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Accident Investigation - UK-HSE
- 1. Accident and Incident Investigation an introduction Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 1 www.uk-hs.co.uk
- 2. Aim of Session • To provide an overview of: – Accident investigation – Human Factors as they relate to accidents and incidents – Immediate causes of accidents and incidents – The “Why? - Because” model of root cause analysis – Responding to an incident Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 2 www.uk-hs.co.uk
- 3. Introduction Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 3 www.uk-hs.co.uk
- 4. Why report accidents and incidents • All accidents and incidents need to be reported • Comply with the law • Identify failings – prevent recurrence • What is YOUR reporting procedure • Some to the Health and Safety Executive (HSE) - RIDDOR Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 4 www.uk-hs.co.uk
- 5. RIDDOR The Reporting of Injuries, Diseases and Dangerous Occurrence Regulations 1995 • Death • Major injuries – e.g. broken leg • Over-3-day injuries • Injuries to members of the public taken from the scene of an accident to hospital • Some work-related diseases e.g. skin cancer from mineral oil • Dangerous occurrences – e.g. scaffolding collapse Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 5 www.uk-hs.co.uk
- 6. Terminology • Hazard - something with the potential to cause harm • Incident - Unplanned, uncontrolled event …….could result in an accident • Accident - Unwanted or unintended sudden event ….harmful consequences Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 6 www.uk-hs.co.uk
- 7. The realisation of harm Hazard Machine Guard Safe System of Work PPE Undesirable event Harm Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Session 5 30 minutes Slide - 7 www.uk-hs.co.uk
- 8. The realisation of harm Hazard Put in extra barriers Machine Guard Safe System of Work PPE Undesirable event Harm Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Session 5 30 minutes Slide - 8 www.uk-hs.co.uk
- 9. The realisation of harm Hazard Identify and remove Machine Guard the holes (e.g. latent Safe System of Work failures) PPE Undesirable event Harm Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Session 5 30 minutes Slide - 9 www.uk-hs.co.uk
- 10. Human Factors Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 10 www.uk-hs.co.uk
- 11. Why Classify the Human Failure • If you understand the human failure, you can start to understand the causation path and what to do about it – If someone has a lapse then training etc. will not help, we should look at the visual clues, process checks and balances – If it is a mistake then we should look at the training, supervision, data supplied, etc. Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 11 www.uk-hs.co.uk
- 12. Human Failure • Error - action or decision which was not intended and which led to an undesirable outcome – Slip / Lapse - performing the wrong action (slip) or omitting to carry out a step in the process (lapse) (Forgets) – Mistake - a person does the wrong thing while believing it to be the right • Violation - when a person deliberately “breaks the rules” and violates a rule, regulation or instruction. Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 12 www.uk-hs.co.uk
- 13. Identifying the Immediate Causes Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 13 www.uk-hs.co.uk
- 14. Accidents and Incidents • Unsafe act – action likely to result in accident – occurs immediately prior to the accident • Unsafe condition – article, equipment or environment in a condition likely to result in accident – exists prior to the accident Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 14 www.uk-hs.co.uk
- 15. Immediate Causes Immediate Causes Unsafe Unsafe Acts Conditions Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 15 www.uk-hs.co.uk
- 16. Underlying Causes Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 16 www.uk-hs.co.uk
- 17. Underlying Causes Immediate Causes Unsafe Unsafe Acts Conditions Underlying Causes Human Missing or Failure Inadequate Slips/Lapses, Control Mistakes or Violations Measures Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 17 www.uk-hs.co.uk
- 18. Why? Because Model Incident Person fell down the stairs due to tripping on a training cable Why Why was the trailing Because The contractor had put it cable at the top of the there stairs? Why The contractor had put Because He was not aware of the Safe it there? System of Work on „Trailing Cables‟ Why He was not aware of Because He had not been briefed by the Safe System of the supervisor Work on „Trailing Cables‟? Why He had not been Because The supervisor had become briefed by the sloppy and failed to brief supervisor? the contractor Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 18 www.uk-hs.co.uk
- 19. Model of Causal Analysis Identify Facts and Failures Immediate Causes Unsafe Unsafe Acts Conditions Underlying Causes Human Missing or Failure Inadequate Slips/Lapses, Control Mistakes or Violations Measures Identify Root Causes Influencing Influencing Factors Factors Job or Personal Organisational Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 19 www.uk-hs.co.uk
- 20. Root Causes Individual Competence, personality, attitudes, risk perception… Job Organisation Task, workload, leadership, resources, equipment, displays, work patterns, controls, procedures communications Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 20 www.uk-hs.co.uk
- 21. Excellent starting checklist Section 2, HASAWA* 1974 Employer’s duties to employees So far as is reasonably practicable • Safe plant and systems of work • Safe storage, handling, use and transportation of articles and substances • Information, training, instruction and supervision • Safe access and egress • Safe working environment and adequate welfare facilities * Health and Safety at Work etc. Act 194 Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 21 www.uk-hs.co.uk
- 22. Responding to an Incident Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 22 www.uk-hs.co.uk
- 23. Response to the Incident • Preserve Information • Gather Evidence • Don‟t make assumption • What was the Safe System of Work in place? • What equipment was being used? • Were people competent? • What supervision was in place? • Is something FACT or OPINION? Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 23 www.uk-hs.co.uk
- 24. Conducting an Interview • Organise the interview • Greet and Personalise • Explain aim and objectives • Initiate Free Reporting • Ask open questions • Encourage retrieval • Summarise – get agreement • Explain next step Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 24 www.uk-hs.co.uk
- 25. Sequence of Events • Determine the chronological listing of events that gave rise to the incident - Before incident - Incident - After the incident Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 25 www.uk-hs.co.uk
- 26. Identifying what went wrong • Barriers in place • What should have happened • Which barrier failed • Human failure • Underlying causes Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 26 www.uk-hs.co.uk
- 27. Identify what needs to be done to address failings • Can include - Individual action plans - Group initiatives to address culture issues - Improvement plans • Should include - Monitoring Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 27 www.uk-hs.co.uk
- 28. Produce SMART Actions • Specific • Measurable • Agreed / Achievable • Realistic / Reasonable • Timescale / Time based Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 28 www.uk-hs.co.uk
- 29. Writing the Report • Use the correct terms • Use of speech marks to „quote‟ • Vocabulary • Clear and to the point • Do not use people‟s names • Do not use the terms violation lapse, mistake in the report Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 29 www.uk-hs.co.uk
- 30. Writing the Report - Some Guidance • Immediate Cause – The last event to occur prior to the Accident / Incident and is either an unsafe act or unsafe condition • Underlying Causes – must cross reference with the problem issues discussed in the “Factors for Consideration” and demonstrate their contribution to the Accident / Incident • Action Plans – The controls to prevent re-occurrence – Make sure they are SMART Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 30 www.uk-hs.co.uk
- 31. Your Report – basic checklist • Have you? – Described Accident - Nature or Description – Identified Hazards – Determined the Sequence of events – Determined the Control Measures or Barriers – Determined Failures and where in the sequence of events – Identified Unsafe Acts and/or Unsafe Conditions – Identified Unsafe Act immediately prior to the accident is the Immediate Cause – Identified Unsafe Condition exists prior to the accident Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 31 www.uk-hs.co.uk
- 32. Aim of Session • Do you have an overview of: – Accident investigation – Human Factors as they relate to accidents and incidents – Immediate causes of accidents and incidents – The “Why? - Because” model of root cause analysis – Responding to an incident Accident and Incident Investigation – an Inroduction Issue 1.0 Augu Slide - 32 www.uk-hs.co.uk