accident investigation reporting

1. ACCIDENT INVESTIGATION & REPORTING

2. Fire Precautions Fire Precautions :- If continuous alarm sounds leave the building by the nearest exit Report to the tutor at the assembly point

3. INTRODUCTION Tea / coffee facilities Toilets No smoking First aid / fire Mobile phone / pagers Trainee introductions Please ask questions at any time

5. OVERALL AIMS An understanding of the process and purpose of investigating incidents Remember : Includes ill health as well as injury accidents An understanding of the legal and organisational requirements for recording and reporting

7. 2003/04 Statistics 235 fatalities 159,809 RIDDOR reported injuries An estimated 2.2 million people suffering from an illness caused or made worse by their current or past work An estimated 39 million working days lost - 30 million due to ill health & 9 million due to injury

9. The Reporting of Injuries, Diseases and dangerous Occurrences Regulations (RIDDOR) 1995

10. What’s the point of RIDDOR? HSE/EHO need to know about the more serious accidents, diseases and dangerous occurrences at work so they can perform their statutory role. They can analyse where and how risks arise and then investigate/enforce.

11. What needs to be reported? Death or major injury: employee or a self-employed person working on your premises is killed or suffers a major injury (including violence), or; a member of public is killed or taken to hospital Over-3-day-injury: employee/self-employed off work, or incapacitated for normal work for more than 3 days; Disease: doctor notifies you of reportable work-related disease; Dangerous occurrence: categories of near-misses.

12. The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995 Reporting procedures cover: fatalities and major injuries incapacity to work for more than three days specified diseases dangerous occurrences

13. RIDDOR Covers: employers employees self-employed trainees other people injured on premises

14. RIDDOR Major injuries include: fracture of: skull, spine, pelvis arm, leg, wrist, ankle amputation through any bone loss of sight (temporary orpermanent

15. RIDDOR Major injuries (continued): certain eye injuries electric shock requiring attention unconsciousness through lack of oxygen acute illness due to exposure to certain materials hospitalisation for more than 24 hours

16. RIDDOR Reportable occurrences: structural collapses fires and explosions release of gases or other dangerous substances failure of breathing apparatus while in use scaffold collapse contact with or arcing of overhead cables

17. RIDDOR Reportable diseases: any disease listed in the regulations as ‘reportable’

18. Social Security Act 1975 and RIDDOR Every accident involving personal injury to an employee must be entered in the accident book by: the employee, or someone acting on behalf of the employee The accident book must be kept accessible. An employer must investigate all accidents reported

19. Reporting to enforcing authorities Since 01 April 2001, you can report accidents and occurrences to the Incident Contact Centre by: telephone fax e-mail post Reporting accidents and occurrences direct to the local HSE Office, on Form F.2508 or F.2508A, is still acceptable.

20. Report to enforcing authorities F.2508 must be sent to the enforcing authorities in cases of: injury at work resulting in more than three consecutive days’ incapacity death of an employee within one year of sustaining a reportable injury a reportable disease when diagnosed by a registered medical practitioner

21. RIDDOR: Answers

22. RIDDOR: Answers

23. Accident/Incident Investigation RIDDOR only requires reporting of incidents etc. No explicit legal requirement in any H&S legislation to investigate - therefore WHY DO IT?

25. Accident/Incident Investigation HSW Act states - “employers must ensure….the health, safety and welfare of employees...” etc. Reactive monitoring - to prevent the same or similar from happening again Review/revise risk assessments and associated H&S documentation/working practices

26. Are you learningthe lessons?

27. Do you investigate incidents & accidents in your company? Do you do it well? Do you find the underlying causes? Do you take corrective action? Do you review your risk assessments as a result? Do you do it?

28. Accident Investigation Law Explicit legal duty to investigate accidents

29. 29 HSE on Accident Investigation 1999 Most accidents are not investigated safety specialists lead rather than line managers effort determined by severity of the injury rather than potential of the event little employee involvement if line managers do investigate, little training in investigation skills and techniques immediate technical causes only cont’d

30. 30 HSE on Accident Investigation 1999 often stops when someone is found to blame fails to get to underlying causes Even if there is an investigation: failure to monitor full implementation of investigation findings failure to systematically record findings so that lessons can be learnt throughout the organisation Most firms don’t know why accidents occur !

33. Near misses are important Powerful advantages why not take the “free lessons”? equivalent learning opportunity… …but, without the legal and liability implications

34. Team based investigation RoSPA study - best practice led by senior managers involving employees, including safety representatives supported by OS&H professionals acting as facilitators

35. Team based investigation Local knowledge, especially operational Building of trust; Creates workforce 'champions' for H&S; Check on safety management standards Investigation of lower risk safety issues is important in creating a positive climate for more structured investigation when major safety failures occur.

