UNit 7 Incident Investigation

1.
Unit 7
Incident
Investigation,
Recording and
Reporting
1.0 Unit 7: Incident Investigation, Recording and

Reporting
Overall aims.
Understand:
the need for an organisation to have a system for internally reporting,

recording and investigating accidents, cases of work-related ill-health
and other occurrences;
local requirements for notifying certain events to external agencies.
Specific learning outcomes.

Be able to:
explain the purpose of and procedures for investigating accidents and

other events at work;
utilise records of accident and ill-health experience in an
organisation;
explain the local requirements for notifying events to external
agencies.
Reference:
Recording and Notification of Occupational Accidents and Diseases, ILO.
Tuition time: 4 hours.
1.2
Role and Function of Accident and Incident Investigation
Introduction.
Why do we investigate accidents and incidents?

The simple answer is to ascertain why the accident
happened and put measures in place to ensure that the
same - or similar - accidents don't happen again.
It is more than that, however; finding the root cause
of an accident and ensuring that measures are put in
place to ensure that it can't happen again are a vital part
of any investigation.
Before we move on to studying the investigation
process, we have provided you with an example
investigation and in this section, we explain the role of the
accident investigator and the function of accident and
incident investigation in the workplace.
The names of the persons involved, dates and times
etc. are all omitted as you would expect. Our intention is to
provide you with a scenario that will support the section
entitled Investigation Process.
1.3
Example Investigation
The last thing that any manager wants to do

is report an accident or incident to the EHO or HSE. When
thinking of this, two things come to mind:
One -
you may feel that you or your safety

management systems have failed.
Two -
you may worry that reporting accidents

and incidents to the enforcing authorities - and
a possible follow-on visit by them - may reveal
even more failings, a bit like going to the
dentist with a slight toothache and ending up
having to have three teeth taken out.
However, we know that as part of your accident

prevention strategy, accident investigation and reporting
plays a vital role and as you are now also aware, having
read through RIDDOR, you have a legal duty to report
certain accidents and incidents.
Below is the detail of how and why we need to

investigate and report accidents and incidents, but to put
it into context, we have included an example for you:
1.3.1
Setting the Scene

We begin with the the accident investigation.
The incident took place on a large project that

included, amongst other aspects, the refurbishment of
places of worship. There were eleven sites in all, some used
by members of the public, others closed and awaiting
refurbishment.
Consider the type of work activities that this might

entail. The work was mostly preparation and painting of
walls, ceilings, floors and woodwork to the interior of these
old buildings, preparing the surfaces ready for painting
and then applying the paint.
The employees were working as painters and

decorators. In all, there were 125 men and women, mostly
inexperienced in the world of work and - to some extent
- not particularly motivated individuals. The project was
funded by the government to help the unemployed back
into work.
1.3.2
The Accident
A telephone call was received from one of the Site
Supervisors to say that one of the men had fallen and an
ambulance had been called. He gave information
concerning the suspected injury and the employee's name.
The Site Supervisor had followed the procedure; he

had not disturbed the site of the accident and had sent a
colleague to the hospital with the injured employee. The
colleague would report back on the injury and the initial
thoughts of the Accident & Emergency Department.
The Project Manager needed to telephone the injured

employee's named contact. All of the employees, at their
induction, had to complete a form stating who should be
the first person to be contacted in the case of such an
event.
The Painting & Decorating team on the site were

made up of 12 young people in the age range 18 to 24 and
one experienced tradesman, plus the Site Supervisor.
The scene of the accident was a corridor just off the

main church hall: two chairs, a table and glass on the
floor. A sketch of the area was quickly made and included
some dimensions such as corridor width, position of
broken glass etc.
1.3.3
The Accident Continued
The input of members of the team was then solicited

on the events of the accident.
The team member who was with the injured person at

the time of the accident was taken into another area and
interviewed; notes were made as the events of the accident
were explained. The Site Supervisor was then interviewed,
notes again being made as he spoke.
At the end of these initial interviews, both
interviewees were told that they might need to be reinterviewed.
Later, each of the other team members was asked if
they knew anything of what had happened. Three of the
team stated that the injured team member (employee A)
had been to them to ask if he could borrow the step ladder
they were using and all had said no, as they were using
them.
An understanding of the events leading up to the
accident was now emerging:
The time of the accident was 2.30.

Two members of the team were involved.
A make shift access platform was used.
A certain amount of rushing could be
attributed to the accident.
A sketch of the immediate area of the accident was

made. This meant that the scene could be cleared and
made safe.
1.3.4
What Had Happened?

In brief, two members of the team had been asked to
prepare the area of the corridor ready for painting. The
injured employee A and his colleague (employee B) had
been asked by the Site Supervisor to replace the bulb in
the corridor that he, the Site Supervisor, suspected had
blown. This must be your first action, the Site Supervisor
had told them, make the area safe first.
Employees A and B tried to find the step ladders but

all ladders on the site were in use and they had given up
because it was nearly tea break, as employee B had stated
in his interview. Employee B had, however, dragged a small
table, a fixed leg chair and a swivel chair from an adjacent
office.
Employee A placed the fixed leg chair on the table and

used the swivel chair as a step up. All went well until
employee A removed the suspected blown light bulb and
placed the new bulb in the light fitting. To his surprise, it
lit up. The switch had been left in the `on` position. It
startled employee A and his reflex action had made the
chair slip and caused him to fall.
1.3.5
What Had Happened?
Continued
The enforcing authority at the time was the HSE. They

were contacted and provided with the details as required
under RIDDOR (see below). Form F2508 was also completed.
Employee A had suffered a suspected fracture to his right arm
and suspected concussion, which meant a night in the
hospital.
It is not always possible immediately to do carry out the

investigative procedure outlined above. End of day accidents,
shift patterns or accident sites that require some distance of
travel can all delay the start of the investigation process.
Within three days of the accident, employee A's

statement was taken. Apart from one or two minor
inconsistencies between witness statements A & B, the report
was concluded and signed off.
The documents were filed and the data processed. What

was left to do was perhaps more important - establishing the
root cause of the accident and ensuring, through suitable
control measures, that the same or similar accident never
happened again.
All parties blamed each other. Employee A blamed

employee B for rushing him and bullying him into climbing on
the table; he also blamed the Site Supervisor for not having
enough step ladders on site at any one time. Employee B
blamed the Site Supervisor for the same reason as employee
A but he also blamed employee A for not taking the step
ladders off another team member. The Site Supervisor blamed
them both for improvising.
After the accident, a toolbox talk was given on correct

access equipment use. The site team also discussed the
importance of reporting all accidents and near-miss incidents
in the future.
Why is it important to sketch or photo graph the scene of an accident?
1.
2.
? all the above

