Accidents and Investigations

1. Accidents and Investigations • Domestic arrangements • Presented by Vincent Theobald • University Safety Office 1 Park Terrace Tel. 6274

2. Session Programme This session will briefly cover : • Some Basics. • Effects of Accidents. • Reporting. • Accident Causation. • Accident Investigation. • Final Reports. “If you think safety is expensive, try an accident” Chairman of Easy Group

3. Why the course? This is a new accident and investigation course and has been put together for the following main reasons. • The HSE have produced an excellent new book on investigating accidents – providing a best practice standard. • The Government is promoting investigation of all accidents – and so are many insurance companies. • The University accident reporting procedures are having to change due to changes in confidentiality and openness legislation.

4. Some BasicsFundamental misconceptions Some frequently quoted misconceptions : • Accidents cannot be prevented • We don’t have many accidents • Safety is expensive • We are insured anyway

5. Some BasicsWhy prevent Accidents ? There are three main reasons : • Because it is Humane to do so; • To prevent suffering and maintain a quality of life • No employee should be expected to risk life and limb • Because it is Legally required; and • Because it is Economically cost effective.

6. Some BasicsSafety savings “We recognise the importance of costing loss events as part of total safety management. Good safety is good business.” (ICI group SHE Manager) “Safety is, without doubt, the most crucial investment we can make, and the question is not what it costs us, but what we save.” (Chairman & Managing Director, Conoco (UK) Ltd) “Prevention is not only better but cheaper than cure … Profits and safety are not in competition. On the contrary, safety at work is good business.” (MD British Petroleum plc)

7. Some BasicsInsurance Issues The main types of insurance are • Employers Liability required by law • Public Liability required by law • Product Liability for organisations making / supplying things or services • Motor Vehicle and specific issues

8. Some BasicsSo we’re covered by insurance? Insured costs: • Covering injury, • ill-health, damage Uninsured costs: • Product and material damage, tool and equipment damage, legal costs, expenditure on emergency supplies, cleaning site, production delays, overtime working and temporary labour, investigation time, supervisors’ time diverted, clerical effort, fines, loss of expertise/experience.

9. Effects of AccidentsWhat could happen? Minor injury Near-miss Death Major injury

10. Effects of AccidentsThe Accident Triangle Practical Loss Control Leadership, F E Bird and G L Germain, 1969.

11. Effects of AccidentsHSE example of consequences • Small engineering firm • Workers sleeve caught on rotating drill • Both bones in lower arm broken • 12 days in hospital • Off work for three months • Light duties for 5 months • Unable to operate machinery for 8 months • Managing director prosecuted • 2 employees made redundant to prevent the company from going out of business

12. Effects of AccidentsHSE example of consequences • Wages for injured worker over period • lost production / remedial work required • Overtime wages to cover lost production • Wages for replacement worker • Loss of time for Manager / MD • Legal expenses • Fines and court costs • Increased insurance premiums • Total £ = 10,000 £ = 8,000 £ = 3,000 £ = 7,000 £ = 4,000 £ = 3,000 £ = 4,000 £ = 6,000 £ = 45,000

13. ReportingWhy report accidents? Accidents should be reported: • Because the law requires some specific types of accidents to be reported to the Enforcing Authorities. • Because the University Safety Policy requires all accidents and near misses to be reported to the USO. • To enable investigation to prevent further accidents. • To identify trends and problem areas.

14. ReportingHow to report accidents Accidents should be reported by: • Using the web form on the USO websitehttp://www.ncl.ac.uk/internal/safety/acc-form.html • Using a paper form – downloadable from the USO website • The books are being withdrawn because they no longer comply with data protection legislation.

15. Accident CausationWhy look at causes of accidents Reasons include : • To prevent further accidents. • To find weaknesses in operating procedures. • To explain to the authorities what, how and why the accident happened. • To improve training / instruction for people who may be at risk. • To have a formal record of what happened to assist fair compensation claims (and refute unfair ones). • To examine the Emergency Plan and Improve on the response - ready for the next incident.

