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UNIVERSITY PROCEDURE ACCIDENT / INCIDENT INVESTIGATION

Document No: Policy Ratified by: Date: Area Applicable: Review Year Impact Assessed

CU/11/AII/P/1.0 Safety Health and Env !"n#ent C"## ttee $%ly &011 All Ca!d ff Un ve!' ty Staff &01( YES

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1.0 Int!"d%)t "n One of the hardest lessons to be learned in accident prevention comes from the investigation of accidents and incidents that have caused serious in ury or loss! "acing up to those lessons can be traumatic for all concerned# which is one reason why investigations are often incomplete! $he depth re%uired for an investigation must be sufficient to obtain information that is of value to line management and others that may wish ma&e use of the information# such as the 'niversity Occupational (afety# )ealth and *nvironment 'nit +O()*',# the 'niversity Insurers or the )ealth - (afety *.ecutive +)(*,! An effective investigation re%uires a methodical# structured approach to information gathering# collation and analysis! $he findings of the investigation will form the basis of an action plan to prevent the accident/incident from happening again# and for improving the overall management of ris&! $he findings will also point to areas of the risk assessment that may need to be reviewed! It has to be remembered that the lin& with ris& assessment+s, is a legal duty! 0onducting an effective accident investigation can be e.pensive in time# but the rewards can also be great! &.0 Inve't *at "n "f A)) dent' &.1 P%!+"'e $he main reason for investigating accidents is prevention! $he purpose of the investigation is to establish whether a reoccurrence can be prevented# or its effects lessened# by the introduction of additional safeguards# procedures# information instruction and training# or any combination of these! &.& The P!")ed%!e $here should be a defined procedure for reviewing or investigating all accidents# however serious or trivial they may appear to be! $he use of a form/chec&list will help to concentrate the attention on the important details! 1ine 2anagers/(upervisors of the wor&place where the accident occurred must complete the initial investigation3 for less serious accidents they may be the only people who ta&e part in the investigation and reporting procedure! 4or&ers5 representatives# senior management# and safety personnel may also be involved at any part of the process as part of the investigating team! &.( ,h" 'h"%ld )a!!y "%t the nve't *at "n"ront line managers/supervisory staff should carry out the initial investigation! $his demonstrates commitment and removes any temptation to leave 6health and safety5 to others!

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(.0 Inve't *at "n P!")e''

.evel 1. C"n'e/%en)e "f 0hat ha++ened and 0hat )"%ld have ha++ened. &. Inve't *at "n Tea# (. 1 nd n*' and a)t "n +lan 2S3ART4 5. Cl"'e "%t

1 1ow

2inor in ury/1i&ely potential outcome no more than first aid 1ocal containment of an environmental incident within area of operation!

(upervisors/line managers

Report any findings on Accident form!

7(afety Representative

& 2edium

1i&ely potential harm/"irst Aid or more 4ider containment of an environmental incident within 'niversity!

As level 8 Departmental (afety Officer

Record findings as level 8 and also on the Incident Investigation "orm +II",! Areas to consider include: Immediate cause Root cause 'nderlying cause li&elihood of reoccurrence and severity of harm control measures

3"n t"! and Rev e0 !e)"##endat "n'

7(afety Representative

( )igh

)igh adverse effect/1i&ely conse%uences could have been serious in ury or fatality! 4ider containment of an environmental incident! (tatutory re%uirements breached! Impact outside of the 'niversity!

As level 8 - 9 O()*'

Record findings as level 8 and also on the Incident Investigation "orm +II",! Areas to consider include: Immediate cause Root cause 'nderlying cause li&elihood of reoccurrence and severity of harm control measures

7(afety Representative E6te!nal )(*/*nvironment Agency!

7(afety representatives may be part of the team as specified in (afety Representatives and (afety 0ommittees Regulations!

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5.0 Ca!!y n* "%t the Inve't *at "n $he first steps in any investigation will be to preserve the accident/incident scene# record the names of the people involved# the e%uipment involved# and the names of any witnesses! Information obtained during investigations is usually given verbally# but may also be provided in writing! 4ritten documentation should be gathered to provide evidence of policy or practice followed in the wor&place and witnesses should be tal&ed to as soon as possible after the accident! $he in ured person should also be interviewed as soon as is practicable! :ey points to note about investigations are: events and issues under e.amination should never be pre udged! total reliance should not be placed on any one sole source of evidence! the value of witness statements decreases with time# it is a proven fact that theorising by witnesses increases as time passes and memory decreases! try to ensure that you as& ;open %uestions<! the first focus of the investigation should be on: o when o the e.act time and date o where = the building# floor# room# location in room etc! o to whom = name# ob title etc! o and the outcome of the accident/incident = in ury# property damage etc! the second focus should be on how and why# giving the immediate cause of the in ury or loss e!g! slipped on spilled substance on floor# and then the secondary or underlying causes e!g! no procedure for dealing with spillages# procedure in place but ignored by staff# unsuitable footwear# carry large load which obscured vision! the amount of detail re%uired will depend on a, the severity of the in ury and/or property damage and b, the use to be made of the investigation and the report! $he report should be as short as possible and as long as necessary for its purpose+s,! 5.1 E/% +#ent $he following are considered essential basic tools in the competent investigation of accidents and incidents: report form# a chec&>list as a routine prompt for basic %uestions noteboo& or pad of paper pen