36. Summary It will help prevent accidents It should fit in with existing risk assessment practice It should be part of H&S management It will become an explicit legal duty but, most importantly… … Good accident / incident investigation will improve safety

37. The Cost of Accidents at Work

38. So why bother with H&S?

39. Humane Prevent suffering and maintain quality of life No-one should be expected to risk life and limb in return for a contract of employment

40. The true cost of an accident To the victim: pain and suffering extra cost, less income continued disability incapacity – for job and other activities the effects on others

41. The true cost of an accident To those responsible: worry and stress recrimination and guilt extra work a) reports b) staff replacement loss of credibility

42. The true cost of an accident To the working group: shock and personal grief low morale affected production

43. Is good health & safety good business?

44. The true cost of an accident To the firm: lost working time a) the victim b) others damaged equipment insurance costs prosecution or civil action

45. “We recognise the importance of costing loss events as part of total safety management. Good safety is good business” Dr. J Whiston, ICI Group SHE Manager

46. “Safety is, without doubt, the most crucial investment we can make, and the question is not what it costs us, but what it saves.” Robert McKee, Chairman Conoco (UK) Ltd.

47. “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.” Basil Butler, MD British Petroleum plc

48. “We saved £750,000 on insurance premiums through improving our systematic management of health and safety.” Birse Group plc

49. Accident Costs Iceberg

50. Insurance Costs Employers Liability Public Liability Product Liability Motor Vehicle

51. Uninsured Costs Product and material damage Lost production time Legal costs Overtime & temporary labour Investigation time/Administration Supervisors time Fines Loss of expertise/experience Loss of morale Bad publicity

52. Piper Alpha 167 dead Estimated cost of over £2 billion

53. Grangemouth BP refinery fire in 1987 One person died Cost £50 million in property damage Cost further £50 million due to business interruption

54. HSE Example Small engineering firm (15 workers) Workers sleeve caught on rotating drill Both bones in lower arm broken 12 days in hospital Off work for 3 months Admin duties for 5 months Unable to operate machinery for 8 months Managing Director Prosecuted 2 employees made redundant to prevent company going out of business

55. Costs to Company

56. Costs of slips and trips in GB To the individual Lost income, pain, reduced quality of life To employers over £500m p.a. Damages, admin. and insurance, lost production, temporary absences To society over £800m p.a. Loss of potential output, medical costs, social security. In addition to the obvious costs to the individual and to the employer, there is a huge cost to society in respect of medical treatment, social security, etc. In addition to the obvious costs to the individual and to the employer, there is a huge cost to society in respect of medical treatment, social security, etc.

57. Looking first at slips risks……… Slipperiness depends on many factors - floor material, wear, degree of contamination, cleaning arrangements, footwear type, people’s tasks, etc. They won’t all be significant in every case, but a structured consideration of all the factors should be the basis for a slips risk assessment. Looking first at slips risks……… Slipperiness depends on many factors - floor material, wear, degree of contamination, cleaning arrangements, footwear type, people’s tasks, etc. They won’t all be significant in every case, but a structured consideration of all the factors should be the basis for a slips risk assessment.

59. Some common causesof accidents Not knowing or not using safe work methods Lack of testing, inspection and maintenance Unsafe manual handling Working too fast or cutting corners Overloading equipment cont’d

60. Some common causes of accidents Not using: guards, scaffolds, platforms, etc. Ignoring or disregarding: warning signs statutory notices Untidiness or carelessness Horseplay

61. Safety in the workplace requires Safe systems of work and good organisation Good defect reporting and maintenance arrangements Careful, safety-based work planning The correct tools and equipment for the job in hand cont’d

62. Safety in the workplace requires Knowledge of, and compliance with, safety law Adequate information, training, instruction and supervision Common sense and a mature attitude

63. Reporting accidents An accident book should be available in all work situations The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 reportable injuries three days or more off work certain listed injuries No report: no proof no future safeguard

64. Reporting accidents Dangerous occurrences: Collapsed or overturned items of plant Explosion or bursting of closed vessels Reportable diseases: Certain diseases associated with specified work activities

66. THE LAW AND HEALTH & SAFETY

67. UK legal system An accident at work can lead to either criminal or civil legal action (or both, or neither!) Compensation is a payment designed to put the individual in the position they would have been in had the accident not happened. Civil cases are initiated by the injured person and must be proved “on the balance of probability”. Civil cases usually hinge on “negligence” (failure to take reasonable care) or “breach of statutory duty” (not meeting the specific regulations designed for workers’ protection). Companies must carry insurance to cover compensation which they are found liable to pay. Criminal cases are initiated by a government inspector (Health and Safety Executive or Local Authority). The usual outcome is a fine. Criminal liability cannot be insured. The criminal law is contained in Acts of Parliament and associated Regulations. Most of the civil law consists of decided cases (precedents) which establish eg what is negligence. Both types of law are in a state of constant development as new laws are made and new precedents are established. An accident at work can lead to either criminal or civil legal action (or both, or neither!) Compensation is a payment designed to put the individual in the position they would have been in had the accident not happened. Civil cases are initiated by the injured person and must be proved “on the balance of probability”. Civil cases usually hinge on “negligence” (failure to take reasonable care) or “breach of statutory duty” (not meeting the specific regulations designed for workers’ protection). Companies must carry insurance to cover compensation which they are found liable to pay. Criminal cases are initiated by a government inspector (Health and Safety Executive or Local Authority). The usual outcome is a fine. Criminal liability cannot be insured. The criminal law is contained in Acts of Parliament and associated Regulations. Most of the civil law consists of decided cases (precedents) which establish eg what is negligence. Both types of law are in a state of constant development as new laws are made and new precedents are established.

68. EXERCISE You are going to work by bus. You buy a ticket (a “contract” with the bus co). During the journey, the driver collides with another vehicle and you suffer minor cuts and bruises. By the time everything is sorted out, you are very late for work. You sprint from the bus stop and trip over a paving stone, breaking your arm. Who is, if anybody, is liable for your injuries?