? so that you can refer to it
3.
? to keep a record
4.
? in case the scene is disturbed
1.4
Basic Accident Investigation Procedures
Basic accident investigation procedures:
Interviews, plans, photographs, relevant records,

checklists.
Identifying immediate causes (unsafe acts and
conditions) and root or underlying causes
(management system failures).
Identifying remedial actions.
1.4.1
Accident Investigation Process

The intention of the above example is to help you put into context
the points made below.
Accident investigations are conducted to

find out the cause of accidents and to prevent
similar accidents in the future. Further to this,
legal requirements are placed on employers
through RIDDOR or through an appointed
competent authority under ILO Recording and
Notification of Occupational Accidents &
Diseases.
The investigation can also be used to

determine costs and will, by the nature of the
investigation, highlight compliance with
statutory requirements.
Near-miss accidents should also be

investigated in the same manner as loss
events. Investigating the near-miss will
identify hazards that can then be
corrected. The forklift truck that nearly
hit a pedestrian on a blind corner may
have a simple corrective action to prevent
a major accident.
1.4.2
Who Undertakes the Investigation?
Ideally, an investigation would be conducted by someone

expert in accident causation, experienced in investigative
techniques, fully knowledgeable of the work processes,
procedures, persons and industrial relations environment of a
particular situation. However, in the real world it is normally a
manager from within an organisation, supported by a member
of the safety team.
It is important that whoever undertakes the investigation
does so in an impartial manner. Looking for someone to blame
at the start of the investigation has only one outcome - failure.
The important point is that even in the most seemingly
straightforward accidents, seldom is there only a single cause.
For example, an "investigation" which concludes that an
accident was due to worker carelessness and goes no further
fails to seek answers to several important questions such as:
Was the worker distracted?

Was a safe work procedure being followed?
Were safety devices in order?
Was the worker trained?
1.4.3
Who Undertakes the Investigation? Continued
As discussed earlier, as little time as possible should be

lost between the moment of an accident or near miss and the
beginning of the investigation. In this way, one is most likely to
be able to observe the conditions as they were at the time,
prevent disturbance of evidence and identify witnesses. The
tools that members of the investigating team may need (pencil,
paper, camera, film, camera flash, tape measure, etc.) should be
immediately available so that no time is wasted.
Here, the actual work procedure being used at the time of the
accident is explored. Members of the accident investigation team
will look for answers to questions such as:
Was a safe work procedure used?

Had conditions changed to make the normal
procedure unsafe?
Were the appropriate tools and materials
available?
Were they used?
Were safety devices working properly?
Was lockout used when necessary?
or most of these questions, an important follow-up
question is "If not, why not?"
1.4.4
Material
To seek out possible causes resulting from the equipment and

materials used, investigators might ask:
Was there an equipment failure?

What caused it to fail?
Was the machinery poorly designed?
Were hazardous substances involved?
Were they clearly identified?
Was a less hazardous alternative substance possible and
available?
Was the raw material substandard in some way?
Should personal protective equipment (PPE) have been
used?
Was the PPE used?
Again, each time the answer reveals an unsafe condition, the

investigator must ask why this situation was allowed to exist.
Environment
1.4.5
The physical environment, specifically sudden changes to

that environment, is a factor that needs to be identified. The
situation at the time of the accident is what is important, not
what the "usual" conditions are.
For example, accident investigators may want to know:
What were the weather conditions?

Was poor housekeeping a problem?
Was it too hot or too cold?
Was noise a problem?
Was there adequate light?
Were toxic or hazardous gases, dusts, or fumes present?
1.4.6
Personnel
The physical and mental condition of those individuals
directly involved in the event must be explored. The purpose of
investigating the accident is not to establish blame against
someone, but the inquiry will not be complete unless personal
characteristics are considered. Some factors will remain
essentially constant while others may vary from day to day:
Were workers experienced in the work being done?

Had they been adequately trained?
Could they physically do the work?
What was the status of their health?
Were they tired?
Were they under stress (work or personal)?
1.4.7
Management
Management holds the legal responsibility for the safety of
the workplace and therefore the role of supervisors and higher
management must always be considered in an accident
investigation. Answers to any of the preceding types of questions
logically lead to further questions such as:
Were safety rules communicated to - and

understood by - all employees?
Were written procedures available?
Were they being enforced?
Was there adequate supervision?
Were workers trained to do the work?
Had hazards been previously identified?
Had procedures been developed to overcome them?
Were unsafe conditions corrected?

Was regular maintenance of equipment carried out?
1.4.8
Were Regular Safety Inspections Carried Out?

This model of accident investigations provides a guide for
uncovering all possible causes and reduces the likelihood of
looking at facts in isolation. Some investigators may prefer to
place some of the sample questions in different categories;
however, the categories are not important as long as each
pertinent question is asked.
Obviously, there is considerable overlap between
categories; this reflects the situation in real life. Again, it should
be emphasised that the above sample questions do not make up
a complete checklist, but are examples only.
1.4.9
How Are the Facts

Collected?
The steps in accident investigation are simple: the accident

investigator gathers the information, analyses it, draws
conclusions and makes recommendations. Although the
procedures are straightforward, each step can have its pitfalls.
As mentioned above, an open mind is necessary in
accident investigation; pre-conceived notions may result in some
wrong paths being followed while leaving some significant facts
uncovered. All possible causes should be considered. Making
notes of ideas as they occur is a good practice but conclusions
should not be drawn until all the information is gathered.
1.4.10
Injured Worker(s)
The most important immediate tasks - rescue operations,

medical treatment of the injured and prevention of further
injuries have priority and others must not interfere with these
activities.
When these matters are under control, the investigators can
start their work.
1.4.11
Physical Evidence
Before attempting to gather information, examine the site
for a quick overview, take steps to preserve evidence and identify
all witnesses. In some cases, an accident site must not be
disturbed without prior approval from the appropriate enforcing
authority, the coroner, or the police.
Physical evidence is probably the most non-controversial

information available. It is also subject to rapid change or
obliteration; therefore, it should be the first to be recorded.
Based on your knowledge of the work process, you may want to
check items such as:
positions of injured workers;

equipment being used;
materials being used;
safety devices in use;
position of appropriate guards;
position of controls of machinery;
damage to equipment;
housekeeping of area;
weather conditions;
lighting levels;
noise levels.
You may want to take photographs before anything is moved,

both of the general area and specific items. Later, careful study
of these may reveal conditions or observations missed
previously. Sketches of the accident scene based on
measurements taken may also help in subsequent analysis and
will clarify any written reports.
Broken equipment, debris and samples of materials involved
may be removed for further analysis by appropriate experts.
Even if photographs are taken, written notes about the location
of these items at the accident scene should be prepared.
1.4.12
Eyewitness Accounts
Although there may be occasions when you are unable to

do so, every effort should be made to interview witnesses. In
some situations, witnesses may be your primary source of
information because you may be called upon to investigate an
accident without being able to examine the scene
immediately after the event.
Because witnesses may be under severe emotional stress

or are afraid to be completely open for fear of recrimination,
interviewing witnesses is probably the hardest task facing an
investigator. Witnesses should be interviewed as soon as
practicable after the accident. If witnesses have an
opportunity to discuss the event with each other, individual
perceptions may be lost in the normal process of accepting a
consensus view where doubt exists about the facts.
Witnesses should be interviewed alone, rather than in a

group. You may decide to interview a witness at the scene of
the accident where it is easier to establish the positions of
each person involved and to obtain a description of the
events. On the other hand, it may be preferable to carry out
interviews in the quiet of an office where there will be fewer
distractions. The decision may depend in part on the nature of
the accident and the mental state of the witnesses.
The steps involved in an accident investigation include...
1.
2.
3.
4.
?
?
?
?
Gather information
All of the above
Make recommendations
Draw conclusions
5.
? Analyse information
What aspects of the accident information should be recorded first due to rapid change or
obliteration?
1.
2.
? Who was to blame

