Learning From Incidents - HSE Approaches

1. Learning From Incidents -HSE Approaches Dave Charnock HM Inspector of Health & Safety

2. Outline: (Flexible within time constraints…) A very quick overview: • HSE mechanisms for Learning from incidents • Why and how HSE investigate incidents • Expectations on dutyholders • Address issues and answer questions

3. Provisional “accident” statistics: 2012 /13 148 Worker Deaths 21,000 “Major Injuries” (RIDDOR ’95) 80,000 RIDDOR reported injuries 646,000 injuries reported at workplace The Scale of the Problem

4. 1999 2006 2008 Useful Incident Trend Analysis? • Most frequent causes of injury are manual handling, slips, trips and falls. • Highest rates in manual occupations. • Higher rates for less experienced workers. • Over half of all fatal accidents accounted for by falls, contact with moving machinery or contact with vehicles. • Any surprises? • Useful for HSE in planning and resourcing, particularly work at sector level – developing guidance with industry etc.

5. Purposes of HSE Incident Investigation • To identify what happened • To identify immediate and underlying causes • To prevent recurrence and promulgate lessons • To identify breaches of H&S law • To take appropriate enforcement action

6. Expectations Upon Dutyholders • No explicit duty to investigate, but difficult to demonstrate effective management otherwise… • Identify causes and failings, and act to prevent recurrence • “Learning” at dutyholder level is required.

7. Analytical Investigation Methods: The “What and How…”

8. Analytical Investigation Methods:The “Why…”

9. Senior Management Leadership Policy Supervision Worker Involvement Risk Assessment Systems of Work Personal Audit & Review Organisation Behaviours Hardware & Equipment Information & Instruction Training & Competency Resources Planning

10. Learning from Mistakes • Honest acknowledgement of mistakes • Don’t stop the investigation at the “how,” look at the “why….” • Where people fail to follow procedures, it’s not always the people who are wrong…

11. Learning from Mistakes • Implement improvements, monitor and review. • Impractical requirements and procedures will generally not be followed. • Knee-jerk responses may not be the best long-term solution

12. HSE-led learning: Prosecution • Construction Contractors (Brothers) • Using casual, untrained labour for demolition work • Fragile factory roof • Inappropriate plan of work • Even this plan of work not followed • Prosecution, national news coverage etc. • Aim to deter others

13. HSE-led learning: Positive Action • Fatal accident • HSE quickly issued “Safety Alert” • Ultimately, “Brogio” and similar equipment banned from supply EU-wide – believed to be the first successful action of this type under Article 9 of the Machinery Directive 2006/42/EC • Aim to protect and inform others of risks

14. Summary: HSE Learning from Incidents • Statistical analysis of UK data is useful to HSE for identifying sector-level issues, prioritising resources etc. Organisation-level statistics useful for identifying risk management priorities – but NOT the whole story e.g. catastrophic events. • Investigation is key to preventing recurrence: • HSE investigations are much more than an exercise in gathering criminal evidence • Addressing root causes and management failures is critical to avoiding inadequate or ineffective risk control • HSE has various tools for “sharing” the findings of its investigations: guidance, campaigns, prosecutions, safety alerts etc.