69. COMMON & STATUTE LAW Common law is unwritten being derived from local & customary laws and the decisions of judges but is nevertheless binding It evolves continuously as precedents are established decisions of a lower court can be overturned by a higher court Statute law is passed by Parliament, approved by the Sovereign & is written (published law) It takes precedent over all other forms of Law (Common Law) etc Some Statute law is derived from decisions of the European Union (Directives etc)

70. BURDEN OF PROOF Criminal Law exists to punish offenders and guilt must be established “beyond reasonable doubt” Civil Law is concerned with compensation and redress: the burden of proof is “the balance of probability” This is a lower standard of proof and a civil action may succeed where a criminal case has failed

71. CIVIL COURTS (ENGLAND & WALES) The County Courts deal with Civil cases. The judge normally sits alone though a Jury may sometimes be empanelled The High Court of Justice may also deal with civil cases The Court of Appeal (Civil Division) hears appeals from the lower courts Once again, the House of Lords is the ultimate court of appeal Civil cases are often settled out of court

72. CIVIL ACTION If an accident occurs and somebody suffers injury or loss and negligence or breach of statutory duty can be proved damages may be recoverable Documents, including accident reports, risk assessments etc must be disclosed on request

73. TIME LIMITATIONS Actions for personal injury claims etc normally have to be brought within 3 years of the accident In the case of a disease such as asbestosis the limitation is 3 years from the diagnosis of the condition Courts have the discretion to allow time barred cases to proceed in some circumstances

74. NEGLIGENCE Donoghue v Stevenson (1932) must take reasonable care to avoid acts/omissions which you can reasonably foresee would be likely to injure your neighbour” This duty of care is owed to people who are closely & directly affected by your acts/omissions (e.g. employers, employees, contractors, visitors, suppliers) defences against actions include: no duty owed, duty not breached, breach did not lead to damage, risk accepted voluntarily,contributory negligence Bradford vs Robinson’s Rentals (1967): employer liable for reasonably foreseeable frostbite injuries to B

75. SAFE SYSTEM OF WORK Wilson & Clyde Coal v English 1938 A leading case which established an Employer’s duty of care towards employees “Master’s duty to a Servant” Safe premises Safe plant & equipment Competent fellow workers Adequate supervision (cf Health & Safety at Work etc Act)

76. BREACH OF STATUTORY DUTY Damages can be recovered if it can be proved that loss occurred because of the defendant’s failure to comply with a statutory requirement May be easier to prove than negligence, especially if the breach has been established by a criminal prosecution Main defences: duty not breached, injured party not protected by statute, harm not of type statute designed to protect, contributory negligence Some statutory duties are absolute

77. VICARIOUS LIABILITY Employers are vicariously liable for the actions of their employees provided that the employees were acting in the course of their employment (sometimes even if the activity was expressly forbidden) Limpus vs London Omnibus Co. (1862) Employer Liable for accident caused by negligent employee

78. DUTIES OF EMPLOYEES Employees may also be sued. They have a duty to: - To carry out duties with reasonable care - To avoid loss to Employer (cf Health & Safety at Work etc Act) NB. Employers not liable for activities that do not form part of employees’ employment “servant’s frolic of his own” Storey v Aston (1869) Employer not liable for accident caused during unauthorised detour

79. REASONABLE PRACTICALITY Edwards v National Coal Board (1949) Risk must be insignificant in relation to sacrifice (time, effort & expense): NCB claimed unsuccessfully that it was not reasonably practicable to shore up all mine roads Marshal v Gotham & Co (1954) If something is practicable, courts will not lightly hold that it is nor reasonably practicable Adsett v K&L Steelfounders & Engineers Ltd (1953) The standard of practicality is that of current knowledge not having sufficient resources is no excuse for inaction

80. DEFENCE OF NECESSITY A defendant may claim that his/her actions arose from necessity (e.g. to prevent a more serious accident) ESSO Petroleum Co v Southport Corporation (1955) A captain of an oil tanker jettisoned oil in bad weather to safeguard the crew: ESSO convinced the court that this was a necessary act and not negligence

81. CONSENT:“VOLENTI” DEFENCE “Volenti non fit injuria”: cannot expect redress if you consent to an act likely to result in injury or loss Cutler v United dairies (1933) Cutler failed to recover damages after being injured trying to restrain a bolting horse: it was held he consented to the risk Haynes v Harwood (1935) A policeman was able to recover damages after being injured restraining a bolting horse: he had a legal duty to protect life & property and was not held to have consented willingly to the action

82. CONTRIBUTORY NEGLIGENCE Where a person suffers damage or loss Partly his/her fault Partly the fault(s) of other person(s) Damages may still be recoverable but the amount will be reduced in proportion to the claimant’s responsibility Saywer vs Harlow UDC (1958) Contributory negligence was accepted after a woman was injured when she put her foot on a revolving toilet roll while trying to get out of a cubicle

83. OCCUPIER’S LIABILITY ACTS (1957 & 1984) Duty of reasonable care to lawful visitors (invitees, licensees, contractors & those with a right under law) Need to ensure premises are reasonably safe. Dangerous defects must be repaired and warning notices displayed as necessary Should expect children to be less careful than adults Common Law duty not to cause trespassers intended harm

