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UNIVERSITY PROCEDURE
ACCIDENT / INCIDENT INVESTIGATION
Document No: CU/11/AII/P/1.0
Policy Ratified by: Safety Health and Env!"n#ent C"##ttee
Date: $%ly &011
Area Applicable: All Ca!dff Unve!'ty Staff
Review Year &01(
Impact Assessed YES
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1.0 Int!"d%)t"n
One of the hardest lessons to be learned in accident prevention comes from the
investigation of accidents and incidents that have caused serious inury or loss!
"acing up to those lessons can be traumatic for all concerned# which is one reason
why investigations are often incomplete! $he depth re%uired for an investigation
must be sufficient to obtain information that is of value to line management and
others that may wish ma&e use of the information# such as the 'niversity
Occupational (afety# )ealth and *nvironment 'nit +O()*',# the 'niversity Insurers
or the )ealth - (afety *.ecutive +)(*,!
An effective investigation re%uires a methodical# structured approach to information
gathering# collation and analysis! $he findings of the investigation will form the basis
of an action plan to prevent the accident/incident from happening again# and for
improving the overall management of ris&! $he findings will also point to areas of the
risk assessment that may need to be reviewed! It has to be remembered that the
lin& with ris& assessment+s, is a legal duty! 0onducting an effective accident
investigation can be e.pensive in time# but the rewards can also be great!
&.0 Inve't*at"n "f A))dent'
&.1 P%!+"'e
$he main reason for investigating accidents is prevention! $he purpose of the
investigation is to establish whether a reoccurrence can be prevented# or its effects
lessened# by the introduction of additional safeguards# procedures# information
instruction and training# or any combination of these!
&.& The P!")ed%!e
$here should be a defined procedure for reviewing or investigating all accidents#
however serious or trivial they may appear to be! $he use of a form/chec&list will
help to concentrate the attention on the important details! 1ine
2anagers/(upervisors of the wor&place where the accident occurred must complete
the initial investigation3 for less serious accidents they may be the only people who
ta&e part in the investigation and reporting procedure! 4or&ers5 representatives#
senior management# and safety personnel may also be involved at any part of the
process as part of the investigating team!
&.( ,h" 'h"%ld )a!!y "%t the nve't*at"n-
"ront line managers/supervisory staff should carry out the initial investigation! $his
demonstrates commitment and removes any temptation to leave 6health and safety5
to others!
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(.0 Inve't*at"n P!")e''
.evel 1. C"n'e/%en)e "f 0hat ha++ened and 0hat
)"%ld have ha++ened.
&. Inve't*at"n Tea# (. 1ndn*' and a)t"n +lan 2S3ART4 5. Cl"'e "%t
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1ow
2inor inury/1i&ely potential outcome no
more than first aid
1ocal containment of an environmental
incident within area of operation!
(upervisors/line managers
7(afety Representative
Report any findings on Accident form!
&
2edium
1i&ely potential harm/"irst Aid or more
4ider containment of an environmental
incident within 'niversity!
As level 8
Departmental (afety Officer
7(afety Representative
Record findings as level 8 and also on the Incident
Investigation "orm +II",!
Areas to consider include:
Immediate cause
Root cause
'nderlying cause
li&elihood of reoccurrence and severity of harm
control measures
(
)igh
)igh adverse effect/1i&ely conse%uences
could have been serious inury or fatality!
4ider containment of an environmental
incident! (tatutory re%uirements breached!
Impact outside of the 'niversity!
As level 8 - 9
O()*'
7(afety Representative
E6te!nal
)(*/*nvironment Agency!
Record findings as level 8 and also on the Incident
Investigation "orm +II",!
Areas to consider include:
Immediate cause
Root cause
'nderlying cause
li&elihood of reoccurrence and severity of harm
control measures
7(afety representatives may be part of the team as specified in (afety Representatives and (afety 0ommittees Regulations!
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5.0 Ca!!yn* "%t the Inve't*at"n
$he first steps in any investigation will be to preserve the accident/incident scene#
record the names of the people involved# the e%uipment involved# and the names of
any witnesses!
Information obtained during investigations is usually given verbally# but may also be
provided in writing! 4ritten documentation should be gathered to provide evidence
of policy or practice followed in the wor&place and witnesses should be tal&ed to as
soon as possible after the accident! $he inured person should also be interviewed
as soon as is practicable!
:ey points to note about investigations are:
events and issues under e.amination should never be preudged!
total reliance should not be placed on any one sole source of evidence!
the value of witness statements decreases with time# it is a proven fact that
theorising by witnesses increases as time passes and memory decreases!
try to ensure that you as& ;open %uestions<!
the first focus of the investigation should be on:
o when
o the e.act time and date
o where = the building# floor# room# location in room etc!
o to whom = name# ob title etc!
o and the outcome of the accident/incident = inury# property damage etc!
the second focus should be on how and why# giving the immediate cause of
the inury or loss e!g! slipped on spilled substance on floor# and then the
secondary or underlying causes e!g! no procedure for dealing with spillages#
procedure in place but ignored by staff# unsuitable footwear# carry large load
which obscured vision!
the amount of detail re%uired will depend on a, the severity of the inury and/or
property damage and b, the use to be made of the investigation and the
report! $he report should be as short as possible and as long as necessary
for its purpose+s,!