? Physical evidence
3.
? Witness statement
1.4.13
Interviewing
Interviewing is an art that cannot be given justice here, but
a few do's and don'ts can be mentioned. The purpose of the
interview is to establish an understanding with the witness and
to obtain his or her own words describing the event:
DO
put the witness (who is probably upset) at ease;

emphasise the real reason for the investigation - determining what
happened and why;
let the witness talk and listen to what they say;
confirm that you have the statement correct;
try to sense any underlying feelings of the witness;
make short notes only during the interview.
DO NOT
intimidate the witness;

interrupt;
prompt;
ask leading questions;
show your own emotions;
make lengthy notes while the witness is talking.
1.4.14
Interviewing
Continued
The actual questions you ask the witness will naturally

vary with each accident but there are some general questions
that should be asked each time:
Where were you at the time of the accident?

What were you doing at the time?
What did you see/hear?
What were the environmental conditions
(weather, light, noise, etc.) at the time?
What was (were) the injured worker(s) doing at
the time?
In your opinion, what caused the accident?
How might similar accidents be prevented in the
future?
If you were not at the scene at the time, asking questions

is a straightforward approach to establishing what happened.
Obviously, care must be taken to assess the credibility of any

statements made in the interviews. Answers to a first few
questions will generally show how well the witness could
actually have observed what happened.
Another technique sometimes used to determine the
sequence of events is to replay them as they happened.
Obviously, great care must be taken so that further injury or
damage does not occur. A witness (usually the injured worker) is
asked to re-enact in slow motion the actions that preceded the
accident.
1.4.15
Background Information
A third - and often overlooked - source of information

can be found in documents such as technical data sheets,
maintenance reports, past accident reports, formalised
safe-work procedures and training reports. Any pertinent
information should be studied to see what might have
happened and what changes might be recommended to
prevent recurrence of similar accidents.
1.4.16
What Should I Know When Making the

Analysis
At this stage of the investigation, most of the facts about
what happened and how it happened should be known. This
has taken considerable effort to accomplish but it represents

only the first half of the objective.
Now the key question - why did it happen?
To prevent recurrences of similar accidents, the

investigators must find all possible answers to this question.
You have kept an open mind to all possibilities and
sought out all pertinent facts. There may still be gaps in your
tracing of the sequence of events that resulted in the
accident. You may need to re-interview some witnesses to fill
these gaps in your knowledge, or you may have to resort to
assumptions. Some authorities claim that assumptions have
no place in accident investigations. On the other hand, it may
be better to make assumptions based on what evidence is
available, than to leave questions unanswered.
When your analysis is complete, jot down a step-by-step
account of what happened (your conclusions) working back
from the moment of the accident, listing all possible causes at
each step. This is not extra work; it is a draft for part of the
final report. Each conclusion should be checked to see if it is
supported by evidence, the evidence is direct (physical or
documentary) or based on eyewitness accounts, the evidence
is based on assumption.
This list serves as a final check on discrepancies that should be explained or eliminated.
1.4.17
Why Recommendations Should Be Made
The most important final step is to come up with a set of
well-considered recommendations designed to prevent
recurrences of similar accidents.
Once you are knowledgeable about the work processes

involved and the overall situation in your organisation, it
should not be too difficult to come up with realistic
recommendations. Resist the temptation to make only general
recommendations to save time and effort.
For example, you have determined that a blind corner
contributed to an accident.
Rather than just recommending "eliminate blind corners"
it would be better to suggest: installing mirrors at the
northwest corner of building X (specific to this accident) and
installing mirrors at blind corners where required throughout
the worksite (general).
Never make recommendations about disciplining a
person or persons who may have been at fault. This would not
only counter the real purpose of the investigation, but it would
jeopardise the chances for a free flow of information in future
accident investigations.
In the unlikely event that you have not been able to
determine the causes of an accident with any certainty, you
probably still have uncovered safety weaknesses in the
operation. It is appropriate that recommendations be made to
correct these deficiencies.
1.4.18
The Written
Report
If your organisation has a standard form that must be used,

you will have little choice in how the written report is to be
presented. Nevertheless, you should be aware of, and try to
overcome, shortcomings such as:
Where limited space is provided for an answer,

the tendency will be to answer in that space
despite recommendations to "use back of form if

necessary."
If a checklist of causes is included, possible
causes not listed may be overlooked.
Headings such as "unsafe condition" will usually
elicit a single response even when more than one
unsafe condition exists.
Differentiating between "primary causes" and
"contributing factors" can be misleading. All
accident causes are important and warrant
consideration for possible corrective action.
Your previously prepared draft of the sequence of events

can now be used to describe what happened. Remember that
readers of your report do not have the intimate knowledge of the
accident that you have, so include all pertinent detail.
Photographs and diagrams may save many words of description.
Identify clearly where evidence is based on certain facts,
eyewitness accounts, or your assumptions.
If doubt exists about any particular part, say so. The

reasons for your conclusions should be stated and followed by
your recommendations. Weed out extra material that is not
required for a full understanding of the accident and its causes,
such as photographs that are not relevant and parts of the
investigation that led you nowhere. The measure of a good
accident report is quality, not quantity.
1.4.19
What Should Be Done if the Investigation Reveals
"Human Error"
A difficulty that has bothered many investigators is the

idea that one does not want to apportion blame. However,
when a thorough worksite accident investigation reveals that

some person or persons were apparently at fault, then this
fact should be pointed out. The intention here is to remedy the
situation, not to discipline an individual.
Failing to point out human failings that contributed to an accident will not only
downgrade the quality of the investigation, it will also allow future accidents to happen
from similar causes because they have not been addressed.
1.
2.
3.
4.
?
?
?
?
it will reduce our insurance premiums

because we should apposition blame
to prevent similar occurrences
because the law says we should
A good point when interviewing a witness is to .....
1.5
1.
2.
? Put the witness at ease

