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Unit 7
Incident
Investigation,
Recording and
Reporting
Reference:
Recording and Notification of Occupational Accidents and Diseases, ILO.
1.2
Role and Function of Accident and Incident Investigation
Introduction.
1.3
Example Investigation
One -
Two -
1.3.1
1.3.2
The Accident
A telephone call was received from one of the Site
Supervisors to say that one of the men had fallen and an
ambulance had been called. He gave information
concerning the suspected injury and the employee's name.
1.3.3
The Accident Continued
they were using and all had said no, as they were using
them.
An understanding of the events leading up to the
accident was now emerging:
1.3.4
1.3.5
What Had Happened?
Continued
1.
2.
3.
? to keep a record
4.
1.4
Basic Accident Investigation Procedures
Basic accident investigation procedures:
1.4.1
1.4.2
1.4.3
Who Undertakes the Investigation? Continued
Here, the actual work procedure being used at the time of the
accident is explored. Members of the accident investigation team
will look for answers to questions such as:
1.4.4
Material
Environment
1.4.5
1.4.6
Personnel
The physical and mental condition of those individuals
directly involved in the event must be explored. The purpose of
investigating the accident is not to establish blame against
someone, but the inquiry will not be complete unless personal
characteristics are considered. Some factors will remain
essentially constant while others may vary from day to day:
1.4.7
Management
Management holds the legal responsibility for the safety of
the workplace and therefore the role of supervisors and higher
management must always be considered in an accident
investigation. Answers to any of the preceding types of questions
logically lead to further questions such as:
1.4.8
1.4.9
1.4.10
Injured Worker(s)
1.4.11
Physical Evidence
Before attempting to gather information, examine the site
for a quick overview, take steps to preserve evidence and identify
all witnesses. In some cases, an accident site must not be
disturbed without prior approval from the appropriate enforcing
authority, the coroner, or the police.
damage to equipment;
housekeeping of area;
weather conditions;
lighting levels;
noise levels.
1.4.12
Eyewitness Accounts
1.
2.
3.
4.
?
?
?
?
Gather information
All of the above
Make recommendations
Draw conclusions
5.
? Analyse information
What aspects of the accident information should be recorded first due to rapid change or
obliteration?
1.
2.
3.
? Witness statement
1.4.13
Interviewing
Interviewing is an art that cannot be given justice here, but
a few do's and don'ts can be mentioned. The purpose of the
interview is to establish an understanding with the witness and
to obtain his or her own words describing the event:
DO
DO NOT
1.4.14
Interviewing
Continued
1.4.15
Background Information
1.4.16
1.4.17
Why Recommendations Should Be Made
The most important final step is to come up with a set of
well-considered recommendations designed to prevent
recurrences of similar accidents.
1.4.18
The Written
Report
1.4.19
What Should Be Done if the Investigation Reveals
"Human Error"
Failing to point out human failings that contributed to an accident will not only
downgrade the quality of the investigation, it will also allow future accidents to happen
from similar causes because they have not been addressed.
1.
2.
3.
4.
?
?
?
?
1.5
1.
2.
3.
? Prompt
nsafe acts
are made by
people; they are
not made by
systems or by
faulty equipment.
People make
unsafe acts.
As an
example, an
employee was loading a vehicle using a fork lift truck. At the
end of his shift, he parked the truck across a walk way. He had
left the forks in the down position; however, he had parked in
the walkway. Later that evening when the security guard was
making his rounds in the dimly-lit yard, he tripped over the
forks, falling and injuring his knee.
We can also refer back to the example made at the
beginning of this unit, where an employee used a chair to gain
access and fell when the chair became unstable.
Speeding.
Rendering safety devices inoperative.
Working in an unsafe position or posture.
Working without permission.
Using unsafe methods.
Horseplay.
Failure to wear PPE or safety clothing.
Lack of concentration, fatigue or ill-health.
Using unsafe equipment.
Using equipment unsafely.