84. T TRESPASS: CASE LAW Tichener v British Railways Board (1984) BRB not liable for injuries to teenage girl hit by a train even though fence was not maintained (Girl frequently & willingly took risk) British Railways Board vs Herrington (1972) BRB liable for injuries to a 6-year old child who had strayed onto the line Bird vs Holbrook (1828) Landowner liable for injuries to a trespasser caused by a spring loaded gun (trespasser unaware of risk)

85. THE WOOLF PROTOCOL Lord Woolf (the Lord Chief Justice) drew up a Personal Injury Pre-action Protocol aimed at simplifying & streamlining claim procedures Claims must proceed to a strict timetable Defendants must investigate claims & disclose relevant documents within the timetable If the protocol is not complied with, Courts may impose tough sanctions

86. CRIMINAL COURTS (E&W) All criminal cases are first dealt with by Magistrates Courts. these can try summary offences and can commit people accused of indictable offences (& commit people for sentencing) to the Crown Court. The Crown Court tries Indictable offences. Trial is before a Judge (with a Jury in contested cases. Can also hear appeals from Magistrates Courts. The High Court of Justice hears appeals from Magistrates & some appeals from Crown Courts. The Court of Appeal (Criminal Division) hears appeals from Crown Courts it can amend or reverse decisions or remit cases to lower courts The House of Lords is the ultimate court of appeal

87. HEALTH & SAFETY AT WORK ETC ACT 1974 (HSAWA) Section 2: duty to ensure, so far as is reasonably practicable the health safety & welfare of employees safe workplace & safe working practices information, training & supervision adequate welfare facilities health & safety policy safety representatives & committees Section 3: employers to conduct undertakings so as to ensure so far as is reasonably practicable that persons not in his employment are not exposed to risks to their health & safety

88. HSAWA - (ii) Section 4: duty of those in control of premises to non-employees Section 6: duties of manufacturers & suppliers (includes provision of safety information) Section 7: duty of employees to take reasonable care for their health & safety and that of others affected by their acts/ omissions and to co-operate with employer Section 8: no person to intentionally/ recklessly interfere with or misuse anything provided for health, safety or welfare Section 9: no charge to employees for H&S items

89. HSAWA - (iii) Section 36: where the commission of an offence is due to the default of another person - that person shall be guilty of the offence Section 37: Directors are responsible (as well as the body corporate) for offences committed with their consent/connivance or attributable to any neglect on their part

90. HEALTH & SAFETY REGULATIONS Made under the Health & Safety at Work etc Act 1974 Often required by European Directives Consultative Documents issued by Health & Safety Commission Signed by the Secretary of State Laid before Parliament Have coming into force (CIF) dates Most may be cited in “breach of statutory duties” actions (but not HSAWA or MHSWR)

91. REGULATIONS ! Management of H&S at Work * Workplace Health, Safety & Welfare * Working time * Provision & Use of Work Equipment * Personal Protective Equipment at Work * Display Screen Equipment * Manual Handling Operations * Safety Signs & Signals * Pressure Systems * Electricity at Work * First Aid at Work * Control of Substances Hazardous to Health * Control of Asbestos at Work * Genetic Modification (Contained Use) Regulations * Dangerous Substances & Explosive Atmospheres * Ionising Radiations * Genetic Modification * Reporting of Accidents, Incidents & Dangerous Occurrences

92. MANAGEMENT OF HEALTH & SAFETY AT WORK REGULATIONS Assessment of risks planning, organisation, control monitoring & review health surveillance competent H&S personnel emergency procedures information & training co-operation with other employers employees to follow instructions & report serious dangers/shortcomings

93. WORKPLACE HEALTH, SAFETY & WELFARE REGULATIONS Maintenance,ventilation, heating & lighting Cleanliness & waste materials Space Workstations, floors & traffic routes Measures to prevent falls or falling objects Windows, skylights & ventilators escalators, walkways, doors & gates toilets, washing facilities, drinking water Facilities for changing, resting & eating

94. PROVISION & USE OF WORK EQUIPMENT REGULATIONS Work equipment suitable for use maintained in good repair information, instruction & training machine guarding precautions against specified hazards controls, isolation, stability, lighting markings & warnings mobile work equipment & power presses

95. CONTROL OF SUBSTANCES HAZARDOUS TO HEALTH REGULATIONS Risk assessment elimination or control of risk maintenance of equipment environmental monitoring health surveillance emergency procedures information, instruction & training

96. APPROVED CODES OF PRACTICE ACOPs are prepared by the Health & Safety Commission Although they are not laid before Parliament, they have a legal status They set out how Regulations may be complied with You do not have to follow the ACOP but if you do not you may have to prove that you complied with the Regulations by other means

97. ENFORCEMENT OF H&S LAW:POWERS OF INSPECTORS (HSE etc) Entry to premises Involvement of police Make necessary examinations & investigations To direct premises are undisturbed To take photographs, measurements & samples To order plant to be dismantled Require witness statements Inspect documents etc

98. HSE ENFORCEMENT POLICY See HSE Enforcement Policy Statement Proportionality: relating enforcement to how far the duty holder has fallen short of legal requirements Targeting: concentrating on the most serious risks Consistency: taking a similar approach in similar circumstances Transparency: telling duty holders what is expected of them

