Accident Investigation Presentation

7/31/2019 Accident Investigation Presentation

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ACCIDENT

INVESTIGATION

&REPORTING


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Fire Precautions

Fire Precautions :-

If continuous alarm sounds leave the building by the nearest exit

Report to the tutor at the assembly point


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INTRODUCTION

Tea / coffee facilities

Toilets

No smoking

First aid / fire

Mobile phone / pagers

Trainee introductions

Please ask questions at any time


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OVERALL AIMS

An understanding of the process andpurpose of investigating incidents

Remember : Includes ill health as well asinjury accidents

An understanding of the legal and

organisational requirementsfor recording and reporting


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2003/04 Statistics

235 fatalities

159,809 RIDDOR reported injuries

An estimated 2.2 million people sufferingfrom an illness caused or made worse bytheir current or past work

An estimated 39 million working days lost -30 million due to ill health & 9 million dueto injury


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The Reporting of Injuries,Diseases and dangerous

Occurrences Regulations(RIDDOR) 1995


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Whats the point of RIDDOR?

HSE/EHO need to know about the moreserious accidents, diseases anddangerous occurrences at work so they

can perform their statutory role.

They can analyse where and how risksarise and then investigate/enforce.


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What needs to be reported? Death or major injury:

employee or a self-employed person working onyour premises is killed or suffers a major injury(including violence), or;

a member of public is killed or taken to hospital

Over-3-day-injury: employee/self-employed off work, or incapacitated

for normal work for more than 3 days;

Disease: doctor notifies you of reportable work-relateddisease;

Dangerous occurrence: categories of near-misses.


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The Reporting of Injuries, Diseases and

Dangerous Occurrences Regulations

(RIDDOR) 1995 Reportingprocedures cover:

fatalities and major

injuries incapacity to work

for more than threedays

specified diseases

dangerousoccurrences2.1


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RIDDOR

Covers:

employers

employees self-employed

trainees

other people injured onpremises


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RIDDOR

Major injuries include:

fracture of: skull, spine, pelvis

arm, leg, wrist, ankle

amputation through any bone

loss of sight (temporary or

permanent


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RIDDOR

Major injuries(continued):

certain eye injuries

electric shock requiring attention

unconsciousness through lackof oxygen

acute illness due to exposure tocertain materials

hospitalisation for more than24 hours


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RIDDOR

Reportable occurrences:

structural collapses

fires and explosions

release of gases or other dangeroussubstances

failure of breathing apparatus while in use

scaffold collapse

contact with or arcing of overhead cables


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RIDDOR

Reportable diseases:

any disease listed in theregulations as reportable


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Social Security Act 1975 andRIDDOR

Every accident involving personal injury to anemployee must be entered in the accidentbook by:

the employee, or

someone acting on behalf of the employee

The accident book must be kept accessible.

An employer must investigate all accidents reported


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Reporting to enforcingauthorities

Since 01 April 2001, you can report accidents andoccurrences to the Incident Contact Centre by:

telephone

fax e-mail

post

Reporting accidents and occurrences direct to the localHSE Office, on Form F.2508 or F.2508A, is stillacceptable.


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Report to enforcing authorities

F.2508 must be sent to the enforcingauthorities in cases of:

injury at work resulting in more than three consecutivedays incapacity

death of an employee within one year of sustaining areportable injury

a reportable disease when diagnosed by a registeredmedical practitioner


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RIDDOR: Answers

Details of employee injury (normal

working Monday to Friday 8.00 am to 5.00pm)

Days off work Hrs in hospital Tick if RIDDOR applies

1 Sprained arm(put on light duty

with 5 days offnormal job)

1 day Nil

The light duty counts as 5 daysoff work

2 Broken arm30days 4 hrs

Any fracture but not toes andfingers

3 Broken finger 1 day 3 hrs No

4 Broken finger 4

days

3 hrs This is because of more than3 days off work

5 Dermatitis 1 day Nil Only if confirmed by doctor

6 Sprained ankle on Thursday,returns to work on Tuesday

2 daysNil

4 days not available for work(includes Sat and Sun)


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RIDDOR: Answers

Details of employee injury (normal workingMonday to Friday 8.00 am to 5.00 pm)

Days off work Hrs inhospital Tick if RIDDOR applies

7 Amputation of finger 2 days 6 hrs

Any amputation

8 Vibration white finger nil nil Only if confirmed by adoctor

9 Twisted ankle 4 days nil 3 days or more off work

10 Twisted ankle 1 days 3 hrs No

11 Electric shock (not unconscious) 2 days nil No

12 Electric shock (unconscious) 2 days 25 hrs Unconscious-ness

13 Electrical fault causing fire but workshop outof use for only 24 hours

N/A N/A

14 6 metre high scaffold collapses N/A N/A Over 5 metreshigh


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Accident/Incident Investigation

RIDDOR only requires reporting ofincidents etc.