? Ask leading questions
3.
? Prompt
Unsafe Acts & Unsafe

Conditions Unsafe Acts
nsafe acts
are made by
people; they are
not made by
systems or by
faulty equipment.
People make
unsafe acts.
As an
example, an
employee was loading a vehicle using a fork lift truck. At the
end of his shift, he parked the truck across a walk way. He had
left the forks in the down position; however, he had parked in
the walkway. Later that evening when the security guard was
making his rounds in the dimly-lit yard, he tripped over the
forks, falling and injuring his knee.
We can also refer back to the example made at the
beginning of this unit, where an employee used a chair to gain
access and fell when the chair became unstable.
Categories of unsafe acts:
Speeding.
Rendering safety devices inoperative.
Working in an unsafe position or posture.
Working without permission.
Using unsafe methods.
Horseplay.
Failure to wear PPE or safety clothing.
Lack of concentration, fatigue or ill-health.
Using unsafe equipment.
Using equipment unsafely.
Working on moving or dangerous equipment.
Active unsafe acts are, for example, where the employee

deliberately removes a guard or uses unsafe equipment. These
can be difficult to deal with as many will go unnoticed.
No matter how many times you explain to some people that

unsafe acts are by their very nature dangerous, some people
don't realise the hazards and will continue to act irresponsibly.
An example of a passive unsafe act is

smoking; we are all aware of the dangers of
smoking, yet some people still smoke.
1.5.1 Unsafe Conditions
1.5.2
Unsafe Conditions can be Mechanical and or Physical
Unsafe conditions can be Mechanical and or Physical

MECHANICAL
Sometimes, is it not possible to make guards

that are 100% effective at all times. Interlocking and
automatic guards should not be thought of as
infallible. There are many regulations relating to
guards and fencing; however, guards fail for all sorts
of reasons.
Some machines are left unguarded because they
are presumed safe by position. In real terms, no
machine is safe by position, because this relies on
people, or the proximity of people to that machine.
Machines can start for some unexpected reason,

by mistake or without the appropriate authority. A
suitable safe system and or permit to work should
remedy this.
PHYSICAL
Physical conditions such as heat, light,

ventilation, humidity and noise can contribute to an
unsafe place of work.
Temperature
Thermal comfort is an important factor and

people have been found to work safer in
temperatures that range from 16 - 24 C. It
stands to reason that those who have heavier
workloads perform better at the lower end and
those that are more sedentary the higher end.
Very hard work or the use of protective
clothing will lower the temperature range, but
this range will be raised where high air
movements cool the body temperature.
Noise
The effects of noise are extremely complex. We know

that it can damage our auditory mechanism and at high
levels, above 120 db, which are sustained over a period of
time; we know that this can lead to permanent damage.
Lower levels interfere with our speech, communication and

concentration and can interfere with our work and how we
work safely.
1.5.3 Unsafe Conditions
Inadequate guarding, wrong height, size of mesh etc.

Unguarded machinery.
Defective, slippery, damaged, sharp surfaces.
Unsafe design of machines or tools.
Unsafe arrangements, housekeeping, congestion,
blocked exits.
Inadequate lighting, glare, reflections.
Inadequate ventilation, contaminated air.
Unsafe clothing, no gloves, or mask.
Unsafe process, mechanical, chemical, electrical,
nuclear.
Humid, cold or noisy environments.
Unsafe acts and unsafe conditions can interact. For

instance, a person may overcome a poorly-designed
guard. You could argue that the poorly-designed guard
was an unsafe act in itself. When unsafe acts and unsafe
conditions interact, the risk of an accident increases as
shown below.
1.5.4 Organisational Factors

The following are organisational factors:
Management system pressures.

Financial restrictions.
Lack of commitment.
Lack of policy.
Lack of standards.
Lack of knowledge and information.
Restricted training and selection of tasks.
Job
1.5.5
Factors
The following are job factors in indirect causes of accidents:
Poor layout of task.

Work schedules and patterns.
Procedures and instructions.
All of these factors need to be considered to determine

the real causes of an accident or incident. These factors can
also be considered as part of an accident prevention
programme. They should be considered at the concept stage
of any new project to ensure a "pro-active" approach to safety.

In other words
Prevention is better than cure

Is speeding an unsafe act or unsafe condition?
1.
? unsafe condition
2.
? unsafe act
Is the removal of a guard an unsafe act or unsafe condition?
1.
? unsafe act
2.
? unsafe condition
Is a missing guard an unsafe act or unsafe condition?
1.
? unsafe act
2.
? unsafe condition
1.6
Root Cause & Immediate

Cause
We will now consider Root Cause and Immediate Causes in more detail. We have
included several examples for you to consider.
Definition of Root Cause :-"the most basic cause that can be reasonably
identified and that management has control to fix"
Typically, an incident report will place emphasis on developing a description of the
consequences rather than causes of the incident, explaining what happened, but not why it
happened.
It is only by adopting investigation techniques that explicitly identify root causes,
i.e. the reasons why an incident occurred, that organisations may learn from past failures
and avoid similar incidents in the future. Root Causes analysis is simply a tool designed to
help incident investigators determine what, how and most importantly, why an incident
occurred.
They are a method of describing and schematically representing the incident
sequence and its contributing conditions; a method of identifying the critical events or
active failures and conditions in the incident sequence and based on this identification; a
method for systematically investigating the management and organisational factors that
allowed the active failures to occur, i.e. a method for root cause analysis.
In selecting or developing a root cause analysis method, the analyst needs to
consider whether the method specifically facilitates the identification of safety management
and organisational inadequacies, oversights which relate to their own operations. The
method needs to identify those factors that exert control over the design, development,
maintenance and review of their risk control systems and procedures.
Typically, an incident report will provide an organisation with a description of
events which principally focus on the status of the system at discrete moments along a
timeline. Reports also usually place the emphasis on developing a description of the
consequences rather than causes of the incident, explaining what happened, but not why it
happened. Such analyses are almost invariably technically orientated, involving detailed
descriptions of plant, equipment, reactions and their governing logic systems.
It is only by adopting investigation techniques which explicitly identify root causes,

i.e. the reasons why an incident occurred, that organisations may learn from past failures
and avoid similar incidents in the future.
Root cause analysis is simply a tool designed to help incident investigators describe
what happened during a particular incident, to determine how it happened and to understand
why it happened.
In simple terms asking why something happened at each event of the investigation
should lead you to the root cause. Knowing the root cause of an accident/incident will allow
control measures to be implemented that are designed to prevent such a similar recurrence
and at the root of the problem.
1.6.1
Example 1
Note:
The main occupier of the track is Rail Ready.