99. NOTICES & PROSECUTION A Prohibition Notice prohibits an activity (e.g. use of a dangerous machine) An Improvement Notice requires improvements (usually within a time scale) Organisations can appeal against notices to an Industrial Tribunal The HSE “names and shames” offenders Enforcing Authorities can prosecute offenders for breaches of HSAWA or Regulations made under HSAWA

100. MAX PENALTIES UNDER HSAWA Failing to comply with an Improvement/ Prohibition Notice: Lower court £20,000 and/or 6 months in prison Higher court unlimited fine and/or 2 years in prison Breaches of sections 2-6 of HSAWA Lower court £20,000; higher court unlimited fine Breaches of regulations etc Lower court £5,000; upper court unlimited fine

101. R v ASSOCIATED OCTEL A contractor working for AO suffered severe burns when a lamp broke setting fire to solvent vapours The contractor’s company was prosecuted under Section 2 of HSAWA (duty to employees) AO was convicted under Section 3 of HSAWA (duties to others) AO appealed on the grounds that the work of the contractors was “not part of AO’s undertaking” The appeal went all the way to the House of Lords before finally being dismissed: the work was part of AO’s undertaking and they had a duty to ensure the H&S of the contractors

102. CORPORATE MANSLAUGHTER A company cannot “have a criminal state of mind” At present, a company can only be convicted of manslaughter if “the Controlling mind” is first proved guilty This is normally only possible with very small companies R v OLL Ltd (1994) following the death of 4 children on a canoe trip OLL fined £60K & the managing director jailed Changes in the law are imminent

103. Legal Requirements Health & Safety at Work etc Act 1974 Management of Health & Safety at Work Regulations 1999 Failure to comply is a criminal act Employers CANNOT insure against failure to comply

104. Section 2 Section 2(1) - employers’ general duty Duty to ensure ‘so far as is reasonably practicable’, the health, safety and welfare at work of employees and any others who may be affected by the undertaking….

105. Legal Standards “Reasonably Practicable” or “SFARP” Implies a weighing up of the risk against the cost (in terms of time, money or trouble) of preventing or controlling the risk

106. Section 2 (cont.) Provision of such information, instruction, training and supervision as is necessary to ensure , SFARP, the health and safety at work of employees and any others who may be affected….

107. Section 2 (cont.) Duty of Employers to Employees cont. 2.2a - safe plant and systems of work 2.2b - safe use, handling, storage and transportation of articles and substances 2.2c - information, instruction, training and adequate supervision 2.2d - safe place of work and a safe means of access and egress 2.2e - safe working environment and adequate welfare facilities

108. Section 7 Duty of Employees at Work It shall be the duty of every employee whilst at work:- to take reasonable care of their own health and safety and of any other person who may be affected by their acts or omissions to co-operate with their employer so far as is necessary to enable that employer to meet their requirements with regards to any statutory provisions

109. Section 21 Improvement Notices If an inspector is of the opinion that a person:- is contravening one or more of the relevant statutory provisions; or has contravened one or more of those statutory provisions, in circumstances that it is likely that the contravention will continue or be repeated, then he will issue an Improvement Notice.

110. Section 22 Prohibition Notices If any activity is being, or is about to be, carried out that could result in serious personal injury, then an inspector may issue a Prohibition Notice. This notice will cause the immediate cessation of the activity involved until all measures are rectified.

111. Enforcement The HSE can take legal action against an employer/employee in a criminal court for H&S failures: Unlimited fine and/or Custodial sentence (Remember - you cannot insure against failure to comply with H&S legislation) If guilty = criminal record

112. British Justice INNOCENT until proven GUILTY beyond ALL REASONABLE DOUBT

113. Civil Litigation Provides for compensation to be paid to persons who suffer harm as a result of a work activity. Can insure - Employers Liability Insurance Burden of proof is NEGLIGENCE Proof is “on the balance of probabilities” Effectively “guilty until you prove your innocence”