No explicit legal requirement in any H&Slegislation to investigate - therefore WHYDO IT?

?


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?


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Accident/Incident Investigation

HSW Act states - employers mustensure.the health, safety and welfare of

employees... etc.

Reactive monitoring - to prevent the sameor similar from happening again

Review/revise risk assessments andassociated H&S documentation/workingpractices


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Are you learning

the lessons?

?


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Do you investigate incidents &

accidents in your company?

Do you do it well?

Do you find the underlying causes?

Do you take corrective action?

Do you review your risk assessments as a

result?

Do you do it?


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Accident Investigation Law

Explicit legal duty to investigate accidents


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HSE on Accident Investigation 1999

Most accidents are not investigated safety specialists lead rather

than line managers

effort determined by severity of the injuryrather than potential of the event

little employee involvement

if line managers do investigate, little trainingin investigation skills and techniques

immediate technical causes only

contd


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Integrated approach to accident investigation and riskassessment

ie it should be integrated but usually isnt!!

from HSE CD169/2001


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Integrated approach to accident investigation and riskassessment

ie it should be integrated but usually isnt !!

from HSE CD169/2001


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Team based investigation

RoSPA study - best practice

led by senior managers

involving employees, includingsafety representatives

supported by OS&H professionals acting

as facilitators


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Team based investigation

Local knowledge, especially operational

Building of trust;

Creates workforce 'champions' for H&S;

Check on safety management standards

Investigation of lower risk safety issues isimportant in creating a positive climate for more

structured investigation when major safetyfailures occur.


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Humane

Prevent suffering and maintain quality of life

No-one should be expected to risk life andlimb in return for a contract of employment


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The true cost of an accident

To the victim:

pain and suffering extra cost, less income

continued disability

incapacity for job and other activities the effects on others


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To those responsible:

worry and stress

recrimination and guilt extra work

a) reports

b) staff replacement loss of credibility


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Is good health &

safety goodbusiness?


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To the firm:

lost working time

a) the victim

b) others

damaged equipment

insurance costs

prosecution or civilaction


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We recognise the importance of costing

loss events as part of total safetymanagement. Good safety is goodbusiness

Dr. J Whiston, ICI Group SHE Manager


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Safety is, without doubt, the most crucial

investment we can make, and thequestion is not what it costs us, butwhat it saves.

Robert McKee, Chairman Conoco (UK) Ltd.


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Prevention is not only better, but cheaper

than cureProfits and safety are not in

competition. On the contrary, safety atwork is good business.

Basil Butler, MD British Petroleum plc


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We saved 750,000 on insurance

premiums through improving oursystematic management of health andsafety.

Birse Group plc


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Accident Costs Iceberg

Uninsured Costs

Insurance Costs


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Insurance Costs

Employers Liability

Public Liability Product Liability

Motor Vehicle


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Uninsured Costs

Product and material damage Lost production time

Legal costs

Overtime & temporary labour

Investigation time/Administration

Supervisors time

Fines

Loss of expertise/experience

Loss of morale

Bad publicity


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Grangemouth

BP refinery fire in 1987

One person died

Cost 50 million in property damage

Cost further 50 million due to businessinterruption


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HSE Example

Small engineering firm (15 workers)

Workers sleeve caught on rotating drill

Both bones in lower arm broken

12 days in hospital

Off work for 3 months

Admin duties for 5 months

Unable to operate machinery for 8 months

Managing Director Prosecuted

2 employees made redundant to prevent

company going out of business


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Costs to Company

Wages for injured worker over period =

Lost production/remedial work required =

Overtime wages to cover lost production =Wages for replacement worker =

Loss of time of manager/MD =

Legal expenses =

Fines and court costs =Increase in Insurance Premiums =

10000

8000

30007000

4000

3000

40006000

Total cost to business = 45000


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Costs of slips and trips in GB

To the individual

Lost income, pain, reduced quality of life

To employers over 500m p.a.Damages, admin. and insurance, lost

production, temporary absences

To society over 800m p.a.Loss of potential output, medical costs, social

security.


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What contributes to the slip /trip risk?

Floor

Environment

Slip/tripPotential

Contamination

Obstacles

People Footwear


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Unsafe people

Unsafe conditions

Accidents


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Some common causes


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Some common causesof accidents

Not using:

guards, scaffolds, platforms, etc.

