ELEMENT 4:

HEALTH AND SAFETY

MONITORING AND MEASURING
 Unit IG1
Element 4.2

INVESTIGATING INCIDENTS
 Learning Outcomes
4.2 Investigating incidents
The different levels of investigations: minimal, low, medium and
high (see HSG245)
Basic incident investigation steps:

• step one: gathering the information

• step two: analysing the information
• step three: identifying risk control measures
• step four: the action plan and its implementation
How occupational accidents and diseases are recorded and notified by the organisation
(Recording and notification of occupational accidents and diseases, ILO Code of Practice –
chapters 4–7)
Reasons for Incident Investigations
(Why do Incident Investigations)
(Role & Function of Investigation)
Reasons to carry out investigations of an accident :
 To identify the immediate and root causes of the incident.
 To identify corrective action to prevent a recurrence.
 To record the facts & evidence of the incident.
 For legal reasons.
 For claim management & Insurance Purposes.
 For staff morale.
 For disciplinary purposes.
 For data gathering purposes.
• To update risk assessments.
• Discover trends of Accidents .
 Types of Incident

• Accident.
• Injury accident.
• Damage-only accident.
• Near-miss.
• Dangerous occurrence.
• Work-related ill health.
 Types of Incident
Accident
An unplanned, unwanted event which leads to injury, damage or
loss:
• Injury accident – where the unplanned, unwanted event
leads to some sort of personal injury, e.g. a cut hand.
• Damage only accident – where the unplanned, unwanted
event leads to equipment or property damage but not personal
injury, e.g. a wall is demolished.
Near-miss
An unplanned, unwanted event that had the potential to lead to
injury, damage or loss but did not.
 Relationship Between
Incident Types
Published by the Health and Safety Executive and licensed under the Open
Government Licence v1.0: (HSG245)

Hazard Near-Miss Injury

Accident Ratios

Frank Bird Accident Triangle

 Types of Incident
Dangerous occurrence:
• A specified event that has to be reported to the
relevant authority by statute law, e.g. a major gas leak.
Ill health:
• A disease or medical condition that is
directly attributable to work, e.g. dermatitis as a result of
exposure
to skin irritants.
Benefits of Investigation
 Level of Investigation
• More minor incidents.
• Investigated by line manager.

• Major incidents, more complex events or incidents with

high potential.
• Investigated by a team:
- Safety specialist.
- Senior manager.
- Technical specialist.
- Worker representative.
 Basic Investigation Procedure
Safety of the scene:
Is the area safe to approach?
Is immediate action needed to eliminate danger before
casualties are approached?
Casualty care:
First-aid treatment.
Hospitalisation:
– Also consider that
by-standers may be in shock.
 Basic Investigation Procedure
Step 1
• Gather factual information.
Step 2
• Analyse the information and draw conclusions.
Step 3
• Identify suitable control measures.
Step 4
• Action plan the remedial actions & its
implementation
 Step 1 - Gathering Information
How and what?
1. Secure the scene.
2. Identify witnesses.
3. Collect factual information:
• Photo/sketch.
• Measurements.
• Notes.
• Mark-up plans.
• Samples.
4. Interview witnesses.
5. Examine documents.
 Witness Interview Technique
 Quiet room, no distractions.
 Establish a rapport.
 Explain the purpose, not about blame.
 Use open questions, e.g. Who? What? Where? When?
Why? How?
 Keep an open mind.
 Take notes.
 Ask for a written statement.
 Thank the witness.
 Document Examination
to be done during investigation.
• Site plans.
• Company health and safety policy.
• Risk assessments.
• Training records.
• Safe systems of work.
• Permits-to-work.
• Maintenance records.
• Previous accident reports.
• Sickness records.
Step 2 – Analysing Information
Immediate causes:
• Unsafe acts.
• Unsafe conditions.
Underlying/root causes:
• Reasons behind the immediate causes.
• Often failures in the management system:
– No supervision.
– No PPE provided.
– No training.
– No maintenance.
– No checking or inspections.
– Inadequate or no risk assessments.
 Immediate causes
Immediate causes are the unsafe acts and unsafe conditions
that gave rise to the event itself. These will be the things that
occurred at the time and place of the accident.