114. Reportable The relevant Enforcing Authority must be notified if an incident results in any of the following outcomes. ·              Fatality as a result of an accident. ·              Major injury to a person at work as a result of an accident.Major injuries include fractures (other than finger, thumb or toe), amputations, dislocations of shoulder, hip, knee or spine, loss of sight (temporary or permanent) and burns or penetrating injuries to the eye. Certain injuries which lead to unconsciousness or admittance to hospital for more than 24 hours are also included. ·              An accident which results in a person not at work being taken to a hospital. ·              A dangerous occurrence.The majority of these are specific to particular equipment, for example pipelines and fairground equipment, or to activities such as diving or train operation. However, some involve more widespread activities, for example, the collapse of lifting equipment and the overturning of fork lift trucks. You should find out which dangerous occurrences may apply to your area by checking with your safety professional or reading the Regulations. This notification must be by the quickest practicable means and this is usually by telephone. RIDDOR also has reporting requirements for incidents with the following outcomes. ·              Absence from normal work for over three days.Incidents resulting in a personal injury which is not a specified major injury but results in absence from normal work for more than three consecutive days. These three days exclude the day of the accident, but include days which would not have been working days, eg weekends. Incidents of this type do not have to be notified immediately but a written report is required within ten days. ·              Death of an employee within a year.Incidents resulting in the death of an employee as a result of a reportable accident within one year of that accident. Where this happens, the Enforcing Authority has to be informed whether or not the original accident had been reported. ·              Specified occupational diseases.Incidents or working conditions resulting in an occupational disease. Only certain types of disease have to be reported, and then only if the person’s work involves one of a specified list of activities. For example- cramp of hand or forearm - handwriting, typing or other repetitive movements- hand arm vibration syndrome - tools or activities creating vibration- rabies - work involving infected animals.Various types of cancer, dermatitis and asthma are also included.When an outcome of this type occurs, the Enforcing Authority must be notified “forthwith”. This is normally done using form F2508A. Records of reportable incidents must be kept by the organisation, not just sent to the Enforcing Authority. In addition, records of individual incidents must be retained for at least three years. The relevant Enforcing Authority must be notified if an incident results in any of the following outcomes. ·              Fatality as a result of an accident. ·              Major injury to a person at work as a result of an accident.Major injuries include fractures (other than finger, thumb or toe), amputations, dislocations of shoulder, hip, knee or spine, loss of sight (temporary or permanent) and burns or penetrating injuries to the eye. Certain injuries which lead to unconsciousness or admittance to hospital for more than 24 hours are also included. ·              An accident which results in a person not at work being taken to a hospital. ·              A dangerous occurrence.The majority of these are specific to particular equipment, for example pipelines and fairground equipment, or to activities such as diving or train operation. However, some involve more widespread activities, for example, the collapse of lifting equipment and the overturning of fork lift trucks. You should find out which dangerous occurrences may apply to your area by checking with your safety professional or reading the Regulations. This notification must be by the quickest practicable means and this is usually by telephone. RIDDOR also has reporting requirements for incidents with the following outcomes. ·              Absence from normal work for over three days.Incidents resulting in a personal injury which is not a specified major injury but results in absence from normal work for more than three consecutive days. These three days exclude the day of the accident, but include days which would not have been working days, eg weekends. Incidents of this type do not have to be notified immediately but a written report is required within ten days. ·              Death of an employee within a year.Incidents resulting in the death of an employee as a result of a reportable accident within one year of that accident. Where this happens, the Enforcing Authority has to be informed whether or not the original accident had been reported. ·              Specified occupational diseases.Incidents or working conditions resulting in an occupational disease. Only certain types of disease have to be reported, and then only if the person’s work involves one of a specified list of activities. For example- cramp of hand or forearm - handwriting, typing or other repetitive movements- hand arm vibration syndrome - tools or activities creating vibration- rabies - work involving infected animals.Various types of cancer, dermatitis and asthma are also included.When an outcome of this type occurs, the Enforcing Authority must be notified “forthwith”. This is normally done using form F2508A. Records of reportable incidents must be kept by the organisation, not just sent to the Enforcing Authority. In addition, records of individual incidents must be retained for at least three years.

116. Why investigate? It is a reactive element in monitoring phase of your safety management system: Eliminate the causes and underlying causes to prevent a recurrence; Identifying safety management lapses by examining shortfall between what you plan to happen and what did happen; Identify trends and patterns for future prevention; Evaluates organisation’s position in relation to potential breaches of law.

117. Why investigate?

118. Accident Reporting & Investigation Objectives for this section: to understand: accident definition accident causation accident costs accident prevention accident reporting/notification accident investigation

119. Accident Reporting & Investigation Common Uninformed Comments accidents just happen we don’t have many accidents safety is expensive the insurance will pay safety is just common sense

120. Accident Reporting & Investigation Accident Definition what is an accident? unplanned & uncontrolled event that led to, or could have led to: injury to persons, damage to property/plant/equipment, impairment to the environment or some other loss to the company

121. Accident Reporting & Investigation Accident Definition accident types minor dangerous occurrence near miss plant/equipment damage minor injury lost time injury disablement/fatality

122. Accident Reporting & Investigation Accident Definition Frank Bird (Accident Triangle) 600 near misses 30 property damage 10 minor injuries 1 serious injury (lost time or fatal)

123. THE ACCIDENT BASIC TYPES OF ACCIDENTS

124. THE ACCIDENT MINOR ACCIDENTS: Such as paper cuts to fingers or dropping a box of materials.

125. THE ACCIDENT More serious accidents that cause injury or damage to equipment or property: Such as a forklift dropping a load or someone falling off a ladder

126. THE ACCIDENT Accidents that occur over an extended time frame: Such as hearing loss or an illness resulting from exposure to chemicals

127. THE ACCIDENTNEAR-MISS Also know as a “Near Hit” An accident that does not quite result in injury or damage (but could have). Remember, a near-miss is just as serious as an accident !