Ignoring or disregarding:

warning signs

statutory notices

Untidiness or carelessness

Horseplay


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Safety in the workplace requires

Safe systems of work and goodorganisation

Good defect reporting and maintenance

arrangements

Careful, safety-based work planning

The correct tools and equipment for the jobin hand

contd


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Safety in the workplace requires

Knowledge of, and compliance with, safetylaw

Adequate information, training, instructionand supervision

Common sense and a mature attitude


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Reporting accidents

An accident book should beavailable in all work situations

The Reporting of Injuries,Diseases and DangerousOccurrences Regulations 1995

reportable injuries

three days or more off work

certain listed injuries

No report: no proof

no future safeguard


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THE LAW AND

HEALTH & SAFETY

Oberon: This is thy negligence - thou mistakest orelse commitst thy knavery wilfully

Shakespeare


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UK legal system

By HSE or LA

Leads to afine/imprisonment

Not insurable

Criminal

By injured person

Leads to award ofdamages

Must be insured

Civil


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EXERCISEYou are going to work by bus. You buy a ticket (a

contract with the bus co). During the journey,

the driver collides with another vehicle and you

suffer minor cuts and bruises. By the timeeverything is sorted out, you are very late forwork. You sprint from the bus stop and trip

over a paving stone,breaking your arm.

Who is, if anybody,

is liable for your injuries?

COMMON & STATUTE LAW


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COMMON & STATUTE LAWCommon law is unwritten being derived from local & customary

laws and the decisions of judges but is nevertheless binding

It evolves continuously as precedents are established

decisions of a lower court can be overturned by a higher court

Statute law is passed by Parliament, approved by the Sovereign &is written (published law)

It takes precedent over all other forms of Law (Common Law)etc

Some Statute law is derived from decisions of the European

Union (Directives etc)


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NEGLIGENCE


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NEGLIGENCE Donoghue v Stevenson (1932)must take reasonable care

to avoid acts/omissions which you can reasonably foreseewould be likely toinjure your neighbour

This duty of care is owedto people who are closely &directly affected by your acts/omissions (e.g. employers,

employees, contractors, visitors, suppliers)

defences against actions include: no duty owed, duty notbreached, breach did not lead to damage, risk accepted

voluntarily,contributory negligence

Bradford vs Robinsons Rentals (1967): employer liable

for reasonably foreseeable frostbite injuries to B

SAFE SYSTEM OF WORK


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SAFE SYSTEM OF WORK

Wilson & Clyde Coal v English 1938Aleading case which established anEmployers duty of care towards

employees Masters duty to a Servant

Safe premises

Safe plant & equipment

Competent fellow workers

Adequate supervision

(cf Health & Safety at Work etc Act)

BREACH OF STATUTORY


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BREACH OF STATUTORYDUTY

Damages can be recovered if it can be proved thatloss occurred because of the defendants failure tocomply with a statutory requirement

May be easier to prove than negligence, especiallyif the breach has been established by a criminalprosecution

Main defences: duty not breached, injured partynot protected by statute, harm not of type statutedesigned to protect, contributory negligence

Some statutory duties are absolute

VICARIOUS LIABILITY


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VICARIOUS LIABILITY

Employers are vicariously liable for theactions of their employees provided thatthe employees were acting in the

course of their employment (sometimeseven if the activity was expresslyforbidden)

Limpus vs London Omnibus Co. (1862)Employer Liable for accident caused bynegligent employee

DUTIES OF EMPLOYEES


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DUTIES OF EMPLOYEES

Employees may also be sued. They have aduty to:

- To carry out duties with reasonable care

- To avoid loss to Employer

(cf Health & Safety at Work etc Act)

NB. Employers not liable for activities that do

not form part of employees employmentservants frolic of his own

Storey v Aston (1869) Employer not liable foraccident caused during unauthorised detour

REASONABLE PRACTICALITY


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REASONABLE PRACTICALITY

Edwards v National Coal Board (1949)Risk must beinsignificant in relation to sacrifice (time, effort & expense):NCB claimed unsuccessfully that it was not reasonablypracticable to shore up all mine roads

Marshal v Gotham & Co (1954) If something is practicable,courts will not lightly hold that it is nor reasonablypracticable

Adsett v K&L Steelfounders & Engineers Ltd (1953) Thestandard of practicality is that of current knowledge

not having sufficient resources is no excuse for inaction


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DEFENCE OF NECESSITY

A defendant may claim that his/her actionsarose from necessity (e.g. to prevent a

more serious accident) ESSO Petroleum Co v Southport

Corporation (1955) A captain of an oil

tanker jettisoned oil in bad weather tosafeguard the crew: ESSO convinced thecourt that this was a necessary act and notnegligence

CONSENT:VOLENTI DEFENCE


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CONSENT: VOLENTI DEFENCE

Volenti non fit injuria: cannot expect redress ifyou consent to an act likely to result in injury orloss

Cutler v United dairies (1933) Cutler failed to

recover damages after being injured trying torestrain a bolting horse: it was held he consentedto the risk

Haynes v Harwood (1935)A policeman was able

to recover damages after being injured restraininga bolting horse: he had a legal duty to protect life& property and was not held to have consentedwillingly to the action


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OCCUPIERS LIABILITY


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ACTS (1957 & 1984)

Duty of reasonable care to lawful visitors(invitees, licensees, contractors & those witha right under law)