16. Accident CausationMain causes of accidents Accident causes are often classified as either • Direct e.g. Lack of machinery guarding e.g. Failure to follow instructions • Indirect e.g. poor building / furniture layout e.g. Excessive time pressures

17. Accident CausationMain causes of accidents • However the causation is normally complex and contains both direct and indirect factors.

18. Accident CausationMain causes of accidents • Because of the complex factors involved in accidents they need to be investigated properly. • In this way the causes can be identified and problems sorted out. • The aim is the prevention of the next accident not punishment or allocation of blame for the current one.

19. Accident CausationInterrupting accident causation • Because accidents do not happen in isolation there are many points at which the development of the accident can be interrupted. This is viewed as a ‘domino effect’

20. Accident CausationInterrupting accident causation • So to look again at the possible causes that could be interrupted in the previous accident considered.

21. Accident InvestigationInvestigating accidents • Any accident investigation must be undertaken as soon after the event as is practicable. • It must be undertaken sensitively - collecting as much relevant information as practicable. • It must seek to find the root causes (however uncomfortable) including the “Indirect Causes”. • It should be formally written up and filed (preferably at the University Safety Office) • The response should also be investigated. Was it right, adequate, could it have been improved ?

22. Accident InvestigationInvestigating accidents • The HSE has published a new guidance document on investigating accidents. This is published as HSG245“Investigating accidents and incidents” • The full documentcan be found onTechnical Indexbut it is a verylarge file.

23. Accident InvestigationInvestigating accidents • The methods in this document will become the new University standard approach to the investigation of health and safety incidents. • New forms and guidance will be published in the next few months.

24. Accident InvestigationInvestigating accidents The steps of Investigation are • Gathering Information W5H • Analysing the information How Come • Identifying Risk Control measures How Else • The Action Plan and it’s implementation To Do

25. Accident InvestigationStep 1 – Gathering information Fundamental Questions • Where • When • Who • What • Why • How These are the basic questions for any investigation that you undertake. The skill involved in accident investigation is to be able to find sensible and relevant answers to these six fundamental questions. The following slides suggest some points in obtaining sensible answers

26. Accident InvestigationStep 1 – Gathering information Where and When • This seems simple enough but can be complex when trying to find exact locations for events. It is insufficient to say ‘outside building x’ or ‘in the lab’ as it leave you with too many unanswered questions later on. • Some events take place over a long period of time and these need to be identified. Ill health and long term incidents (e.g.DSE and Manual Handling issues) can take years to fully show themselves.

27. Accident InvestigationStep 1 – Gathering information Who • Not all events have a Who directly involved. • Sometimes the Who will be the person that experienced a near miss event. • Sometimes the Who is a person reporting a potential incident (undesired circumstance) that has the potential to be a serious accident. • Sometimes the accident event may have involved several people but not resulted in injury (e.g. vehicle accident). • Also consider the witnesses – they can tell you a lot.

28. Accident InvestigationStep 1 – Gathering information What happened • Who were all the people involved (including witnesses) • Normally a simple sequential description of events will tell you a lot. Particularly note equipment and substances involved and how they were used. • Describe the environment in which the accident occurred. This will tell you a lot later on. Photographs are very useful for this. • Find out about the management environment, who gave instructions etc. as well as the protocols that should have been in place.

29. Accident InvestigationStep 1 – Gathering information What happened… cont. • What else was going on at the time. • Was there anything unusual going on at the time. • What injuries were caused – be accurate. This can assist you in determining what actually happened. • Were there known risks involved in the work. • What training and experience did the people involved have to undertake the work in progress. • Was specific safety equipment needed (and in use). • Obtain witness statements if possible.

30. Accident InvestigationStep 1 – Gathering information Why • Why was the work being undertaken • Why was that method being used • Why was it being done now (was there a time pressure, was it being rushed for some reason) • Why was it being done here (was this the most suitable place for the work). • Why was PPE used (or not used) what did people think it was protecting against. • Why do the people involved think that the accident happened.