Contractor A is the Technical Services, and are not
employees of Rail Ready.
Contract B is a local construction company, often used by
Rail Ready.
Contract C is a local fencing and security company.
A report from a train driver employed by Rail Ready to his Supervisor stated that he
witnessed a child on the tracks near a busy junction. He claims that the child - aged
approximately eight years old - was crossing the lines and that his train nearly hit the child.
The Supervisor makes his report to the Health & Safety Manager for that region and
copies this report to his immediate manager.
The H&S Manager investigates the incident and reports the following:
"At approximately 10 am on the morning of Tuesday 24th March 2009, a child was seen
by the driver of train 22345 north-bound to Manchester near the junction of Evergreen,
Birmingham.
CCTV also caught the image of a child crossing this junction at the time witnessed by
the train driver. Video evidence is contained within this report."
1.6.2
Example 1
(cont.)
The report continues:

"I visited the scene and noted the following:
A lane runs parallel to the track, from the A19. This lane is
used by walkers of dogs etc, (photos included).
The lane is located on the south side of the track. It is a dead
end and is not suitable for road vehicles.
The wooden fence is there to prevent members of the public
gaining access to the tracks.
A section of perimeter fence was missing.
The missing section of fence was approximately 2 metres in
length. The fence was laying in the undergrowth near the
scene. I replaced the fence using wire to secure it and
telephoned the District Rail Manager who sent a crew to make
the temporary fix permanent.
I can confirm that this work was carried out that afternoon.
I noted that works had been carried out at the track side, near
the position of the missing fence (what appeared to be recent
earth works and disturbance of the ground)."
1.6.3
Example 1
(cont.)
"I visited the District Rail Manager the following day and discussed the matter with him.
He informed me that work had been carried out by a team of contract technicians,
Contractors A, and that this work was to a railside signal box, some two weeks
earlier at that location.
Another contractor C, had first removed the section of fence and yet another
contractor B, had been engaged to ready the ground area for the technicians.
I interviewed contractor A, a Technical Supervisor, who informed me that his team

had arrived at that the site and that the fence had been removed and the area cleared
so that his team could install a new signal box.
I interviewed the contactor B, who was engaged to make the area accessible and to
excavate an area, ready for the sitting of the signal box. He informed me that the
section of fence referred to had indeed been removed by another contractor C, so
that his men and work equipment could gain access to side of the track.
I interviewed the contractor C, who was engaged to remove the fence. He explained
that his contract was to remove the fence to allow excavation equipment to gain
access to the south side of the track. He said to me that no mention was made of reinstalment of the fence, once the job had been completed.
I noted that the paper systems used in this instance made no reference to ensuring
that the fence should be replaced.
I also noted that the contract to each contractor, A, B or C, made no mention of the
fact that the site should be secure at any time."
1.6.4
Example 1
(cont.)
Let us now examine what went wrong:
Incident: near miss accident.

Child on tracks.
Why?
Causal Factors/Immediate Causes/Unsafe Acts.
Curiosity? Walking the dog and dog ran off? Taking short cut?
How did child gain access to track?
Through gap in fence?
Why a gap in the fence?
Contractor C did not replace fence when work completed.
Why?
Contract from Rail Ready did not specify that contractor C should
replace fence.
Why?
Typing error, poorly-written contract, assumption - another
department's job to ensure safety?
Written Safe Procedure for these works lacking in instruction.
Why?
Poorly-written safe procedure, typing error, assumption?
Why was the site not monitored by Rail Ready H&S Dept?
Communication error; H&S not aware of works.
No monitoring of safety for prevention of access while works being
carried out.
Why was it that contractors A & B did not undertake to make the site
secure?
No mention in contract, assumption that contractor C would do this.
Root Cause.
Poor communications between Rail Ready, all the contractors and

their own departments, including H&S.
Example 2
1.6.5
The Plant Manager walked into the plant and found oil on
the floor. He called the Supervisor over and told him to have
maintenance clean up the oil.
The next day, while the Plant Manager was in the same
area of the plant he found oil on the floor again and he
subsequently berated the Supervisor for not following his
directions from the day before. His parting words were to
either get the oil cleaned up or he'd find someone that would.
1.6.6
Example 2
(cont.)
Root Cause Example
The Plant Manager walked into the plant and found oil on the floor. He called the
Supervisor over and asked him why there was oil on the floor. The Supervisor indicated that
it was due to a leaky gasket in the pipe joint above. The Plant Manager then asked when the
gasket had been replaced and the Supervisor responded that Maintenance had installed four
gaskets over the past few weeks and each one seemed to leak.
The Supervisor also indicated that maintenance had been talking to Purchasing
about the gaskets because it seemed they were all bad. The Plant Manager then talked with
Purchasing about the situation with the gaskets. The Purchasing Manager indicated that
they had in fact received a bad batch of gaskets from the supplier. The Purchasing Manager
also indicated that they had been trying for the past two months to try to get the supplier to
make good on the last order of 5,000 gaskets that all seemed to be bad.
The Plant Manager then asked the Purchasing Manager why they had purchased
from this supplier if they were so disreputable. The Purchasing Manager said because they
were the lowest bidder when quotes were received from various suppliers. The Plant
Manager then asked the Purchasing Manager why they went with the lowest bidder and he
indicated that was the directive he had received from the Director of Finance.
The Plant Manager then went to talk to the Director of Finance about the situation.
When the Plant Manager asked the Director of Finance why Purchasing had been directed
to always take the lowest bidder, the Director of Finance said, "Because you indicated that
we had to be as cost conscious as possible and purchasing from the lowest bidder saves us
lots of money."
The Plant Manger was horrified when he realised that he was the ultimate reason
there was oil on the plant floor.
Everyone in the organisation was doing their best to do the right things, and
everything ends up messed up. The root cause of this whole situation is local optimisation
with no global thought involved.
This also provides a good example of how we should proceed to do root cause
analysis. We simply have to continue to ask "Why?" until the pattern completes and the
cause of the difficulty in the situation becomes rather obvious.
1.6.7
Example 3
In the tragic accident of Air France Concorde flight 4590 on 25th July 2000,
engine failure was suspected. Only a thorough investigation by the Bureau de
l'Aviation Civile showed that one of the tyres had been punctured on take off. The
runway was not swept as procedure required because of a fire test that day. This one
element of the Root Cause could not - and would not - have been discovered
without the investigation being undertaken. We are working back from the result
Root Cause, through the immediate causes to the crash.
Please note that we have not attempted to detail the events; this is a very
brief model of the events that took place.
The basic events that took place in the tragic accident of Concorde
Ref
Event
Causal Factor or Root

Cause
1.
Aircraft Crashes.
2.
Concorde stalls in flight.
Causal Factor
3.
Crew fight to gain altitude.
Causal Factor
4.
Engine No 2 caught fire.
Causal Factor
5.
Design failure in fuel tank materials.
Causal Factor
6.
Fuel tank ruptures.
Causal Factor
7.
One or more pieces of tyre thrown against fuel tank.
Causal Factor
8.
Cut to tyre on wheel No 2.
Causal Factor
9.
Concorde runs over strip of metal from a DC 10 that had taken

off a few minutes earlier.
Causal Factor
10.
Runway not swept as procedure required.
Causal Factor
11.
Fire Exercise carried out & delays runway inspection.
Causal Factor
12.
Incorrect repair/material to DC10 ten days earlier.
Causal Factor
13.
Material not available.
Causal Factor
14.
Management failed to ensure that correct materials available &

used in repair to DC 10 ten days earlier.
The root cause of an accident is the reason why an incident occurred.
1.
? False
2.
? True
Root Cause
1.7
Recommendations for Remedial Actions

We will now consider
making recommendations for
remedial actions or control
measures. It is not enough that
the investigation concludes
with what went wrong and why.
A good investigation will also
make recommendations that
are designed to prevent such a
recurrence.
Initiate preventative action.