Need to ensure premises are reasonablysafe. Dangerous defects must be repairedand warning notices displayed as necessary

Should expect children to be less carefulthan adults

Common Law duty not to cause trespassers

intended harm

TRESPASS: CASE LAW


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TRESPASS: CASE LAW Tichener v British Railways Board (1984)

BRB not liable for injuries to teenage girl hitby a train even though fence was notmaintained (Girl frequently & willingly took

risk) British Railways Board vs Herrington (1972)

BRB liable for injuries to a 6-year old childwho had strayed onto the line

Bird vs Holbrook (1828) Landowner liable forinjuries to a trespasser caused by a springloaded gun (trespasser unaware of risk)

THE WOOLF PROTOCOL


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THE WOOLF PROTOCOL

Lord Woolf (the Lord Chief Justice) drewup a Personal Injury Pre-action Protocolaimed at simplifying & streamlining claim

procedures Claims must proceed to a strict timetable

Defendants must investigate claims &

disclose relevant documents within thetimetable

If the protocol is not complied with, Courts

may impose tough sanctions

CRIMINAL COURTS (E&W)


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( ) All criminal cases are first dealt with by Magistrates Courts.

these can try summary offences and can commit people

accused of indictable offences (& commit people forsentencing) to the Crown Court.

The Crown Court tries Indictable offences. Trial is before aJudge (with a Jury in contested cases. Can also hear appeals

from Magistrates Courts.

The High Court of Justice hears appeals from Magistrates &some appeals from Crown Courts.

The Court of Appeal (Criminal Division) hears appeals fromCrown Courts it can amend or reverse decisions or remit casesto lower courts

The House of Lords is the ultimate court of appeal

HEALTH & SAFETY AT WORK


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ETC ACT 1974 (HSAWA)Section 2: duty to ensure, so far as is reasonably practicable

the health safety & welfare of employees

safe workplace & safe working practices

information, training & supervision

adequate welfare facilities

health & safety policy

safety representatives & committees

Section 3: employers to conduct undertakings so as to ensureso far as is reasonably practicable that persons not in hisemployment are not exposed to risks to their health & safety

HSAWA - (ii)


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HSAWA (ii)

Section 4: duty of those in control of premises to

non-employees

Section 6: duties of manufacturers & suppliers(includes provision of safety information)

Section 7:duty of employees to take reasonablecare for their health & safety and that of othersaffected by their acts/ omissions and to co-operatewith employer

Section 8:no person to intentionally/ recklesslyinterfere with or misuse anything provided for health,safety or welfare

Section 9:no charge to employees for H&S items

HSAWA (iii)


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HSAWA - (iii)

Section 36:where the commission of anoffence is due to the default of another

person - that person shall be guilty of theoffence

Section 37:Directors are responsible (as

well as the body corporate) for offencescommitted with their consent/connivance orattributable to any neglect on their part

HEALTH & SAFETY


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HEALTH & SAFETYREGULATIONS

Made under the Health & Safety at Work etcAct 1974

Often required by European Directives

Consultative Documents issued by Health &Safety Commission

Signed by the Secretary of State

Laid before Parliament Have coming into force (CIF) dates

Most may be cited in breach of statutory

duties actions (but not HSAWA or MHSWR)

REGULATIONS !


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REGULATIONS !Management of H&S at Work * Workplace Health,

Safety & Welfare * Working time * Provision & Use ofWork Equipment * Personal Protective Equipment atWork * Display Screen Equipment * Manual Handling

Operations * Safety Signs & Signals * PressureSystems * Electricity at Work * First Aid at Work *

Control of Substances Hazardous to Health * Controlof Asbestos at Work * Genetic Modification (Contained

Use) Regulations * Dangerous Substances &Explosive Atmospheres * Ionising Radiations *Genetic Modification * Reporting of Accidents,

Incidents & Dangerous Occurrences

MANAGEMENT OF HEALTH &


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SAFETY AT WORK REGULATIONS

Assessment of risks

planning, organisation, control monitoring &review

health surveillance competent H&S personnel

emergency procedures

information & training

co-operation with other employers

employees to follow instructions &reportserious dangers/shortcomings

WORKPLACE HEALTH, SAFETY


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,& WELFARE REGULATIONS

Maintenance,ventilation, heating & lighting

Cleanliness & waste materials

Space

Workstations, floors & traffic routes

Measures to prevent falls or falling objects

Windows, skylights & ventilators

escalators, walkways, doors & gates toilets, washing facilities, drinking water

Facilities for changing, resting & eating

PROVISION & USE OF WORK


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PROVISION & USE OF WORKEQUIPMENT REGULATIONS

Work equipment suitable for use

maintained in good repair

information, instruction & training

machine guarding

precautions against specified hazards

controls, isolation, stability, lighting markings & warnings

mobile work equipment & power presses

CONTROL OF SUBSTANCES


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HAZARDOUS TO HEALTH

REGULATIONS Risk assessment

elimination or control of risk maintenance of equipment

environmental monitoring

health surveillance emergency procedures

information, instruction & training

APPROVED CODES OF


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PRACTICE

ACOPs are prepared by the Health & SafetyCommission

Although they are not laid before Parliament, theyhave a legal status

They set out how Regulations may be compliedwith

You do not have to follow the ACOP but if you donot you may have to prove that you complied with

the Regulations by other means

ENFORCEMENT OF H&S LAW:


