Accident Investigation

Dr. Richard Griffiths, PhD, MSc, MEd, Cert Ed, Grad R.S.C, FRSH, FRIPH, CMIOSH, MIIRSM

Accidents are a particular type of incident, which may result in personal loss, minor injury, serious injury or death. Where no such outcome results, the accident is classified as a near miss.

Generally, investigations are performed in the following circumstances:

• Any fatality arising from work activities, excluding those relating to road traffic accidents.

• Certain RIDDOR-defined major injuries, diseases and dangerous occurrences, related to the severity of the outcome.

• All RIDDOR incidents likely to give rise to serious public concern, whether major or minor injuries, or dangerous occurrences.

• All RIDDOR incidents where there is likely to have been a serious breach of health.

  (RIDDOR stands for the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995.)

The primary purpose for the investigation and reporting of accidents is to prevent further occurrences and to address the issues identified, i.e. the immediate and underlying causes, and compliance with legal standards. Another purpose is to prevent any further loss, develop a safety culture and certain managerial skills. Outside of the organisation, others have different reasons for investigating incidents: Enforcement Agencies look for evidence of an offence and identify those responsible, then the courts or insurance claims assessors look for evidence of liability.

The HSE publication HSG245 Investigating Accidents and Incidents complements and expands on the accident procedures set out in HSG65 Successful Health and Safety Management. The guidance sets out the four stages of accident investigation:

• Gathering information.

• Analysing information.

• Identifying risk control measures.

• Risk control action plan.

Gathering Information

The first stage of the investigation process is to find out what happened and to gather evidence; this should begin as soon as possible. The first priority should be to treat the victim(s) and secure the area from further danger, making it safe, but secure and where possible, undisturbed. An accident investigation process should start with the formation of an investigation team. The level of investigation will depend on the accident, its complexity and the severity of its consequences. The investigation should be conducted by, or under the supervision of, a competent person. This would be someone with the knowledge and skills in the specific working practices within which the incident occurred, and who understands the nature of the safety requirements that need applying, for example the immediate supervisor or foreman, a member of management or a safety officer or representative. The investigation should also cover clearing-up operations and reinstatement, as further evidence may throw light on the incident.

The next stage is to carry out witness interviews, if possible, at the scene of the accident. It is important not to come to any preconceived conclusions and to allow witnesses to explain what happened, in their own words. There are three types of witness who should all be assured that the purpose of the interview is not to blame anyone, but to attempt to find out the cause and reduce the possibility of recurrence. Such witnesses may be those involved directly in the incident, including the victim(s) or eyewitnesses, as well as witnesses who did not see the incident, but can provide certain information on the actions of people, or can collaborate other witness statements.

The physical circumstances should be recorded graphically, through the use of plans, figures and diagrams, and by photographs or video evidence. These should be used to identify environmental conditions, such as temperature, lighting, actions, locations, positions of persons, vehicles, etc. as well as the extent and severity of the damage, locally and further from the scene.

The plans should be accurately labelled to indicate any physical measurements at the time; noise or light levels, substances involved, speeds of vehicles, the moving parts of machines and distances involved, such as reach distances. Once the immediate effects have been dealt with, the relevant records should be consulted: the accident book, information about the people, plant and environment, machinery involved in the incident, as well as inspection and maintenance records, risk assessments, environmental measurements, medical records, specific safety reports and analyses.

Checklists are commonly used to list key points, which must be investigated. They also detail what happened and what caused the accident, including physical conditions and acts of persons. Depending on the nature of the workplace and the operations, such as an office environment or machinery workshop, the checklists will contain differing amounts of information.

Analysing Information

The next priority of the investigation is to identify the immediate, direct cause of the incident, because there is a risk that the same circumstances may recur. Steps need to be taken to ensure that there is no repetition of the problem, e.g. unsafe acts or unsafe conditions. Whilst there may be an underlying reason for these acts or conditions, it is important to establish exactly what has caused the incident.

• Unsafe acts - these are where the actions (or omissions of action) of people at the workplace directly cause, or contribute to, the incident. They may include: operating without permission, contravention of specific rules and not using safety devices.

• Unsafe conditions - these are where the physical conditions at the workplace or the methods of work directly cause, or contribute to, the incident. They may include: unguarded machinery, inadequate guarding, the provision of unsafe equipment, unsafe floors and working surfaces and unsafe systems of work. There must also be a requirement to consider human error as a possible factor. Similarly, one should consider human factors , i.e. environmental, organisational and job factors, and individual characteristics, which influence behaviour at work, and ultimately affect health and safety failure through the organisation, its culture, management, and resources.

The next part of the investigation involves finding out what caused the unsafe acts (and omissions) or the unsafe conditions. If there are underlying reasons for the immediate cause, these must also be remedied to prevent the same circumstances recurring. The process of investigating the reason for each underlying cause goes on until the real root of the problem is established.

However, the purpose of the investigation is not to attribute blame, but to establish all the reasons for the incident and to see if there are any lessons that can be learned for the future.

Identifying Risk Control Measures

The next stage in the investigations is to identify any control measures required. The investigation of a single incident may lead to that of a range of wider issues, relating to the immediate and underlying causes.

All risk-control-measure options need to be analysed and evaluated according to the control hierarchy; elimination, substitution, engineering controls, etc. They must be prioritised with appropriate control measures and actions specified. Responsibilities and timeframes for actions must be considered and allocated, and most importantly, the controls must be "so far as is reasonably practicable".

Wider implications also need to be considered:

• Can lessons learned be applied elsewhere?

• Could similar events occur elsewhere?

• Would recommended controls prevent similar accidents?

Risk Control Action Plan

The final stage is to formulate a risk control action plan from the control measures required. These may be immediate measures, as well as short- or long-term actions. These are required to be documented accurately and prioritised accordingly.

Control targets, which are Specific, Measurable, Attainable, Realistic and within a certain Timescale (SMART ), need to be set. These measures are to be reviewed, assessed and appropriate procedures put in place to perform such actions. Similarly, there must be procedures to discuss findings relating to the incident with staff, through safety meetings and verbal and written communication.

Conclusion

Unfortunately, accident investigations are not only part of the workplace, as in Flixborough, Clapham and Herald of Free Enterprise, but are also part of sporting and leisure activities, for example Hillsborough and Lyme Bay. A properly conducted investigation is useful to understand the causes and possibly prevent similar or parallel accidents happening in the future. Accident investigations are important because they contribute to the continual improvement of health and safety performance.

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