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(pecialist e%uipment# e!g! camera# monitoring e%uipment# building plans# video recorder# measuring tape# which should be reasonably long and robust etc! may be obtained via O()*'! 5.& Re)"!d n* f nd n*' and the Inve't *at "n 1"!# An action plan should be put together in light of an Incident! It should be specific and well defined3 measurable in attaining the goal3 achievable with sta&eholders3 realistic with the availability of resources and time>bound to a reasonably practicable amount of time +(2AR$,! "or all purposes# the report that emerges from the investigation must provide answers to the following: 8! 4hat was the: I##ed ate )a%'e7 R""t )a%'e7 the most obvious reason why an event happens! $here may be more than one immediate cause identified! an initiating event or failing from which all other causes or failings spring! *g! 2anagement# planning# organisational failings etc!

Unde!ly n* )a%'e7 the less obvious system or organisational reason for the accident happening! *g! $he ha?ard has not been ade%uately considered via a suitable and sufficient risk assessment# lac& of e.perience or information# instruction and training! I#+a)t "n the Env !"n#ent7 An incident that caused or had the potential to cause damage to the environment either via the water system# atmospheric release or to land contamination including interference with "lora and "auna! 9! 4hat is the li&elihood of it happening again@ Ce!ta n7 . 8ely7 P"'' 9le7 Unl 8ely7 it will happen again! it will probably happen again! it will possibly happen again! it is unli&ely to happen again!

A! )ow do we prevent a reoccurrence# what is the necessary corrective action@ B! C! If we do not have suitable procedures in place# what new procedures are either necessary or desirable to prevent a reoccurrence@ If procedures are in place# what reviews are needed of for e.ample information# instruction and training# the ris& assessment or wor& e%uipment@

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6.

4hat realistically could be the result if no action is ta&en e!g! If the incident was a near miss what could have been the result@

It is not the tas& of the investigation report to allocate blame# although some discussion of this is almost inevitable! Reports are usually 6discoverable53 this means they can be used by parties in any action for damages! It is a sound policy to assume that accident investigation reports will be seen by solicitors and e.perts acting on behalf of any in ured party! $hey are entitled to see the report and this will include anything in it that may later prove embarrassing = it should never contain comments on blame! $he report and supporting documentation for serious accidents should contain: a summary of what happened# with detail of any person+s, in ured a summary of events prior to the accident information gained during investigation details of witnesses# and witness statements information about any in ury or loss sustained conclusions and recommendations supporting materials +photographs# diagrams to clarify the situation, relevant policy / procedural documents relevant ris& assessments training records the date = and signature+s, by the person+s, carrying out the investigation! Def n t "n' A)) dent7 An unplanned# uncontrolled event that has resulted in an in ury or damage to property! Nea! # ''7 An unplanned# uncontrolled event that# under slightly different circumstances# could have resulted in an in ury or damage to property! Se! "%' "! P"tent ally Se! "%' 2S"PS4 In) dent'7 $hose incidents +in uries# near misses# vehicle incidents# fire incidents, that d d: "! had the !ea'"na9le +"tent al t"# result in significant and permanent harm to staff# contractors# tenants# users# visitors at 0' sites or for staff while travelling and wor&ing on 0' business away from 0' sites! Env !"n#ental In) dent7 An incident that caused or had the potential to cause damage to the environment either via the water system# atmosphere or to the land +"lora and "auna,! RIDDOR In) dent7 An in ury specified in (chedule 8 of RIDDOR 8DDC!

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*!g! fatality# fractures# amputations or dislocations or where a person has been admitted to hospital for more than 9B hours! OR An Incident that is specified in (chedule 9 of RIDDOR 8DDC! *!g! "ailure of a load bearing part of a crane# e.plosion or bursting of a pressure system# electrical failure causing a fire# collapse of a large structure or accidental release of a biological agent! OR An in ury which# although not a ma or in ury# has resulted in the in ured person being away from wor& or unable to carry out the full range of his/her duties for more than seven days +including wee&ends and rest days but e.cluding the day of the accident,! 0hanges in the reporting process to the )(* re%uire three day in uries to be recorded but not reported to the )(*! ;.0 1%!the! Inf"!#at "n 8! )(* Publication > Investigating Accidents and Incidents! A wor&boo& for employers# unions# safety representatives and safety professionals!