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ENFORCEMENT OF H&S LAW:POWERS OF INSPECTORS (HSE

etc) Entry to premises

Involvement of police

Make necessary examinations & investigations

To direct premises are undisturbed

To take photographs, measurements & samples

To order plant to be dismantled

Require witness statements

Inspect documents etc

HSE ENFORCEMENT POLICY


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HSE ENFORCEMENT POLICY

See HSE Enforcement Policy Statement Proportionality:relating enforcement to

how far the duty holder has fallen short oflegal requirements

Targeting: concentrating on the mostserious risks

Consistency: taking a similar approach insimilar circumstances

Transparency: telling duty holders what isexpected of them

NOTICES & PROSECUTION


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NOTICES & PROSECUTION

A Prohibition Notice prohibits an activity (e.g. use of adangerous machine)

An Improvement Notice requires improvements (usually

within a time scale) Organisations can appeal against notices to an Industrial

Tribunal

The HSE names and shames offenders

Enforcing Authorities can prosecute offenders for breaches

of HSAWA or Regulations made under HSAWA

MAX PENALTIES UNDER HSAWA


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MAX PENALTIES UNDER HSAWA

Failing to comply with an Improvement/ ProhibitionNotice:

Lower court 20,000 and/or 6 months in prison

Higher court unlimited fine and/or 2 years in prison Breaches of sections 2-6 of HSAWA

Lower court 20,000; higher court unlimited fine

Breaches of regulations etcLower court 5,000; upper court

unlimited fine

R v ASSOCIATED OCTEL


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A contractor working for AO suffered severe burns

when a lamp broke setting fire to solvent vapours The contractors company was prosecuted under

Section 2 of HSAWA (duty to employees)

AO was convicted under Section 3 of HSAWA(duties to others)

AO appealed on the grounds that the work of thecontractors was not part of AOs undertaking

The appeal went all the way to the House of Lordsbefore finally being dismissed: the work was part of

AOs undertaking and they had a duty to ensure the

H&S of the contractors

CORPORATE


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MANSLAUGHTER

A company cannot have a criminal state of mind

At present, a company can only be convicted ofmanslaughter if the Controlling mind is first proved

guilty

This is normally only possible with very smallcompanies

R v OLL Ltd (1994) following the death of 4 childrenon a canoe trip OLL fined 60K & the managingdirector jailed

Changes in the law are imminent

Legal Requirements


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Health & Safety at Work etc Act 1974

Management of Health & Safety at WorkRegulations 1999

Failure to comply is a criminal act

Employers CANNOT insure against failureto comply

Section 2


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Section 2

Section 2(1) - employers general duty

Duty to ensure so far as is reasonablypracticable, the health, safety and welfare atwork of employees and any others who may beaffected by the undertaking.

Legal Standards


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Legal Standards

Reasonably Practicable or SFARP

Implies a weighing up of the risk against the cost

(in terms of time, money or trouble) of preventingor controlling the risk

Section 2 (cont )


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Section 2 (cont.) Provision of such information, instruction,

training and supervision as is necessary toensure , SFARP, the health and safety at work

of employees and any others who may beaffected.

Section 2 (cont )


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Section 2 (cont.)

Duty of Employers to Employees cont. 2.2a - safe plant and systems of work

2.2b - safe use, handling, storage andtransportation of articles and substances

2.2c - information, instruction, training andadequate supervision

2.2d - safe place of work and a safe means of

access and egress 2.2e - safe working environment and adequate

welfare facilities

Section 7


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Section 7

Duty of Employees at WorkIt shall be the duty of every employee whilst at

work:-

to take reasonable care of their own health andsafety and of any other person who may beaffected by their acts or omissions

to co-operate with their employer so far as isnecessary to enable that employer to meet theirrequirements with regards to any statutoryprovisions

S ti 21


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Section 21

Improvement NoticesIf an inspector is of the opinion that a person:-

is contravening one or more of the relevant

statutory provisions; or has contravened one or more of those statutory

provisions, in circumstances that it is likely thatthe contravention will continue or be repeated,

then he will issue an Improvement Notice.

S ti 22


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Section 22

Prohibition NoticesIf any activity is being, or is about to be, carriedout that could result in serious personal injury,

then an inspector may issue a ProhibitionNotice. This notice will cause the immediatecessation of the activity involved until allmeasures are rectified.