Working on moving or dangerous equipment.
1.5.2
PHYSICAL
Temperature
Noise
Job
1.5.5
Factors
The following are job factors in indirect causes of accidents:
1.
? unsafe condition
2.
? unsafe act
1.
? unsafe act
2.
? unsafe condition
1.
? unsafe act
2.
? unsafe condition
1.6
We will now consider Root Cause and Immediate Causes in more detail. We have
included several examples for you to consider.
Definition of Root Cause :-"the most basic cause that can be reasonably
identified and that management has control to fix"
Typically, an incident report will place emphasis on developing a description of the
consequences rather than causes of the incident, explaining what happened, but not why it
happened.
It is only by adopting investigation techniques that explicitly identify root causes,
i.e. the reasons why an incident occurred, that organisations may learn from past failures
and avoid similar incidents in the future. Root Causes analysis is simply a tool designed to
help incident investigators determine what, how and most importantly, why an incident
occurred.
They are a method of describing and schematically representing the incident
sequence and its contributing conditions; a method of identifying the critical events or
active failures and conditions in the incident sequence and based on this identification; a
method for systematically investigating the management and organisational factors that
allowed the active failures to occur, i.e. a method for root cause analysis.
In selecting or developing a root cause analysis method, the analyst needs to
consider whether the method specifically facilitates the identification of safety management
and organisational inadequacies, oversights which relate to their own operations. The
method needs to identify those factors that exert control over the design, development,
maintenance and review of their risk control systems and procedures.
Typically, an incident report will provide an organisation with a description of
events which principally focus on the status of the system at discrete moments along a
timeline. Reports also usually place the emphasis on developing a description of the
consequences rather than causes of the incident, explaining what happened, but not why it
happened. Such analyses are almost invariably technically orientated, involving detailed
descriptions of plant, equipment, reactions and their governing logic systems.
1.6.1
Example 1
Note:
A report from a train driver employed by Rail Ready to his Supervisor stated that he
witnessed a child on the tracks near a busy junction. He claims that the child - aged
approximately eight years old - was crossing the lines and that his train nearly hit the child.
The Supervisor makes his report to the Health & Safety Manager for that region and
copies this report to his immediate manager.
The H&S Manager investigates the incident and reports the following:
"At approximately 10 am on the morning of Tuesday 24th March 2009, a child was seen
by the driver of train 22345 north-bound to Manchester near the junction of Evergreen,
Birmingham.
CCTV also caught the image of a child crossing this junction at the time witnessed by
the train driver. Video evidence is contained within this report."
1.6.2
Example 1
(cont.)
1.6.3
Example 1
(cont.)
"I visited the District Rail Manager the following day and discussed the matter with him.
He informed me that work had been carried out by a team of contract technicians,
Contractors A, and that this work was to a railside signal box, some two weeks
earlier at that location.
Another contractor C, had first removed the section of fence and yet another
contractor B, had been engaged to ready the ground area for the technicians.
I interviewed the contactor B, who was engaged to make the area accessible and to
excavate an area, ready for the sitting of the signal box. He informed me that the
section of fence referred to had indeed been removed by another contractor C, so
that his men and work equipment could gain access to side of the track.
I interviewed the contractor C, who was engaged to remove the fence. He explained
that his contract was to remove the fence to allow excavation equipment to gain
access to the south side of the track. He said to me that no mention was made of reinstalment of the fence, once the job had been completed.
I noted that the paper systems used in this instance made no reference to ensuring
that the fence should be replaced.
I also noted that the contract to each contractor, A, B or C, made no mention of the
fact that the site should be secure at any time."
1.6.4
Example 1
(cont.)
Example 2
1.6.5
The Plant Manager walked into the plant and found oil on
the floor. He called the Supervisor over and told him to have
maintenance clean up the oil.
The next day, while the Plant Manager was in the same
area of the plant he found oil on the floor again and he
subsequently berated the Supervisor for not following his
directions from the day before. His parting words were to
either get the oil cleaned up or he'd find someone that would.
