of the fire which may prove useful.
A typical routine of investigation is as follows:
Take a careful look at the scene noting the extent and severity of damage, damage to surrounding property, environmental conditions such as temp, ventilation, humidity and illumination. Survey the accident site for obvious dangerous physical conditions that may have been responsible. In the case of spillages or splashes it may be necessary to take samples for testing. Where machinery or other equipment has been involved, it may be necessary to issue instructions prohibiting its use or repair until the investigation has been completed.
INTERVIEWING WITNESSES Types of witness Putting the witness at ease Interview location Question phrasing Attitude Conclusion
Explain the the 2nd step of an accident investigation
STEP 2 - ANALYSIS OF INFORMATION
Examine the facts, piecing them together to establish what actually happened and determining why it happened.
Assemble data
Extract relevant information
Identify gaps and following leads to fill those gaps
Discovering the immediate, underlying and root causes by systematically working through the event
Explain the the 3rd step of an accident investigation
STEP 3 - IDENTIFY CONTROL MEASURES
Identify all possible control measures and then select the ones which are most suitable. This may involve justifying selected controls using formal cost-benefit analysis.
Explain the the 4th step of an accident investigation
STEP 4 - PLAN & IMPLEMENT
Plan what you have decided to do and do it. This will involve setting timescales, allocating specific actions to individuals and checking that the proposed actions have actually been implemented.
List the four steps to an accident investigation
Step 1 - Gather relevant information
Step 2 - Analyse information
Step 3 - Identify control measures
Step 4 - Plan & Implement
What role do the following people have in the investigation process?
Managers
Supervisors
Employees Representatives
Safety Practitioner
MANAGER
Many causes of accidents are due to management systems, or rather the lack of effective systems. The objective of any analysis is to provide management with a means of deciding why their policies and procedures failed to prevent accidents, injuries and ill health. As it is management who ultimately make the decisions and allocate resources, it is vitally important that they are actively involved at every step of the way
SUPERVISORS
Usually it is the immediate supervisor of the injured person, or the supervisor in whose department the damaged property belonged, who is better qualified to carry out the investigation than any other member of the management team, including the safety practitioner.
He is likely to know most about the situation, he should know his own workers better than anyone else does and he has a personal interest in establishing the causes of accident because they affect the efficiency and morale of his department.
EMPLOYEES REPRESENTATIVES
Employees representatives have the right to investigate both accident and ill health incidents and this is usually carried out with approval of management
SAFETY PRACTITIONER
In the case of serious accidents, the immediate supervisor may not have the necessary authority to conduct the investigation, so the company safety practitioner should be in charge of the investigation, although he will find it helpful to have the assistance of the supervisory staff. It is essential that the investigator has the authority to go as far as is necessary to get to the cause of the problem.