Enforcement


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Enforcement

The HSE can take legal action against anemployer/employee in a criminal court for H&Sfailures:

Unlimited fine and/orCustodial sentence

(Remember - you cannot insure against failure tocomply with H&S legislation)

If guilty = criminal record

British Justice


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British Justice

INNOCENT

until proven

GUILTY

beyond

ALL

REASONABLEDOUBT

Civil Litigation


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Civil Litigation

Provides for compensation to be paid topersons who suffer harm as a result of awork activity.

Can insure - Employers Liability InsuranceBurden of proof is NEGLIGENCE

Proof is on the balance of probabilities

Effectively guilty until you prove yourinnocence

Reportable


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Reportable

Reporting of:

Injuries (accidents & incidents)

Disease

Dangerous Occurrences

(Regulations)


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Why investigate?


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It is a reactive element in monitoringphase of your safety managementsystem: Eliminate the causes and underlying

causes to prevent a recurrence; Identifying safety management lapses by

examining shortfall between what you planto happen and what did happen;

Identify trends and patterns for futureprevention;

Evaluates organisations position in relationto potential breaches of law.

Why investigate?


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Accident Reporting &I i i


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Investigation

Objectives for this section:

to understand:

accident definitionaccident causation

accident costs

accident prevention

accident reporting/notification

accident investigation



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Investigation

Common Uninformed Comments

accidents just happen

we dont have many accidents safety is expensive

the insurance will pay

safety is just common sense



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Investigation

Accident Definitionwhat is an accident?

unplanned & uncontrolled event that led to, orcould have led to:

injury to persons, damage to property/plant/equipment,impairment to the environment or some other loss to thecompany

Accident Reporting &I ti ti


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Investigation

Accident Definition

accident types

minor dangerous occurrence

near miss

plant/equipment damage

minor injury

lost time injury

disablement/fatality

Accident Reporting &I ti ti


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Investigation

Accident Definition

Frank Bird (Accident Triangle)

600 near misses

30 property damage

10 minor injuries

1 serious injury (lost time or fatal)

THE ACCIDENT


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THE ACCIDENT

BASIC TYPES OFACCIDENTS

THE ACCIDENT


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THE ACCIDENT

MINOR ACCIDENTS:

Such as paper cuts to fingers or dropping

a box of materials.

THE ACCIDENT


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CC

More serious accidents that cause injuryor damage to equipment or property:

Such as a forklift dropping a load orsomeone falling off a ladder


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THE ACCIDENTNEAR MISS


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NEAR-MISS

Also know as a Near Hit

An accident that does not quite result in

injury or damage (but could have).

Remember, a near-miss is just as serious

as an accident !

THE ACCIDENT


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ACCIDENTS HAVE TWO THINGS IN

COMMON

THE ACCIDENT


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They all have outcomes from the accident

THE ACCIDENT


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They all have contributory factors thatcause the accident

Accident Reporting &Investigation


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Investigation

Accident Causation

environment

personal fault

unsafe act

unsafe condition

accident

injury/damage



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Investigation

Accident Causation

causal factors

individual

job

organisation


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Investigation

Accident Causation

causal factors

job

task

workload

equipment

controls

proceduresenvironment



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Investigation

Accident Causation

causal factors

organisation

culture

leadership

resources

work patterns

communications

ACCIDENT CAUSATION MODELS - 1


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ACCIDENT

INVESTIGATE PROCESS AND OUTCOMESTEERED BY INVESTIGATORS PRE-CONCEPTIONSOF CAUSATION

CONCLUDE PRIMARY CAUSE IS EITHER:

UNSAFE ACT, or; UNSAFE CONDITION

DEVISE A RULEFORBIDDINGBEHAVIOUR

DEVISE A TECHNICALSOLUTION



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Investigation

Accident Causation

Kings Cross Fire (1987) - 31died

discarded cigarette

accumulation of rubbish

poor cleaning regime

wooden escalator

failure of fire fighting equipment

lack of emergency training poor safety culture



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Investigation

Accident Causation

Herald of Free Enterprise (1987) - 189 died

failure to close bow doors

no checking/reporting system

commercial pressures

internal friction

disease of sloppiness



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Investigation

Accident Causation

Clapham Junction (1988) - 35 died & 500 injured

signal failure

incorrect maintenance

degradation of working practices

training problems

communication problems

poor supervision excessive working hours

failure to learn lessons



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Investigation

Accident Causation

Piper Alpha (1988) - 167 died

maintenance error

inexperience

poor maintenance procedures

communications breakdown

permit to work system fault

safety procedures not practised



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Investigation

Accident Causation

Automotive Supplier (1999) - 1 died

poor safety culture

lack of guarding

lack of training

poor perception of risk

no safe systems of work

no risk assessment programme no effective accident system

no communication

OUTCOMES OF ACCIDENTS


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NEGATIVE ASPECTS

Injury & possible death

Disease Damage to equipment & property

Litigation costs, possible citations

Lost productivity Morale

OUTCOMES OF ACCIDENTS


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POSITIVE ASPECTS

Accident investigation

Prevent recurrence Change to safety programs

Change to procedures

Change to equipment design

The Aim of the Investigation


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The key result should be to prevent arecurrence of the same accident.