1.6.6
Example 2
(cont.)
Root Cause Example
The Plant Manager walked into the plant and found oil on the floor. He called the
Supervisor over and asked him why there was oil on the floor. The Supervisor indicated that
it was due to a leaky gasket in the pipe joint above. The Plant Manager then asked when the
gasket had been replaced and the Supervisor responded that Maintenance had installed four
gaskets over the past few weeks and each one seemed to leak.
The Supervisor also indicated that maintenance had been talking to Purchasing
about the gaskets because it seemed they were all bad. The Plant Manager then talked with
Purchasing about the situation with the gaskets. The Purchasing Manager indicated that
they had in fact received a bad batch of gaskets from the supplier. The Purchasing Manager
also indicated that they had been trying for the past two months to try to get the supplier to
make good on the last order of 5,000 gaskets that all seemed to be bad.
The Plant Manager then asked the Purchasing Manager why they had purchased
from this supplier if they were so disreputable. The Purchasing Manager said because they
were the lowest bidder when quotes were received from various suppliers. The Plant
Manager then asked the Purchasing Manager why they went with the lowest bidder and he
indicated that was the directive he had received from the Director of Finance.
The Plant Manager then went to talk to the Director of Finance about the situation.
When the Plant Manager asked the Director of Finance why Purchasing had been directed
to always take the lowest bidder, the Director of Finance said, "Because you indicated that
we had to be as cost conscious as possible and purchasing from the lowest bidder saves us
lots of money."
The Plant Manger was horrified when he realised that he was the ultimate reason
there was oil on the plant floor.
Everyone in the organisation was doing their best to do the right things, and
everything ends up messed up. The root cause of this whole situation is local optimisation
with no global thought involved.
This also provides a good example of how we should proceed to do root cause
analysis. We simply have to continue to ask "Why?" until the pattern completes and the
cause of the difficulty in the situation becomes rather obvious.
1.6.7
Example 3
In the tragic accident of Air France Concorde flight 4590 on 25th July 2000,
engine failure was suspected. Only a thorough investigation by the Bureau de
l'Aviation Civile showed that one of the tyres had been punctured on take off. The
runway was not swept as procedure required because of a fire test that day. This one
element of the Root Cause could not - and would not - have been discovered
without the investigation being undertaken. We are working back from the result
Root Cause, through the immediate causes to the crash.
Please note that we have not attempted to detail the events; this is a very
brief model of the events that took place.
The basic events that took place in the tragic accident of Concorde
Ref
Event
1.
Aircraft Crashes.
2.
Causal Factor
3.
Causal Factor
4.
Causal Factor
5.
Causal Factor
6.
Causal Factor
7.
Causal Factor
8.
Causal Factor
9.
Causal Factor
10.
Causal Factor
11.
Causal Factor
12.
Causal Factor
13.
Causal Factor
14.
1.
? False
2.
? True
Root Cause
1.7
1. Immediate.
Put the parts in order to form a sentence. When you think your answer is correct, click on
"Submit" to check your answer. If you get stuck, click on "Hint" to find out the next correct
part.
measures
happened
investigate
ascertain
accidents
1.7.1
1.7.2
1.7.3
Establish Whether Initial Management Response Was
Adequate
Prompt and appropriate action such as making safe and dealing with any
continuing risks, electrical isolation, suitable fire fighting, effective first-aid
response and correct spillage procedures.
1.7.4
Identify the Underlying Causes
1.7.5
1.7.6
Implement, Analyse and Review
1.7.7
Be SMARTER
MEASURABLE -
TIMELY -
EFFECTIVE -
REVIEWABLE -
Prioritise recommendations based on the potential for eliminating the incident in the
future.
1.8
ILO Recording and Notification of Occupational
Accidents and Diseases
The below eLearning material is extracted from the publication from the outcome of a
PIACT project.
1.8.1.
