Unit A5 Questions Ollie Flashcards
An Employee was on an elevated work platform when it was struck by a contractors vehicle. The platform over turned, the employee then fell and was seriously injured. An initial report recommends further investigation.
(a) Outline steps that should be followed when investigating the accident. (10)
(b) Outline the benefits of conducting an accident investigation. (6)
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(c) Outline the criteria that should be used to determine whether the event and any subsequent
injury is reportable under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations. (4)
(a) The steps that should be followed are:
Gathering information -as soon as possible after the event. Inspection of the scene, taking photographs/making sketches, taking measurements, isolating equipment, all whilst ensuring that the area no longer presents a danger to the investigation team or others.
Interviewing witnesses including the accident victim and any eye witnesses to establish the sequence of events, details of injuries, plant/equipment involved
Analysis of information assembling all evidence, identify any gaps, determining immediate and root causes (use of 5 WHY’s or cause or effects of diagrams
Identify all possible control measures and selection of those most suitable/likely to be effective -use of cost- benefit analysis. Do similar controls need to be considered elsewhere?
Planning and Implementation of measures- Involving setting timescales, allocating responsibilities and checking that actions have been implemented/are successful.
(b) Some of the benefits include:
Prevention of similar events occurring again which in turn would lead to various negative effects on the business due to disruption, loss of production, damage to reputation and cost of criminal or civil actions. Improvement in employee morale due to the fact that their employer is seen to take these issues seriously. Development of managerial skills which can be applied to other areas of the organisation.
(c) The criteria are:
The accident must be work related associated with the way the work was organized, carried out or supervised. Or involving work machinery, plant or substances Or related to the condition of the site/premises. The injury must be fall into 1 of the following categories:
Resulting in death
Result in >7 consecutive day absence from work
Gas related injuries
Are a specified injury listed under reg 4 including eg serious burns, amputation, unconsciousness Results in a diagnosis of certain occupational diseases including eg dermatitis, asthma, carpal tunnel syndrome
Results in diagnosis of cancer or disease from Exposure to Carcinogens or biological agent
It is also required to report any Dangerous occurrences such as malfunction of breathing apparatus, part/full collapse of scaffolding, part/full collapse of building.
Outline active failure
Outline Latent Failure
AF=(immediate causes)
LF=(Root/Underlying causes).
Explain FTA
FTA is a deductive procedure used to determine the various combinations of hardware and software failures and human errors that could cause undesired events (referred to as “top” events) at the system level.
The deductive analysis begins with a general conclusion, then attempts to determine the specific causes of the conclusion by constructing a logic diagram called a fault tree. This is also known as taking a top-down approach.
The main purpose of the fault tree analysis is to help identify potential causes of system failures before the failures occur. It can also be used to evaluate the probability of the top event using analytical or statistical methods. These calculations involve system quantitative reliability and maintainability information, such as failure probability, failure rate, and repair rate
Explain ETA
An inductive technique that often complements FTA (as can be seen (“Bow-Tie analysis), ETA focuses on the consequential event which flow from the initiating event.
It considers the possibility of both the success and failure of the safety controls designed to prevent or mitigate escalation of the accident sequence.
Explain Bow tie Model
The Bow Tie also combines the concepts of fault and event trees used in quantitative risk assessment.The Bow Tie, as a structured way of looking at how hazards are managed and how consequences are prevented, forms a basis not only for risk assessment but also, provides a structure for incident analysis and even audits.
Swiss cheese Model
The model includes, in the causal sequence of human failures that lead to an accident or an error, both active failures, and latent failures.
Witness interviews are an important part of the information gathering process of an accident investigation.
Describe the requirements of an interview process that would help to obtain the best quality of information from witnesses. (10)
Interview asap - but take account of effects of injury / shock on ability to provide a witness statement; Interview one witness at a time; keep witnesses apart so no influence / collusion; Record - witness name and employment / personal details / date / time / location of interview / others present; Establish rapport - put interviewee at ease; adopt suitable level of formality / non-threatening manner; Invite witness to have someone else present - union rep etc Allow sufficient time - factor in breaks if likely to be prolonged; Ensure suitable / comfortable / quiet environment - no interruptions / distractions; Explain purpose of interview process - preventive focus - not allocation of blame; Use appropriate language / terms - avoid over technical / legalistic approach; Take account of language difficulties - use of interpreter?; Use open questions - when where, what, who - focus on facts / observations rather than opinion / conjecture; Listen without interruption; Provide relevant photographs, sketches, visit scene together etc to support witness; Take accurate notes / record the interview; Avoid leading the witness / leading” questions or drawing conclusions; Clarify any uncertainties / ambiguities; Seek views on preventive measures; Summarise and check agreement / verify statement (interviewer and witness signatures / date / time); Explain the possible need for further interview / contacts; Offer thanks
Explain the ‘domino’ and ‘multi-causality’ theories of accident causation, including their respective uses and possible limitations in accident investigation and prevention. (10)
Domino theory: Heinrich’s five-step model: ancestry / social environment - fault of person - unsafe act / condition - accident - injury.