Fact finding: What happened?

What was the root cause?

What should be done to prevent recurrence?

The Aim of the InvestigationIS NOT TO:


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IS NOT TO:

Exonerate individuals or management.

Satisfy insurance requirements.

Defend a position for legal argument.

Or, to assign blame.



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Investigation

Accident Costs

insured costsuninsured costs



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Investigation

Accident Prevention

reasons

humane

economic

legal



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Investigation

Accident Prevention

control measures

safety procedures/work instructions

adequate training

effective communications

good housekeeping

guards/safety devices/warning signs

adequate working environment regular safety inspections

risk assessment



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Investigation

Accident Reporting/Notification

internal report form

HSE RIDDOR report

injury claim requirement



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Investigation

Accident Investigation

reasons

identify root causes

identify faults

identify corrective/preventative action

prevent recurrence


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THEINVESTIGATION

Objectives


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Recognise the need for an investigation

Investigate the scene of the accident

Interview victims & witnesses

Distinguish fact from fiction

Determine root causes

Compile data and prepare reports

Make recommendations

ACCIDENTS & ILL HEALTHREASONS FOR INVESTIGATION


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REASONS FOR INVESTIGATION

to record what happened RIDDOR legal reporting requirement

compensation claims/insurance to find out what & why it happened

immediate causes (What)

underlying causes (Why)

to prevent recurrence the next incident could be more serious

Traditional approach to accidentinvestigation


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investigation

Safety management has concentrated onaccident investigation as it is a good dealeasier than proactive prevention

Key features: Search for the primary cause, and

Debate whether the primary cause was

and unsafe act or unsafe condition

HEINRICH'S TRIANGLE( )


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300

29

1 MAJOR INJURY

MINOR INJURIES

NON-INJURY INCIDENTS

(1950)

Accident causation


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First accident model was Heinrich (1931).Domino theory

Social environment Fault ofperson

Unsafe Act

Unsafe condition

Accident Injury


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HSE Guidance on accidentinvestigations [HSG 65]


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Need for line managers to take responsibilityfor investigation;

need for adequate training for investigators;

importance of investigating both accidentsand other incidents and near-misses - esp.those with potential for serious injury;

need to deal with immediate consequences atscene by treating, helping and rescuingpersons and making site safe;

contd

investigations [HSG 65]

HSE Guidance on accidentinvestigations [HSG 65] contd


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investigating to appropriate depth, depending on itsseriousness; guidance on investigation process to investigators,

including: structured approach

appropriate use of observation, documents andinterview evidence; use of model to guide collection of evidence and its

assembly for evaluation need to explore immediate and underlying causes

developing specific objectives for implementingfindings

need to record essential data

Attending the accident scene


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OBSERVE

Look at the scene and the surrounding area Take measurements and produce a diagram

Take photographs

INTERVIEW

The injured person and/or witnesses(preferably separately)

At the scene if possible(within 48 hours)

Note down beforehand some key questions to beanswered - CHECKLIST

Ask open-ended questions in a friendly manner

KEEP AN OPEN MIND (be aware of your bias)


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Statements


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Introduce yourself (if necessary)and explainyour role what needs to be done

Invite safety rep or another person they would

like to sit in, but not answer questions If trainee under 18 years, interview with an

adult, preferably a parent

Run through your questions and what theywitnessed and make notes to help structure astatementEach persons summary

A modern approach


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Immediate causes and underlying causes HSG65

Accidents are Multi-causal

Understanding of the complexities ofhuman factors

Understanding of management systems

Promotion of a safety culture

HS(G)65 Appendix 5Immediate causes (what)


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Immediate causes (what)

4 Ps Premises

Plant/Substances

Procedures

People

Premises


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Physical layout Condition of building

Environment (weather)

Tripping & slipping hazards

PLANT/SUBSTANCES


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Machinery guarding Substance in usetoxic, harmful

Mobile plant

Item of work equipment hand tools,chairs

PROCEDURE


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Written system of work/operatingprocedure to be followed

Safety Policy

Work instruction Quality standard

Custom and Practice does not have to

be a document

People


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Human factors State of health (eye sight)

Abilities

Errors skill based (slip or lapse), rulebased, knowledge based or violations

Behaviour pressures, culture

Underlying causesRoot causes (Why)


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( y)

5) Planning

6) Risk Assessment

7) Control(Supervision)