Actions should be taken to
remedy all of the deficiencies determined in the stages
described in the above section, Incident Investigation.
These remedial actions can be divided into two types.
1. Immediate.
For example, the actions that can be taken by local

supervision such as replacing a guard on a machine if it
is immediately available and safe to do so; arranging for
spillages to be cleaned up; erecting temporary barriers,
etc.
2. Long term.
There may be a need to raise job orders or purchase

requisitions or to submit recommendations for design
and/or process changes which need to be actioned and
approved by other departments.
The investigation may identify a training need which
is a long-term action. All of these action points need to
be considered relative to other areas of the organisation
where similar processes or equipment are involved.
Role and function of accident investigation
Please select the correct missing words, in order, for the sentence below.
We _________ accidents to _________ why the accident ___________ and put
_________ in place to ensure that the same or similar ________ do not happen again.
Put the parts in order to form a sentence. When you think your answer is correct, click on
"Submit" to check your answer. If you get stuck, click on "Hint" to find out the next correct
part.
measures
happened
investigate
ascertain
accidents
1.7.1
Ensure Actions Are Complete

It is essential that progress on the identified remedies is
closely monitored to ensure that they do not get unnecessarily
delayed or even forgotten. There should be a follow-up review
to ensure that the actions taken are effective and do not
create other unforeseen hazards.
These objectives may appear to be overkill when the
accident only resulted in a minor injury, minor damage or a
near-miss. However, every apparent minor accident may be a
potentially fatal accident. This first part of the investigation
should be to establish the potential severity of injury or
damage that could have resulted. The effort and resource
devoted to the remainder of the investigation must be in
direct proportion to this potential.
1.7.2
Identify Preventive Measures:
Assess/reassess the risk.

Question the adequacy of existing physical
safeguards, work methods and discrepancies
with those intended.
Reappraise the intended safeguards and work
methods.
Do they satisfy the intentions of the company health and

safety policy, and do they meet the statutory requirements?
1.7.3
Establish Whether Initial Management Response Was
Adequate
Prompt and appropriate action such as making safe and dealing with any
continuing risks, electrical isolation, suitable fire fighting, effective first-aid
response and correct spillage procedures.
1.7.4
Identify the Underlying Causes
These might include:
management or supervision failure;

lack of competence;
inadequate training;
shortcomings in original design;
inadequate performance standards set by
firm;
absence of a system for maintenance.
1.7.5
Determine Action Needed to Prevent a Recurrence
In deciding on the right course of action, employers need

to think whether the outcome could have been more serious
and what prevented this from happening.
Examples of action are:
improve physical safeguards;

provide and use local exhaust ventilation;
use mechanical handling aids such as pile
turners and mobile lifts;
introduce better test and maintenance
arrangements;
improve work methods;
provide and use personal protective
equipment;
make changes to supervision and training
arrangements;
review similar risks in other departments;
set up a system to assess the risks from new
plant and substances at the planning stage;
review procedures involving contractors;
update standards and policies;
introduce monitoring and audit systems.
1.7.6
Implement, Analyse and Review
Once the initial action is taken, management need

to:
identify underlying causes and corrective

action;
implement follow-up action promptly;
check that follow-up action has been taken

(standard report forms can help);
analyse data systematically to identify
trends and features - safety
representatives and company safety
committees will find this useful;
question the overall response - did it fully
reflect the risks?
review performance periodically.
They can then make sound decisions for the future.
1.7.7
Be SMARTER
Recommendations of remedial actions

should be:
SMARTER
SPECIFIC
MEASURABLE -
who will do what and when.

the corrective actions must be measurable.
ACCOUNTABLE - the persons responsible for implementing the corrective

actions should be clearly defined.
REASONABLE -
the corrective action should be practical, i.e. will it work?

Can it be implemented?
TIMELY -
the due date of the corrective action(s) must be timely; are

there any interim actions can be implemented sooner if
required?
EFFECTIVE -
the corrective actions must prevent or significantly reduce the

risk of this problem happening again.
REVIEWABLE -
will this corrective action cause any problems? What might

be the negative impact if any?
Those involved must:

ADAP
Agree on how to eliminate the immediate hazard.
Develop actionable recommendations for each root cause.
Assign responsibility for each recommendation.
Prioritise recommendations based on the potential for eliminating the incident in the
future.
1.8
ILO Recording and Notification of Occupational
Accidents and Diseases
The International Programme for the Improvement of Working Conditions and

Environment (PIACT) was launched by the International Labour Organisation in 1976 at
the request of the International Labour Conference and after extensive consultations with
member States.
PIACT is designed to promote or support action by member States to set and attain
definite objectives aiming at making work more human. The Programme is thus concerned
with improving the quality of working life in all its aspects: for example, the prevention of
occupational accidents and diseases, a wider application of the principles of ergonomics,
the arrangement of working time, the improvement of the content and organisation of work
and of conditions of work in general, a greater concern for the human element in the
transfer of technology.
To achieve these aims, PIACT makes use of and coordinates the traditional means of
ILO action, including:
the preparation and revision of international labour standards;
operational activities, including the dispatch of multidisciplinary teams to assist

member States on request;
tripartite meetings between representatives of governments, employers and workers,
including industrial committees to study the problems facing major industries,
regional meetings and meetings of experts;
action-oriented studies and research; and
clearing-house activities, especially through the International Occupational Safety
and Health Information Centre (CIS) and the Clearing-house for the Dissemination
of Information of Conditions of Work.
The below eLearning material is extracted from the publication from the outcome of a
PIACT project.
Please follow this linkto view the full publication.
1.8.1.
Arrangements for Recording at National Level
National laws or regulations should require that employers establish and maintain
records on occupational accidents, occupational diseases, commuting accidents, dangerous
occurrences and incidents as determined by the competent authority.
To ensure that all required data and information are collected systematically, and to
provide the methodology for investigating occupational accidents, occupational diseases,
dangerous occurrences and incidents, national laws or regulations should prescribe which
data and information are to be recorded. Where forms are used for this purpose, they should
be standardised.
The information required to be recorded at the level of the enterprise should include
at least the information to be notified, as set out in Chapter 6 of the code.
National laws or regulations should specify which additional information must be
recorded by employers, although it is not required to be notified. This should apply to:
(a)
all incidents where no immediate personal injury is recognised;
(b)
specified categories of dangerous occurrences;
(c)
commuting accidents, if applicable.
National laws or regulations should specify, in particular:

(a)
the content and format of such records;
(b)
the period of time within which records are to be established;
(c)
the period of time for which records are to be retained;
(d)
that such records are to be obtained and maintained in such a way that
respects the confidentiality of personal and medical data in accordance with
national laws and regulations, conditions and practice, and are consistent
with paragraph 6 of the Occupational Health Services Recommendation,
1985 (No. 171);
(e)
that the employer should identify a competent person at the level of the
enterprise to prepare and keep records; and
(f)
the cooperation in recording procedures where two or more employers

engage in activities simultaneously at one worksite.
1.8.2
At the Level of the Enterprise
The employer should set up arrangements, in accordance with national laws or

regulations, to record occupational accidents, occupational diseases, commuting accidents,
dangerous occurrences and incidents.
These arrangements should include:
(a)
the identification of a competent person to prepare and keep records of all

occupational accidents, occupational diseases, commuting accidents,
dangerous occurrences and incidents, as required by national laws and
regulations; and
(b)
cooperation in recording procedures where two or more employers engage

in activities simultaneously at one worksite, as required by national laws and
regulations.
The employer should ensure that records of occupational accidents, occupational

diseases, commuting accidents, dangerous occurrences and incidents are available and
readily retrievable at all reasonable times.
In cases in which more than one worker is injured in a single occupational accident,
a record should be made for each of the injured workers.
Workers' compensation insurance reports and accident reports to be submitted for
notification are acceptable as records if they contain all the facts required for recording or
are supplemented in an appropriate manner.
For inspection purposes and as information for workers' representatives and health
services, employers should prepare records within a period of time to be determined by the
competent authority, but preferably within no more than six days after reporting has
occurred.
Workers in the course of performing their work should cooperate with the employer
in carrying out the arrangements within the enterprise for recording and notification of
occupational accidents, occupational diseases and dangerous occurrences.
The employer should give appropriate information to workers and their
representatives concerning:
(a)
the arrangements for recording; and
(b)
the competent person identified by the employer to receive and record

information on occupational accidents, occupational diseases, commuting
accidents, dangerous occurrences and incidents.
The employer should provide appropriate information to workers or their

representatives on all occupational accidents, occupational diseases, dangerous occurrences
and incidents in the enterprise, as well as commuting accidents, to assist workers and
employers to reduce the risk of exposure to similar events.
1.8.3
Arrangements For Notification
At national level.
The competent authority should, through national laws or

regulations or by any other method consistent with national
conditions and practice, establish and apply procedures for the
notification of occupational accidents, occupational diseases,
dangerous occurrences and commuting accidents, as appropriate.
Close cooperation should be ensured between the competent

authority or authorities, public authorities, and representative
organisations of employers and workers, as well as other bodies
concerned in the formulation and application of the procedures
referred to above.
National laws or regulations should specify that occupational

accidents, occupational diseases, commuting accidents and
dangerous occurrences be notified, as appropriate, to:
(a)
the relevant enforcement body (e.g.

labour inspectorate);
(b)
the appropriate insurance institution;
(c)
the statistics-producing body; or
(d)
any other body.
National laws or regulations should specify:
(a)
the respective information on occupational

accidents, occupational diseases, dangerous
occurrences and commuting accidents, as
appropriate, to be notified to the competent
authority, labour inspectorate, insurance institution
or other bodies;
(b)
the timing of the notification, which should

preferably be made by the employer:
(i)
by the quickest possible means immediately

after reporting of an occupational accident
causing loss of life;
(ii)
within a prescribed time for other occupational

accidents and occupational diseases;
(c)
the prescribed standardised form of notification to

be used for submission of notifications to the
competent authority, labour inspectorate, insurance
institution or other bodies;
(d)
that the employer identify a competent person at

the level of the enterprise for notification;
(e)
the responsibilities, appropriate arrangements and

procedures enabling employers to cooperate in the
notification procedure where two or more
enterprises engage in activities simultaneously at
one workplace; and
(f)
the systems for the classification of information to

be used (see section 3.2 of the code).
National laws or regulations should specify that

notification of an occupational disease by an employer is
mandatory, at least whenever the employer receives a
medical certificate to the effect that one of his or her workers
is suffering from an occupational disease.
If more detailed information is needed beyond that

required for notification, national laws or regulations should
specify:
(a)
the content and format of the returns to the

competent authority containing supplementary
information;
(b)
the frequency and manner in which such

returns are to be made by employers to the
competent authority.
The competent authority should register notifications in

such a way as to enable them to be used for compiling
appropriate statistics, using classification systems as referred
to in the code, and for making analyses.
At the level of the enterprise.
The employer, after consultation with the workers

and their representatives, should set up arrangements
within the enterprise, in accordance with national laws or
regulations, to notify occupational accidents,
occupational diseases, dangerous occurrences and
commuting accidents, as appropriate.
The arrangements within the enterprise should include:
(a)
the identification of a competent person to

prepare the appropriate notification for
submission by the employer;
(b)
the determination of responsibility for

notification, where two or more employers
engage in activities simultaneously at one
worksite, as required by national law and

regulations.
1.8.4
Notification of Occupational Accidents
General.
All occupational accidents should be notified, as required by national laws or
regulations, to the competent authority, the labour inspectorate, the appropriate
insurance institution or any other body:
(a)
immediately after reporting of an occupational accident

causing loss of life;
(b)
within a prescribed time for other occupational accidents.
Notification should be made within such time as may be specified, and in

prescribed specific forms, such as:
(a)
an accident report for the labour inspectorate;
(b)
a compensation report for the insurance institution;
(c)
a report for the statistics-producing body; or
(d)
a single form which contains all essential data for all bodies.
Minimum information.
With a view to meeting the requirements of labour inspectorates, insurance
institutions and the statistics-producing body, the forms prescribed in either a
specific or single format should include at least the following information:
(a)
(b)
(i)
(c)
enterprise, establishment and employer:

(i)
name and address of the employer, and his or her

telephone and fax numbers (if available);
(ii)
name and address of the enterprise;
(iii)
name and address of the establishment (if different);
(iv)
economic activity of the establishment; 1 and
(v)
number of workers (size of the establishment);
injured person:
name, address, sex and age;

(ii)
employment status; 2
(iii)
occupation; 3
(i)
fatal accident;
(ii)
non-fatal accident;
(iii)
nature of the injury (e.g. fracture, etc.); 4
injury:
(iv)
location of the injury (e.g. leg, etc.); 5
(d) accident and its sequence:

(i)
geographical location of the place of the accident

(usual workplace, another workplace within the
establishment or outside the establishment);
(ii) date and time;

(iii) action leading to injury type of accident (e.g. fall, etc.); 6
See paragraph 3.2.1(a) and Annex C.