Arrangements for Recording at National Level
National laws or regulations should require that employers establish and maintain
records on occupational accidents, occupational diseases, commuting accidents, dangerous
occurrences and incidents as determined by the competent authority.
To ensure that all required data and information are collected systematically, and to
provide the methodology for investigating occupational accidents, occupational diseases,
dangerous occurrences and incidents, national laws or regulations should prescribe which
data and information are to be recorded. Where forms are used for this purpose, they should
be standardised.
The information required to be recorded at the level of the enterprise should include
at least the information to be notified, as set out in Chapter 6 of the code.
National laws or regulations should specify which additional information must be
recorded by employers, although it is not required to be notified. This should apply to:
(a)
(b)
(c)
(b)
(c)
(d)
that such records are to be obtained and maintained in such a way that
respects the confidentiality of personal and medical data in accordance with
national laws and regulations, conditions and practice, and are consistent
with paragraph 6 of the Occupational Health Services Recommendation,
1985 (No. 171);
(e)
that the employer should identify a competent person at the level of the
enterprise to prepare and keep records; and
(f)
1.8.2
(b)
(b)
1.8.3
At national level.
(a)
(b)
(c)
(d)
(a)
(b)
(i)
(ii)
(c)
(d)
(e)
(f)
(a)
(b)
(a)
(b)
1.8.4
Notification of Occupational Accidents
General.
All occupational accidents should be notified, as required by national laws or
regulations, to the competent authority, the labour inspectorate, the appropriate
insurance institution or any other body:
(a)
(b)
(a)
(b)
(c)
(d)
a single form which contains all essential data for all bodies.
Minimum information.
With a view to meeting the requirements of labour inspectorates, insurance
institutions and the statistics-producing body, the forms prescribed in either a
specific or single format should include at least the following information:
(a)
(b)
(i)
(c)
(ii)
(iii)
(iv)
(v)
injured person:
employment status; 2
(iii)
occupation; 3
(i)
fatal accident;
(ii)
non-fatal accident;
(iii)
injury:
(iv)
(iv)
(b)
(c)
(i)
(ii)
(iii)
(iv)
(v)
injured person:
(i)
(ii)
employment status; 3
(iii)
occupation; 4
(iv)
(i)
fatal accident;
(ii)
non-fatal accident;
injury:
(d)
(iii)
(iv)
(v)
(ii)
See Annex I.
See paragraph 3.2.1(a) and Annex C.
3
See paragraph 3.2.1(c) and Annex E.
4
See paragraph 3.2.1(b) and Annex D.
5
See Annex F.
6
See Annex G.
2
(iii)
(iv)
(v)
(vi)
(vii)
(viii)
(ix)
1.8.5
Notification of Occupational Diseases
(b)
(i)
(ii)
(iii)
(iv)
(v)
(ii)
employment status; 4
(iii)
(iv)
(i)
(ii)
See Annex H.
See Annex I.
3
See paragraph 3.2.1(a) and Annex C.
4
See paragraph 3.2.1(c) and Annex E.
2
(iii)
(iv)
(v)
1.8.6
Notification of Dangerous Occurrences
(a)
(i)
(ii)
(iii)
(iv)
(v)
(ii)
(iii)
See paragraph 3.2.1(a) and Annex C. 2 See paragraph 3.2.1(c) and Annex E.
1.9
Extension of Recording and Notification Systems
To Self-Employed Persons
At national level.
(a)
(b)
(b)
1.9.1
At the Level of the Enterprise
The person in control of the establishment where the selfemployed person is contracted to work should make
arrangements for the reporting, recording and notification of
occupational accidents, occupational diseases, commuting
accidents, dangerous occurrences and incidents which can be
applied to self-employed persons.
1.10.
Statistics of Occupational Accidents, Occupational
Diseases, Commuting Accidents and Dangerous
Occurrences: Compilation and Publication
At national level
(a)
(b)
the person affected as a result of an occupational
disease; or
(c)
(b)
(c)
(d)
(e)
(f)
1.11
Statistics of Occupational Accidents, Occupational
Diseases and Dangerous Occurrences: Classifications
General.