For example, a worker slips on a patch of oil spilt on the floor

- immediate causes: the slip hazard (unsafe condition), the
worker walking through it (unsafe act).
 Underlying or root causes
Underlying or root causes are the things that lie behind the
immediate causes.
For example, with the slip we described above, the root causes
might be a poorly maintained machine that has leaked oil onto the
floor, and a poorly inspected and maintained workshop with broken
light-fittings and inadequate lighting levels.
Here, the worker might be blameless on the basis that, given those
conditions, the accident was bound to happen eventually.
 Root causes due to failures in the
management system

• Failure to adequately supervise workers.

• Failure to provide appropriate PPE.

• Failure to provide adequate training.

• Lack of maintenance.

• Inadequate checking or inspections.

• Failure to carry out proper risk assessments.

Immediate Cause & Root Cause
 Forklift Truck Accident
Immediate causes:
• Failure to secure the pallet.
• Poor positioning of the truck close to the pedestrian exit.
• Aggressive braking by the driver.
• Inattentive pedestrian steps into the path of the forklift
truck.
Underlying/root causes:
• No training for the driver.
• Lack of segregation of vehicles and pedestrians.
• Poor driver induction.
• Poor truck maintenance.
• No refresher training.
 Step 3 – Identifying Suitable Control
Measures
Controls measures should be appropriate to unsafe act
and unsafe condition of the worker and management
failure. e.g. strict monitoring , trainings to workers.

For immediate causes:

• Clean up the spill.
• Replace the missing guard.
• Relocate the trailing cable.
For underlying/root causes:
• More difficult.
• Need to make changes in management system.
 Step 4 – Action plan the Remedial
Actions & implementation
Remedial action should focus the prioritise to be given , within the
timescale and action to be taken along with personal responsible to
complete the action.

 Dangerous conditions must be dealt with immediately.

 Interim actions may be possible.
 Underlying causes will require more complex actions:
• It will take time, effort, disruption, money.
• Need for prioritisation.
 Step 4 – Action plan the Remedial
Actions & implementation

Recommended action Priority Timescale Responsible

Introduce induction training Medium 1 month Warehouse Manager

for all new FLT drivers
 Typical contains of
investigation reports
i/ Date and time of the incident
ii/ Location of the incidents
iii/ Details of injured persons/ person involve.
iv/ Details of the injury
v/ Assessment of breaches of the legislation.
vi/ Causes of the incident.
RECORDING AND REPORTING
INCIDENTS
 Incident Reporting
Reasons for reporting incidents:

• To trigger the First aid.

• Preserve accident scene.

• Enable investigations to be carried out to prevent

recurrence.

• Legal requirement
Incident Reporting Requirement-
What required ?
Barriers to Reporting of Accidents
• Unclear organisational policy.
• No reporting system in place.
• Culture of not reporting (peer
pressure).
• Overly-complicated reporting procedures.
• Excessive paperwork.
• Takes too much time.
• Blame culture.
 Accident Record Contents
• Name and address of casualty.

• Date and time of accident.

• Location of accident.

• Details of injury.

• Details of treatment given.

• Description of event causing injury.

• Details of any equipment or substances involved.

 Internal and External
Incident-Reporting
Will depend on the severity:
Internal External
• Directors • Family of the casualty
• Senior managers • External authorities
• Human resources managers • Insurance companies
• Health, safety and • Public relations advisers
environmental advisers
• Worker representatives
 Externally-Reportable Events
Some incidents need to be reported to
regulator by law, e.g.:
• Fatality.
• Major injury.
• Dangerous occurrence.
• Disease.
• Lost-time injuries.
 Reason of Data Collection
Why Analysis the data
Analysis of data:
• What is the trend in accident/incidence rate over the past 5
years?

• What are the most common types of accident?

• What are the most common types of injury?

• Between what times of the day do most accidents occur?

 Lessons Learnt
What Organisations need to ask:

• ‘What is essential to securing the health and safety of

the workforce today?

• What cannot be left until another day?

• How high is the risk to employees if this risk control

measure is not implemented immediately?’