128. THE ACCIDENT ACCIDENTS HAVE TWO THINGS IN COMMON

129. THE ACCIDENT They all have outcomes from the accident

130. THE ACCIDENT They all have contributory factors that cause the accident

131. Accident Reporting & Investigation Accident Causation environment personal fault unsafe act unsafe condition accident injury/damage

132. Accident Reporting & Investigation Accident Causation causal factors individual job organisation

133. Accident Reporting & Investigation Accident Causation causal factors individual knowledge skills training experience personality attitude risk perception

134. Accident Reporting & Investigation Accident Causation causal factors job task workload equipment controls procedures environment

135. Accident Reporting & Investigation Accident Causation causal factors organisation culture leadership resources work patterns communications

136. ACCIDENT CAUSATION MODELS - 1

137. Accident Reporting & Investigation Accident Causation Kings Cross Fire (1987) - 31died discarded cigarette accumulation of rubbish poor cleaning regime wooden escalator failure of fire fighting equipment lack of emergency training poor safety culture

138. Accident Reporting & Investigation Accident Causation Herald of Free Enterprise (1987) - 189 died failure to close bow doors no checking/reporting system commercial pressures internal friction disease of sloppiness

139. Accident Reporting & Investigation Accident Causation Clapham Junction (1988) - 35 died & 500 injured signal failure incorrect maintenance degradation of working practices training problems communication problems poor supervision excessive working hours failure to learn lessons

140. Accident Reporting & Investigation Accident Causation Piper Alpha (1988) - 167 died maintenance error inexperience poor maintenance procedures communications breakdown permit to work system fault safety procedures not practised

141. Accident Reporting & Investigation Accident Causation Automotive Supplier (1999) - 1 died poor safety culture lack of guarding lack of training poor perception of risk no safe systems of work no risk assessment programme no effective accident system no communication

142. OUTCOMES OF ACCIDENTS NEGATIVE ASPECTS Injury & possible death Disease Damage to equipment & property Litigation costs, possible citations Lost productivity Morale

143. OUTCOMES OF ACCIDENTS POSITIVE ASPECTS Accident investigation Prevent recurrence Change to safety programs Change to procedures Change to equipment design

144. The Aim of the Investigation The key result should be to prevent a recurrence of the same accident. Fact finding: What happened? What was the root cause? What should be done to prevent recurrence?

145. The Aim of the InvestigationIS NOT TO: Exonerate individuals or management. Satisfy insurance requirements. Defend a position for legal argument. Or, to assign blame.

146. Accident Reporting & Investigation Accident Costs insured costs uninsured costs

147. Accident Reporting & Investigation Accident Prevention reasons humane economic legal

148. Accident Reporting & Investigation Accident Prevention control measures safety procedures/work instructions adequate training effective communications good housekeeping guards/safety devices/warning signs adequate working environment regular safety inspections risk assessment

149. Accident Reporting & Investigation Accident Reporting/Notification internal report form HSE RIDDOR report injury claim requirement

150. Accident Reporting & Investigation Accident Investigation reasons identify root causes identify faults identify corrective/preventative action prevent recurrence

151. THE INVESTIGATION

152. Objectives Recognise the need for an investigation Investigate the scene of the accident Interview victims & witnesses Distinguish fact from fiction Determine root causes Compile data and prepare reports Make recommendations

153. ACCIDENTS & ILL HEALTHREASONS FOR INVESTIGATION to record what happened RIDDOR legal reporting requirement compensation claims/insurance to find out what & why it happened immediate causes (What) underlying causes (Why) to prevent recurrence the next incident could be more serious

154. Traditional approach to accident investigation Safety management has concentrated on accident investigation as it is a good deal easier than proactive prevention Key features: Search for the primary cause, and Debate whether the primary cause was and unsafe act or unsafe condition

155. HEINRICH'S TRIANGLE (1950)

156. Accident causation First accident model was Heinrich (1931). Domino theory

157. Acts and Conditions UNSAFE ACT Human errors Failure to follow procedures Violations mistakes UNSAFE CONDITIONS No guarding Trip hazards Poor maintenance Poor design

158. Need for line managers to take responsibility for investigation; need for adequate training for investigators; importance of investigating both accidents and other incidents and near-misses - esp. those with potential for serious injury; need to deal with immediate consequences at scene by treating, helping and rescuing persons and making site safe; cont’d HSE Guidance on accident investigations [HSG 65]

159. investigating to appropriate depth, depending on its seriousness; guidance on investigation process to investigators, including: structured approach appropriate use of observation, documents and interview evidence; use of model to guide collection of evidence and its assembly for evaluation need to explore immediate and underlying causes developing specific objectives for implementing findings need to record essential data HSE Guidance on accident investigations [HSG 65] cont’d

160. Attending the accident scene OBSERVE Look at the scene and the surrounding area Take measurements and produce a diagram Take photographs INTERVIEW The injured person and/or witnesses (preferably separately) At the scene if possible(within 48 hours) Note down beforehand some key questions to be answered - CHECKLIST Ask open-ended questions in a friendly manner KEEP AN OPEN MIND (be aware of your bias)

161. Interviews Start with initial discussions with preferably the injured person and peers/witnesses (Mainly what happened) Then move on to interview supervisors and senior managers (Mainly why) Do not rush into statement taking, get an overview first

162. Statements Introduce yourself (if necessary)and explain your role – what needs to be done Invite safety rep or another person they would like to sit in, but not answer questions If trainee under 18 years, interview with an adult, preferably a parent Run through your questions and what they witnessed and make notes to help structure a statement – ‘Each persons summary’

163. A modern approach Immediate causes and underlying causes – HSG65 Accidents are Multi-causal Understanding of the complexities of human factors Understanding of management systems Promotion of a safety culture

164. HS(G)65 Appendix 5Immediate causes (what)“4 Ps” Premises Plant/Substances Procedures People

165. Premises Physical layout Condition of building Environment (weather) Tripping & slipping hazards

166. PLANT/SUBSTANCES Machinery guarding Substance in use –toxic, harmful Mobile plant Item of work equipment – hand tools, chairs