Subsequent developments of Heinrich’s model by Bird and Loftus: lack of management / organisational control – basic causes (personal / job factors) - immediate causes (unsafe acts / conditions) - accident - loss.
Bird and Loftus variant is an advance on Heinrich as it takes account of organisatiomal / management failures / underlying causation.
Uses: both theories provide a basis for structured accident investigations.
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(a) Describe the statutory reporting and recording requirements under RIDDOR 2013 that apply when someone is either injured at work or by a work activity. (10)
(b) Good accident investigation requires an analysis of information that has already been gathered so that immediate and underlying causes of the accidents can be identified.
Outline FIVE methods or techniques that can be used to help in the identification of immediate and underlying causes during such an analysis. (10)
a) The reporting and recording duties under the Regulations fall to the responsible person who is nominally the employer or the person in control of the premises where the accident occurred. When a person at work is killed or suffers a major injury such as an amputation or permanent or temporary loss of sight, a report has to be sent to the enforcing authority/ incident control centre by the quickest practicable means (e.g. telephone) and a written report submitted forthwith on F2508. If a person who has suffered a major injury accident subsequently dies within a year of the date of the accident, the enforcing authority must be informed in writing. If an employee suffers an accident which is not classed as major but following which he/she is incapable of carrying out their normal work for a period of more than [three] [now seven] days not including the day of the accident or any holidays / weekends when the person would not normally be required to work, a written report on F2508 must be submitted to the enforcing authority within ten days. In the case of an accident to a non-employee as a result of a work activity, the responsible person must report forthwith both those that cause death or result in major injury or hospitalisation. Alternative reporting arrangements to the above involving electronic or telephone reporting direct to the Incident Contact Centre may also be used. Finally, records of reportable incidents including the name of the injured person, the date and time of the accident and the date the report was submitted to the enforcing authority, must be kept for a period of three years.
(b) Methods / techniques that may be used to identify immediate and underlying causes of accidents include: identifying the immediate causes for each event leading up to the accident and then for each immediate cause, identifying one or more underlying causes;
Using a structured 5‘why’ questioning analysis,
Using immediate and underlying cause checklists such as HSG245 (adverse event analysis) or HSG65 (Appendix 5);
Carrying out an events and causal effects analysis – a graphical method of linking accident events with causal factors and using a team of people with relevant knowledge to identify both the immediate and underlying causes. Other techniques or methods could include the use of fault tree analysis, event tree analysis, or the
Ishikawa (fishbone) cause and effect analysis.
A solvent spillage occurred when a tank was accidentally over-filled and solvent escaped into the bund. The tank had been over-filled because the tank level gauge often understated the amount of solvent in the tank. In addition, a high level alarm system on the tank had failed to operate because of a defective switch but there was no information on when this system had failed. The level gauge was known to be unreliable and after previous overfill incidents, operators had been instructed verbally by their supervisor to check the tank level before filling by the use of a dipstick. However, it was known that this was not always done and had not been done on this occasion.
(a) Outline:
(i) the immediate causes of the accident; (3)
(ii) the possible underlying causes of the accident. (7)
(b) Outline the role that fault tree analysis could play in the investigation of this accident.
A description of the technique of fault tree analysis or an illustrative fault tree is NOT required. (5)
(c) If the spillage is a notifiable dangerous occurrence under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013, outline the requirements of the Regulations with respect to reporting and record - keeping in this case. (5)
(a) (i) The immediate (“frontline” equipment / operator) causes are: a faulty gauge giving a misleading reading; a defective switch resulting in a failure of the high level alarm; operative failing to follow dipstick test procedure
(ii) the underlying causes are: lack of maintenance / inspection; poor communication; lack of training; lack of supervision; lack of investment
(b) FTA can be applied as an investigative technique by formulating a logical “tree” structure which sets out the underlying causal factors and sequences of events that can lead to the undesirable TOP EVENT = “loss of containment”. Having established the potential causal factors it is then possible to identify the most effective points at which interventions can be made to prevent a recurrence and /or to mitigate the effects.
(c) A reportable DO under RIDDOR must be reported to the relevant enforcing authority / Incident Contact
Centre without delay eg by phone / email. Records of the incident must include the date and method of reporting; the date,time and place of the event; personal details of those involved; and a brief description of the nature of the event; records can be kept as: copies of report forms in a file; details on a computer; an Accident Book entry; a written log