The statistics of occupational accidents, occupational
diseases and dangerous occurrences should be classified
at least according to branch of economic activity and, as
far as possible, according to:
(a)
1.11.1
Occupational Diseases
1.11.2
Dangerous Occurrences
The competent authority should publish statistics of
the numbers and types of dangerous occurrences that
have been notified.
1.12
Investigation of Occupational Accidents, Occupational
Diseases, Commuting Accidents, Dangerous
Occurrences and Incidents
At national level.
(a)
(b)
(c)
(a)
(b)
and
(c)
identify measures necessary to prevent a
recurrence.
2.0
Summary
This summary will now refer you back to the learning outcomes for this lesson and give
a summary of the information.
The simple answer is to ascertain why the accident happened and put measures in place
to ensure that the same - or similar - accidents do not happen again.
It is, however, much more complicated than that. Finding the root cause of an accident
and ensuring that measures are put in place to ensure that it cannot happen again is a
vital part of any investigation.
Basic accident investigation procedures:
interviews;
plans;
photographs;
relevant records;
checklists;
identifying immediate causes (unsafe acts and conditions)
and root or underlying causes (management system
failures);
Identifying remedial actions.
What is RIDDOR
It stands for the Reporting of Injuries, Diseases and Dangerous Occurrences
Regulations 1995. Sometimes referred to as RIDDOR 95, or RIDDOR for short, these
Regulations came into force on 1 April 1996 .
It is important that you make reference to the full title: Reporting of Injuries, Diseases
and Dangerous Occurrences Regulations 1995, when answering a question that refers to
RIDDOR in your NEBOSH examination.
Persons who are employers, the self-employed or are in control of work premises have
duties under RIDDOR. The regulations apply to all work activities.
There is little to do when reporting incidents and accidents under RIDDOR. For most
businesses, a reportable accident, dangerous occurrence or case of disease is a
When to Report
Within ten days of making the telephone call, this must be followed
up with a completed accident report form (F2508). Again, you will see that
the form asks for basic information.
Over-Three-Day Injury
If there is an accident connected with work (including an act of physical
violence) and an employee, or a self-employed person working on the
premises, suffers an over-three day injury, form F2508 must be completed
and sent to the enforcing authority within ten days.
An over-three-day injury is one which is not major but results in the injured
person being away from work, or unable to do the full range of their normal
duties, for more than three days (including any days they would not
normally be expected to work such as weekends, rest days or holidays), not
counting the day of the injury itself.
So in simple terms, if someone suffers a major injury, including death or a
major incident occurs, then the enforcing authority must be notified
immediately, normally by telephone. This must be followed on within 10
days of the telephone call by completing the F2508 form.
Amputation.
Acute illness requiring medical treatment.
Injury resulting from an electric shock or burn.
Loss of sight (temporary or permanent), and so
on.
Failure of industrial radiography equipment.
Plant in contact with overhead power lines.
Explosion or fire causing suspension of normal
work for over 24 hours.
Failure of load-bearing parts of lifting
equipment.
Reportable diseases.
Some skin diseases, infections such as
legionellosis.
Lung diseases such as occupational asthma.
Disease
If a doctor notifies an employee that they are suffering from a reportable workrelated disease, the employer must send a completed disease report form (F2508A)
to the enforcing authority.
A full list of these reportable diseases is included in 'the guide to the Regulations'. It
is also possible to contact the H.S.E Information Line to check whether a disease is
reportable.
Dangerous Occurrence
If something happens which does not result in a reportable injury but which clearly
could have done, it may be a dangerous occurrence which must be reported
immediately (e.g. by telephone) to the enforcing authority.
Again, within ten days of reporting the incident by telephone, this must be followed
up with a completed accident report form F2508.
Incident Investigation
Congratulations - end of lesson reached