5.1 E/%+#ent
$he following are considered essential basic tools in the competent investigation of
accidents and incidents:
report form# a chec&>list as a routine prompt for basic %uestions
noteboo& or pad of paper
pen
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(pecialist e%uipment# e!g! camera# monitoring e%uipment# building plans# video
recorder# measuring tape# which should be reasonably long and robust etc! may be
obtained via O()*'!
5.& Re)"!dn* fndn*' and the Inve't*at"n 1"!#
An action plan should be put together in light of an Incident! It should be specific and
well defined3 measurable in attaining the goal3 achievable with sta&eholders3 realistic
with the availability of resources and time>bound to a reasonably practicable amount
of time +(2AR$,!
"or all purposes# the report that emerges from the investigation must provide
answers to the following:
8! 4hat was the:
I##edate )a%'e7 the most obvious reason why an event happens! $here
may be more than one immediate cause identified!
R""t )a%'e7 an initiating event or failing from which all other causes or
failings spring! *g! 2anagement# planning# organisational
failings etc!
Unde!lyn* )a%'e7 the less obvious system or organisational reason for the
accident happening! *g! $he ha?ard has not been
ade%uately considered via a suitable and sufficient risk
assessment# lac& of e.perience or information# instruction
and training!
I#+a)t "n the Env!"n#ent7 An incident that caused or had the potential to
cause damage to the environment either via the water
system# atmospheric release or to land contamination
including interference with "lora and "auna!
9! 4hat is the li&elihood of it happening again@
Ce!tan7 it will happen again!
.8ely7 it will probably happen again!
P"''9le7 it will possibly happen again!
Unl8ely7 it is unli&ely to happen again!
A! )ow do we prevent a reoccurrence# what is the necessary corrective action@
B! If we do not have suitable procedures in place# what new procedures are
either necessary or desirable to prevent a reoccurrence@
C! If procedures are in place# what reviews are needed of for e.ample
information# instruction and training# the ris& assessment or wor& e%uipment@
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6. 4hat realistically could be the result if no action is ta&en e!g! If the incident
was a near miss what could have been the result@
It is not the tas& of the investigation report to allocate blame# although some
discussion of this is almost inevitable! Reports are usually 6discoverable53 this means
they can be used by parties in any action for damages! It is a sound policy to
assume that accident investigation reports will be seen by solicitors and e.perts
acting on behalf of any inured party! $hey are entitled to see the report and this will
include anything in it that may later prove embarrassing = it should never contain
comments on blame!
$he report and supporting documentation for serious accidents should contain:
a summary of what happened# with detail of any person+s, inured
a summary of events prior to the accident
information gained during investigation
details of witnesses# and witness statements
information about any inury or loss sustained
conclusions and recommendations
supporting materials +photographs# diagrams to clarify the situation,
relevant policy / procedural documents
relevant ris& assessments
training records
the date = and signature+s, by the person+s, carrying out the investigation!
Defnt"n'
A))dent7 An unplanned# uncontrolled event that has resulted in an inury or damage
to property!
Nea! #''7 An unplanned# uncontrolled event that# under slightly different
circumstances# could have resulted in an inury or damage to property!
Se!"%' "! P"tentally Se!"%' 2S"PS4 In)dent'7 $hose incidents +inuries# near
misses# vehicle incidents# fire incidents, that dd: "! had the !ea'"na9le +"tental
t"# result in significant and permanent harm to staff# contractors# tenants# users#
visitors at 0' sites or for staff while travelling and wor&ing on 0' business away
from 0' sites!
Env!"n#ental In)dent7 An incident that caused or had the potential to cause
damage to the environment either via the water system# atmosphere or to the land
+"lora and "auna,!
RIDDOR In)dent7 An inury specified in (chedule 8 of RIDDOR 8DDC!
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*!g! fatality# fractures# amputations or dislocations or where a person has been
admitted to hospital for more than 9B hours!
OR An Incident that is specified in (chedule 9 of RIDDOR 8DDC! *!g! "ailure of a
load bearing part of a crane# e.plosion or bursting of a pressure system# electrical
failure causing a fire# collapse of a large structure or accidental release of a
biological agent!
OR An inury which# although not a maor inury# has resulted in the inured person
being away from wor& or unable to carry out the full range of his/her duties for more
than seven days +including wee&ends and rest days but e.cluding the day of the
accident,! 0hanges in the reporting process to the )(* re%uire three day inuries to
be recorded but not reported to the )(*!
;.0 1%!the! Inf"!#at"n
8! )(* Publication > Investigating Accidents and Incidents! A wor&boo& for
employers# unions# safety representatives and safety professionals!
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