167. PROCEDURE Written system of work/operating procedure to be followed Safety Policy Work instruction Quality standard Custom and Practice – does not have to be a document

168. People Human factors State of health (eye sight) Abilities Errors – skill based (slip or lapse), rule based, knowledge based or violations Behaviour – pressures, culture

169. Underlying causes‘Root causes’ (Why) 5) Planning 6) Risk Assessment 7) Control (Supervision) 8) Co-operation 9) Communication 10) Competence 11) Monitoring 12) Reviewing

172. Essential data in investigation reports Details of injured person - age, sex, experience and training, etc; Description of circumstances - place, date, time and conditions; Details of the event - actions leading directly to event/ direct injury causes; Underlying causes; cont’d

173. Essential data in investigation reports Details of outcomes: nature of injuries, ill-health, losses; severity of harm; immediate management response and its adequacy; First-aid response; Potential consequences: what was the worst that could have happened? What prevented it from happening? How often could it recur and how many affected?

175. Accident Reporting & Investigation - team Accident Investigation investigation team supervisor safety rep engineer manager safety officer

176. Accident Reporting & Investigation - objectives Accident Investigation investigation objectives establish chain of events identify root causes identify faults identify corrective/preventative action

177. Accident Reporting & Investigation - techniques Accident Investigation investigation techniques attend promptly ensure medical attention leave scene undisturbed take photographs/sketches take measurements take samples gather documentation interview witnesses

178. Accident Reporting & Investigation - techniques Accident Investigation investigation techniques interviewing witnesses explain purpose their version of events do not listen to ‘hear say’ ask open questions avoiding leading or implying do not apportion blame express appreciation

179. Accident Reporting & Investigation - report Accident Investigation investigation report identify team summarise consequential events identify root causes describe other weaknesses identify corrective/preventative action allocate responsibility & timescale

180. ACCIDENTS ……..... DON’T JUST REPORT THEM & ………PREVENT THEM !

181. Working together …

183. What is workforce involvement? Involve the workforce as equal partners Actively seek their views Value their positive contribution Enable effective involvement in all areas of H&S management Be ready to change things and challenge previous management practices Nurture, support and sustain the partnership.

184. Do you shape up? Have the workforce as well as managers been involved in writing the company safety policy? Are all H&S Committee members equal partners? Have safety reps, supervisors and others been trained to enable them to play an equal role in the H&S Committee? Does your company provide cover for workers to enable attendance at safety meetings and training courses?

185. Do you shape up? Are employees involved in long term H&S Are workers involved in writing safe working procedures? When accidents are investigated are safety reps fully involved? Do H&S audits include safety reps as well as managers?

186. Where is all this from? HSE booklet HSG217 “Involving employees in health and safety” Aimed at the chemical industry – but should apply to everyone Does it apply to you?

187. Health and Safety Management Safety Representatives Safety Officers And Safety Committees

188. Members and Meetings All work areas should be represented Members should be interested,concerned and willing to learn more about h&s Willing to meet once a month and to communicate with workers Meetings discuss workers’ concerns Possible solutions Approaches to management negotiations Ongoing concerns and progress reports to union

189. Functions of Committee Conduct regular inspections and surveys on safety and health Respond to workers concerns on OHS Make reports and recommendations to improve compliance with law and standards Propose policies, work plans, projects and activities to reduce accidents and illness Propose and organise training programmes for the workforce

190. Functions of Committee Promote and support activities on OHS Follow up progress of proposals Report on results achieved, point out obstacles and problems Investigate, record and report on all accidents, ill health and near misses Propose regulations on health and safety Organise occupational health services

191. What makes a committee work? Have a plan and objectives and actively pursue them with the broadest support possible Communicate and educate to get that support Need facilities, time off, info and training Agendas in advance, proper minutes, decisions If union reps make coherent proposals in writing: describe the problem, include the facts; suggest improvements; decide who will do what; timetable and budget.

192. Directors Responsibilities “The board needs to recognise its role in engaging the active participation of workers in improving H&S” “You should encourage workers at all levels to become actively involved in all aspects of your health and safety management system” “The best form of participation is a partnership for prevention, where workers and their representatives are involved in identifying and tackling potential or actual problems, rather than being consulted only after decisions have already been taken” “Directors’ responsibilities for health and safety” UK HSE IND(G)343

193. Employer’s role- Planning and Coordination Understand the legislative requirements and have a written health and safety policy. Identify hazards, make a site specific health and safety plan and method statements before work starts Designate OSH responsibilities - safety officer to implement safety management on site Conduct inspections, and meetings with all subcontractors and with workers to inform, communicate and coordinate and to provide training Have the necessary information on site regarding hazards and conduct regular tool box meetings Use the safety committee as the motor for prevention

195. This is what you need to do Involve the workforce as equal partners Actively seek their views Value their positive contribution Enable effective involvement in all areas of H&S management Be ready to change things and challenge previous management practices Nurture, support and sustain the partnership.

196. If you do that … We will genuinely be working together You will be improving H&S The workers will be healthier and safer You will be financially healthier and safer

197. Take question and answer as required Any question that cannot be answered take note and give a timescale of when feed back will be given Take question and answer as required Any question that cannot be answered take note and give a timescale of when feed back will be given

198. For attending this course