An introduction to accident investigation. www.UK-HSE.co.uk

1. Accident and
Incident
Investigation
an introduction
Accident and Incident Investigation – an Inroduction Issue 1.0 Augu
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2. Aim of Session
• To provide an overview of:
– Accident investigation
– Human Factors as they relate to
accidents and incidents
– Immediate causes of accidents and
incidents
– The “Why? - Because” model of
root cause analysis
– Responding to an incident
Accident and Incident Investigation – an Inroduction Issue 1.0 Augu
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3. Introduction
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4. Why report accidents and
incidents
• All accidents and incidents need to
be reported
• Comply with the law
• Identify failings – prevent recurrence
• What is YOUR reporting procedure
• Some to the Health and Safety
Executive (HSE) - RIDDOR
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5. RIDDOR
The Reporting of Injuries, Diseases and Dangerous Occurrence
Regulations 1995
• Death
• Major injuries – e.g. broken leg
• Over-3-day injuries
• Injuries to members of the public taken
from the scene of an accident to hospital
• Some work-related diseases e.g. skin
cancer from mineral oil
• Dangerous occurrences – e.g. scaffolding
collapse
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6. Terminology
• Hazard
- something with the potential to cause
harm
• Incident
- Unplanned, uncontrolled event
…….could result in an accident
• Accident
- Unwanted or unintended sudden
event ….harmful consequences
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7. The realisation of harm
Hazard Machine Guard
Safe System of Work
PPE
Undesirable event
Harm
Accident and Incident Investigation – an Inroduction Issue 1.0 Augu
Session 5 30 minutes
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8. The realisation of harm
Hazard Put in extra barriers
Machine Guard
Safe System of Work
PPE
Undesirable event
Harm
Accident and Incident Investigation – an Inroduction Issue 1.0 Augu
Session 5 30 minutes
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9. The realisation of harm
Hazard Identify and remove
Machine Guard
the holes (e.g. latent
Safe System of Work
failures)
PPE
Undesirable event
Harm
Accident and Incident Investigation – an Inroduction Issue 1.0 Augu
Session 5 30 minutes
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10. Human Factors
Accident and Incident Investigation – an Inroduction Issue 1.0 Augu
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11. Why Classify the Human Failure
• If you understand the human
failure, you can start to
understand the causation path
and what to do about it
– If someone has a lapse then
training etc. will not help, we
should look at the visual clues,
process checks and balances
– If it is a mistake then we should
look at the training, supervision,
data supplied, etc.
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12. Human Failure
• Error - action or decision which was
not intended and which led to an
undesirable outcome
– Slip / Lapse - performing the wrong
action (slip) or omitting to carry out a
step in the process (lapse) (Forgets)
– Mistake - a person does the wrong
thing while believing it to be the right
• Violation - when a person
deliberately “breaks the rules” and
violates a rule, regulation or
instruction.
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13. Identifying the
Immediate Causes
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14. Accidents and Incidents
• Unsafe act
– action likely to result in accident
– occurs immediately prior to the
accident
• Unsafe condition
– article, equipment or
environment in a condition likely
to result in accident
– exists prior to the accident
Accident and Incident Investigation – an Inroduction Issue 1.0 Augu
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15. Immediate Causes
Immediate Causes
Unsafe
Unsafe Acts
Conditions
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16. Underlying
Causes
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17. Underlying Causes
Immediate Causes
Unsafe
Unsafe Acts
Conditions
Underlying Causes
Human Missing or
Failure Inadequate
Slips/Lapses, Control
Mistakes or
Violations Measures
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18. Why? Because Model
Incident Person fell down the stairs due to tripping on a training cable
Why Why was the trailing Because The contractor had put it
cable at the top of the there
stairs?
Why The contractor had put Because He was not aware of the Safe
it there? System of Work on „Trailing
Cables‟
Why He was not aware of Because He had not been briefed by
the Safe System of the supervisor
Work on „Trailing
Cables‟?
Why He had not been Because The supervisor had become
briefed by the sloppy and failed to brief
supervisor? the contractor
Accident and Incident Investigation – an Inroduction Issue 1.0 Augu
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19. Model of Causal Analysis
Identify Facts and Failures
Immediate Causes
Unsafe
Unsafe Acts
Conditions
Underlying Causes
Human Missing or
Failure Inadequate
Slips/Lapses, Control
Mistakes or
Violations Measures
Identify Root Causes
Influencing Influencing
Factors Factors
Job or
Personal
Organisational
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20. Root Causes
Individual
Competence, personality,
attitudes, risk
perception…
Job Organisation
Task, workload, leadership, resources,
equipment, displays, work patterns,
controls, procedures communications
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21. Excellent starting checklist
Section 2, HASAWA* 1974
Employer’s duties to employees
So far as is reasonably practicable
• Safe plant and systems of work
• Safe storage, handling, use and transportation of
articles and substances
• Information, training, instruction and supervision
• Safe access and egress
• Safe working environment and adequate welfare
facilities
* Health and Safety at Work etc. Act 194
Accident and Incident Investigation – an Inroduction Issue 1.0 Augu
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22. Responding to an
Incident
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23. Response to the Incident
• Preserve Information
• Gather Evidence
• Don‟t make assumption
• What was the Safe System of Work in
place?
• What equipment was being used?
• Were people competent?
• What supervision was in place?
• Is something FACT or OPINION?
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24. Conducting an Interview
• Organise the interview
• Greet and Personalise
• Explain aim and objectives
• Initiate Free Reporting
• Ask open questions
• Encourage retrieval
• Summarise – get agreement
• Explain next step
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25. Sequence of Events
• Determine the chronological listing of
events that gave rise to the incident
- Before incident
- Incident
- After the incident
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26. Identifying what went wrong
• Barriers in place
• What should have happened
• Which barrier failed
• Human failure
• Underlying causes
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27. Identify what needs to be done
to address failings
• Can include
- Individual action plans
- Group initiatives to address culture
issues
- Improvement plans
• Should include
- Monitoring
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28. Produce SMART Actions
• Specific
• Measurable
• Agreed / Achievable
• Realistic / Reasonable
• Timescale / Time based
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29. Writing the Report
• Use the correct terms
• Use of speech marks to „quote‟
• Vocabulary
• Clear and to the point
• Do not use people‟s names
• Do not use the terms violation lapse,
mistake in the report
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30. Writing the Report - Some
Guidance
• Immediate Cause
– The last event to occur prior to the Accident / Incident
and is either an unsafe act or unsafe condition
• Underlying Causes
– must cross reference with the problem issues
discussed in the “Factors for Consideration” and
demonstrate their contribution to the Accident /
Incident
• Action Plans
– The controls to prevent re-occurrence
– Make sure they are SMART
Accident and Incident Investigation – an Inroduction Issue 1.0 Augu
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31. Your Report – basic checklist
• Have you?
– Described Accident - Nature or Description
– Identified Hazards
– Determined the Sequence of events
– Determined the Control Measures or Barriers
– Determined Failures and where in the
sequence of events
– Identified Unsafe Acts and/or Unsafe
Conditions
– Identified Unsafe Act immediately prior to the
accident is the Immediate Cause
– Identified Unsafe Condition exists prior to the
accident
Accident and Incident Investigation – an Inroduction Issue 1.0 Augu
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32. Aim of Session
• Do you have an overview of:
– Accident investigation
– Human Factors as they relate to
accidents and incidents
– Immediate causes of accidents and
incidents
– The “Why? - Because” model of root
cause analysis
– Responding to an incident
Accident and Incident Investigation – an Inroduction Issue 1.0 Augu
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