Accident/Incident investigation

 


Starting an Investigation

• Health and safety policy sets the standard you want to achieve

• Suitable procedure explains how you want to achieve it

• Guidance HSE STANDERD

Initial Actions

• Emergency response:

– Prompt emergency action (eg first aid)

– Make the area safe (in some cases this may need to be done first

• preserve the scene

• note the names of the people, equipment involved and the names of the witnesses

• report the adverse event to the person responsible for health and safety who will decide what further action (if any) is needed

Initial Assessment and Investigation Response

• Report the adverse event to the regulatory authority if appropriate.

– RIDDOR

• Fatals, major injuries, dangerous occurrences

– COMAH

• Major accident

– Ill-Health

– Reported on diagnoses

• Reported “forthwith” - Immediately

Investigation - Methods

Four Step Investigation

• Step one - Gathering the information

• Step two - Analysing the information

• Step three – Identifying suitable risk control measures

• Step four – The action plan and its implementation

Step one – Gathering the information

• Find out what happened and what conditions and actions influenced the adverse event.

• Begin straight away, or as soon as practicable.

• Talk to everyone who saw or know what happened or led to the adverse evenStep one – Gathering the information

• Collect all available and relevant information.

• That includes:

– opinions, experiences, observations – Process drawings, sketches, measurements, photographs – check sheets, procedures, permits-to-work, method statements, risk assessments – details of the environmental conditions at the time etc.

Gathering Detailed Information – Where, When and Who?

• 1 Where and when did the adverse event happen?

• 2 Who was injured/suffered ill health or was otherwise involved with the adverse event?

• 3 How did the adverse event happen? Note any equipment involved

• 4 What activities were being carried out at the time?• 5 Was there anything unusual or different about the working conditions?

• 6 Were there adequate safe working procedures and were they followed?

• 7 What injuries or ill health effects, if any, were caused?

• 8 If there was an injury, how did it occur and what caused it?• 9 Was the risk known? If so, why wasn’t it controlled? If not, why not?

• 10 Did the organisation and arrangement of the work influence the adverse event?

• 11 Was maintenance and cleaning sufficient? If not, explain why not.

• 12 Were the people involved competent and suitable? • 13 Did the workplace layout influence the adverse event?• 14 Did the nature or shape of the materials influence the adverse event?

• 15 Did difficulties using the plant and equipment influence the adverse event?

• 16 Was the safety equipment sufficient?

• 17 Did other conditions influence the adverse event?

Step Two – Analysing the Information

• Analysis of all information available

– Physical

– scene of incident

– Verbal

– accounts of witnesses

– Written

– documents

• Process drawings

• Risk assessments

• Permits to work

• Procedures • Instructions, job guides etc.• What were the immediate, underlying and root causes?

• Method of analysis

– Events & Causal Factor Analysis (ECFA)

– Timeline

– Why?..... because

– Question set / Checklist Method

• (Place, Plant, Procedures and People)

• What happened and why

Step Two – Analysing the Information

• Job Factors

• Human Factors

• Organisational Factors

• Plant & Equipment Factors

Step Three – Identify Suitable Risk Control Measures

• What risk control measures are needed/recommended?

– What worked, what failed

• Do similar risks exist elsewhere? If so, what and where?

• Have similar adverse events happened before? Give details.

Step Four – The Action Plan and its Implementation

• Which risk control measures should be implemented in the short and long term?

• Which risk assessments and safe working procedures need to be reviewed and updated?

• Have the details of adverse event and the investigation findings been recorded and analysed? – Are there any trends or common causes which suggest the need for further investigation? – What did the adverse event cost?

Investigation Review

• Do we know how and why things went wrong

• Do we know how people can be exposed to substances or conditions that may affect their health

• Have we exhausted all reasonable lines of enquiry

• Have we identified the immediate, underlying and root causes of the adverse event

• Do we know if our risk control measures are adequate • Do we have an action plan to implement improvements or additional control measures

• Has it given a true snapshot of what really happens at your site - and how work is really done

• Do not forget - have we praised what went well

• Can we learn anything new about the investigation process or our procedures

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