31. Accident InvestigationStep 1 – Gathering information How • How else could the work have been done. • How else could protection measures have been organised. • How do the people involved believe that they should have done the job (if there were no constraints on them). • How would the people involved want to do the job in future.

32. Accident InvestigationStep 2 – Analysing information How Come the accident happened • The purpose of this stage is to determine the causes of the accident or incident. • To concentrate on finding the underlying causes not just the immediate causes. • You can then re-examine Risk Assessments that apply and learn from the incident. • This is the step that enables future accidents to be prevented.

33. Accident InvestigationStep 2 – Analysing information • There are many methods to undertake cause analysis – one of the simplest is to use the causation tree.

34. Accident InvestigationStep 2 – Analysing information • On each branch of the tree keep on asking the Why type questions until no new information is forthcoming. • At the end of the process you have root causes, in between are the “dominos” and together they offer chances to prevent future accidents. • This will reveal many types of circumstances and sub events that can also be individually investigated. • Human Factors • Job Factors • Organisational Factors • Environmental Factors

35. Accident InvestigationStep 2 – Human Factors These particularly include • Physical abilities • Size, Strength, Mobility, Injuries, Health etc. • Competence • Knowledge Skill and Experience in undertaking the task(s) involved. • Behavioural issues • See next slide • Other factors • Fatigue, Stress, Morale, Alcohol, Drugs (including medicines) etc.

36. Accident InvestigationStep 2 – Human Factors Why people did not follow a system. • Skill based errors – Slips and Lapses • Mistakes – Rule and Knowledge based • Violations

37. Accident InvestigationStep 2 – Job Factors • How much attention is needed for the task being undertaken. • Too little and too much attention being needed can both result in increased error rates. • Divided attention and Distractions. • Trying to operate too many systems or being constantly interrupted by other demands. • Inadequate procedures • Can include excessively detailed systems as well as the failure to provide a clear procedure. • The amount of time available for the task. • Short timescales and boredom both cause problems

38. Accident InvestigationStep 2 – Organisational Factors • Work Pressure and Long Hours • Availability of sufficient resources • Quality of supervision • Management beliefs in Health and Safety(The Safety Culture)

39. Accident InvestigationStep 2 – Environmental Factors • The workplace • Housekeeping • Lighting • Noise • Layout • Traffic • The Equipment • How easy is it to interpret the controls • Is the equipment designed to detect or prevent error • Are the guarding standards suitable

40. Accident InvestigationStep 3 – Identifying Risk Control How Else could you arrange the work • To prevent the next accident from happening. • To make other tasks safer. • To improve understanding of the issues. • To finish learning from the event.

41. Accident InvestigationStep 3 – Identifying Risk Control • In this stage you need to use your imagination to see what you can change to alter the risk and the perception of risk. • This is the opportunity to re-address the Risk Assessments for the tasks in hand and develop an action plan (if one is needed). • This is the step that is most often missed out in investigation. Especially when people are looking to attribute blame.

42. Accident InvestigationStep 4 – Action Plan Having decided what you need to do you must make sure that it happens. This requires an Action Plan. • Specify what is to be done. • Specify who is to do it. • Specify when it is to be done by. • Determine how you will know (and if necessary be able to demonstrate) that is has been done. • Decide how and when you are going to check that the actions are complete.

43. Final ReportsWhy write a report The report provides • Conclusion for the accident and investigation • Evidence of the lessons learnt • A record for the authorities and any civil claims made • A means to communicate lessons learnt to others • A means of demonstrating that you have identified and corrected deficiencies • A vehicle to explain the need for further resources e.g. a business case for future significant expenditure

44. Final ReportsWho and where to keep reports • Schools should keep reports of all investigations that they undertake. • Accident investigations requested by the USO should have copies sent to the USO to be kept on file. • Investigations undertaken by the USO will be kept by the USO and copies sent to the School. • Investigations involving civil or criminal liabilities may also be kept by the University Insurance Officer.

45. QuestionsFurther information and Questions • The HSE document “Investigating Accidents and Incidents”HSG 245 • The University Safety Office