8) Co-operation

9) Communication

10) Competence

11) Monitoring 12) Reviewing

HSG65 APPENDIX 5

IMMEDIATE CAUSE UNDERLYING CAUSE


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PREMISES

PLANT AND

SUBSTANCES

PROCEDURES

PEOPLE

PLANNING

ASSESSING

RISKS

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

ORGANISATION

CONTROL

ORGANISATION

CO-OPERATION

ORGANISATION

COMMUNICATION

ORGANISATION

COMPETENCE

MONITORING

REVIEW

Hazards


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IdealReality

Management

Arrangements

RCS

WorkplacePrecautions

Underlying

Causes

ImmediateCauses

Hazards

Accident

Essential data in investigation reports


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Details of injured person - age, sex,experience and training, etc;

Description of circumstances - place, date,

time and conditions; Details of the event - actions leading directly

to event/ direct injury causes;

Underlying causes;

contd

Essential data in investigation reports


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Details of outcomes: nature of injuries, ill-health, losses;

severity of harm;

immediate management response and its adequacy;

First-aid response;

Potential consequences:

what was the worst that could have happened?

What prevented it from happening? How often could it recur and how many affected?

Accident investigationNotified of accident

S d f


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Scene made safe

Collect facts to answer 5 Qs: What, when, where, who, how?

By: 1. observation 2. documentation 3. interviews

Refer to relevant standards for comparison:[a] legal or good practice, and;[b] safety management plan.

Analyse differences between what happened and what should have happenedto identify causes and underlying SMS lapses

Target report atdecision-makers

Feed into monitoring/review stages of SMS forvalidation/verification comparison

Follow-up to implement necessary changesto SMS plan AND site

Accident Reporting &Investigation - team


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g


investigation team

supervisor

safety rep

engineer

manager

safety officer

Accident Reporting &Investigation - objectives


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g j


investigation objectives

establish chain of events

identify root causes

identify faults


Accident Reporting &Investigation - techniques


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g q


investigation techniques

attend promptly

ensure medical attention

leave scene undisturbed

take photographs/sketches

take measurements

take samples gather documentation

interview witnesses


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Accident Reporting &Investigation - report


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investigation report

identify team

summarise consequential events identify root causes

describe other weaknesses


allocate responsibility & timescale


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Working together

improving safety


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What are you doingto involve your

workforce?

What is workforce involvement?


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Involve the workforce as equal partners Actively seek their views

Value their positive contribution

Enable effective involvement in all areas ofH&S management

Be ready to change things and challengeprevious management practices

Nurture, support and sustain the partnership.


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Do you shape up?


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Are employees involved in long term H&S Are workers involved in writing safe working

procedures?

When accidents are investigated are safety repsfully involved?

Do H&S audits include safety reps as well asmanagers?

Where is all this from?


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HSE booklet HSG217 Involving employeesin health and safety

Aimed at the chemical industry but should

apply to everyone Does it apply to you?

Health and Safety


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Health and Safety

Management

Safety Representatives

Safety Officers

And Safety Committees

Members and Meetings


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All work areasshould berepresented

Members should beinterested,concerned and willing to learnmore about h&s

Willing to meet oncea month and tocommunicate withworkers

Meetings discussworkers concerns

Possible solutions

Approaches tomanagementnegotiations

Ongoing concerns

and progressreports to union

Functions of Committee Conduct regular inspections and

surveys on safety and health


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surveys on safety and health

Respond to workers concerns on OHS

Make reports and recommendationsto improve compliance with law andstandards

Propose policies, work plans, projectsand activities to reduce accidents and

illness

Propose and organise trainingprogrammes for the workforce

Functions of Committee


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Promote and support activities on OHS

Follow up progress of proposals

Report on results achieved, point out

obstacles and problems Investigate, record and report on all

accidents, ill health and near misses

Propose regulations on health andsafety

Organise occupational health services

What makes a committee work?

Have a plan and objectives and actively pursue


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Have a plan and objectives and actively pursue

them with the broadest support possible

Communicate and educate to get that support

Need facilities, time off, info and training

Agendas in advance, proper minutes, decisions

If union reps make coherent proposals in writing:describe the problem, include the facts; suggestimprovements; decide who will do what; timetableand budget.


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PLANNING

Building Partnerships


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POLICY

ORGANISATION

PLANNING

MEASURING

AUDIT &

REVIEW

commitment

agreed goals

leadershiprespect forlegitimateinterests

shared vision

positiveculturechange

openness

transparency

trust

honesty

Partnership

building

blocks

H&S

management

system

HSG65

This is what you need to do


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Involve the workforce as equal partners

Actively seek their views

Value their positive contribution

Enable effective involvement in all areas ofH&S management

Be ready to change things and challenge

previous management practices Nurture, support and sustain the partnership.

If you do that


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We will genuinely be working together

You will be improving H&S

The workers will be healthier and safer

You will be financially healthier and safer

it works !


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For attendingthis course


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