See paragraph 3.2.1(c) and Annex E.
3
See paragraph 3.2.1(b) and Annex D.
4
See Annex F.
5
See Annex G.
6
See Annex H.
2
Recording and notification.
(iv)
agency related to the accident (e.g. ladder, etc.). 1
For commuting accidents, the relevant necessary information to be notified

should be specified.
More detailed information.
National laws or regulations should provide for the specification of more

detailed information, which should include the following:
(a) enterprise, establishment and employer:
(b)
(c)
(i)
name and address of the employer, and his or

her telephone and fax numbers (if available);
(ii)
(iii)
name and address of the establishment (if

different);
(iv)
(v)
number of workers (size of the

establishment);
injured person:
(i)
name, address, sex and date of birth;
(ii)
(iii)
occupation; 4
(iv)
length of service for present employer;
(i)
fatal accident;
(ii)
non-fatal accident;
injury:
(d)
(iii)
nature of the injury (e.g. fracture, etc.); 5
(iv)
location of the injury (e.g. leg, etc.); 6
(v)
incapacity for work in calendar days;
accident and its sequence:

(i)
geographical location of the place of the

accident (usual workplace, another workplace
within the establishment or outside the
establishment);
(ii)
date and time;

1
See Annex I.
3
4
See paragraph 3.2.1(b) and Annex D.
5
See Annex F.
6
See Annex G.
2
(iii)
shift, start time of work of the injured person

and hours worked in the activity in which the
accident occurred;
(iv)
work environment (e.g. workshop area, office,

road, etc.);
(v)
work process (e.g. welding, maintenance,

manual transport, etc.);
(vi)
activity of the injured person at time of the

accident (e.g. welding, maintaining press,
operating machine, driving, walking, etc.);
(vii)
item or items associated with activity of the

injured person (e.g. machine, tool, power
press, vehicle, etc.);
(viii)
action leading to injury type of accident (e.g.

fall, etc.); 1
(ix)
agency related to injury (e.g. ladder, etc.). 2
For commuting accidents, the relevant necessary information to be notified should

be specified.
1.8.5
Notification of Occupational Diseases
National laws or regulations should specify that notification of occupational

diseases include at least the following information:
(a) enterprise, establishment and employer;
(b)
(i)

(ii)
(iii)

different);
(iv)
(v)

establishment);
person affected by the occupational disease:

(i)
name, address, sex and date of birth;
(ii)
(iii)
occupation at the time when the disease was

diagnosed; and
(iv)
length of service with present employer;
(c) occupational disease:
(i)
name and nature of occupational disease;
(ii)
harmful agents, processes or exposure to

which the occupational disease is attributable;
1
See Annex H.
See Annex I.
3
4
2
(iii)
description of work which gave rise to the

condition;
(iv)
length of exposure to harmful agents and

processes;
(v)
date of diagnosis of the occupational disease.
1.8.6
Notification of Dangerous Occurrences
National laws or regulations should specify that notification of a dangerous

occurrence arising in connection with work activities, and which is required to be
notified to the competent authorities, include at least the following information:
(a)
enterprise, establishment and employer;
(i)
(ii)
(iii)
(iv)

different);
(v)

establishment); 2
(b) Dangerous occurrence:

(i)
date, time and location;
(ii)
type of dangerous occurrence;
(iii)
circumstances leading up to the dangerous

occurrence.
See paragraph 3.2.1(a) and Annex C. 2 See paragraph 3.2.1(c) and Annex E.
1.9
Extension of Recording and Notification Systems
To Self-Employed Persons
At national level.
National laws or regulations on the reporting, recording and notification of

occupational accidents, occupational diseases, dangerous occurrences and incidents
should also apply to self-employed persons, 1 as specified by the competent
authority.
National laws or regulations should specify that notification to the competent

authorities of occupational accidents, occupational diseases and dangerous
occurrences involving self-employed persons in their own enterprise should be
submitted as follows:
(a)
in the case of death or a non-fatal occupational accident,

occupational disease or dangerous occurrence rendering the
self-employed person incapable of submitting notification,
the notification should be submitted by the person in control
of the establishment, or as prescribed by the competent
authority;
(b)
in other cases, the notification should be submitted by the

self-employed persons themselves.
National laws or regulations should specify that notification to the competent

authority of occupational accidents of self-employed persons in other than their own
enterprises should be:
(a)
recorded and notified by the employer of the enterprise in

which the self-employed person was required to work;
(b)
notified by the self-employed person to his or her insurance

institution, with a record as requested in above.
1.9.1
At the Level of the Enterprise
The person in control of the establishment where the selfemployed person is contracted to work should make
arrangements for the reporting, recording and notification of
occupational accidents, occupational diseases, commuting
accidents, dangerous occurrences and incidents which can be
applied to self-employed persons.
1.9.2 The Self-Employed Person
The self-employed person should cooperate with the person in control

of the establishment where he or she is contracted to work, to enable
notification of occupational accidents, occupational diseases, commuting
accidents and dangerous occurrences.
The self-employed person should, in accordance with national laws or
regulations, submit notification to the competent authorities of non-fatal
occupational accidents, occupational diseases, commuting accidents and
dangerous occurrences. If he or she is not in a position to do so, the selfemployed person should make suitable alternative arrangements.
1.10.
Statistics of Occupational Accidents, Occupational
Diseases, Commuting Accidents and Dangerous
Occurrences: Compilation and Publication
At national level
The competent authority should arrange for the

compilation and publication, at least once a year, of
statistics of occupational accidents, occupational
diseases, commuting accidents and dangerous
occurrences, on the basis of the information notified to it.
Where practicable, the statistics should be compiled
by the competent authority from notifications of
occupational accidents, occupational diseases,
commuting accidents and dangerous occurrences without
recourse to additional returns.
The unit to be recorded should be:
(a)
the person killed or injured as a result of an

occupational accident or commuting accident;
(b)
the person affected as a result of an occupational
disease; or
(c)
the dangerous occurrence.
Where one person has suffered more than one

separate occupational accident or disease during the
period covered by the statistics, he or she should be

counted separately with respect to each accident or
disease.
The period covered by the statistics should be
clearly defined, and ideally should not exceed one
calendar year.
Information on occupational accidents and
occupational diseases relating to self-employed persons,
as well as commuting accidents, should be included in
the statistics; however, such information should be
shown separately so that appropriate comparisons may
be made with countries which do not include such
information in their national statistics.
In presenting statistics on occupational accidents,
occupational diseases, commuting accidents and
dangerous occurrences, the competent authority should
ensure that information is provided on:
(a)
the nature of the sources of the statistics; e.g. direct reporting

by employers or by various bodies, such as insurance
institutions or labour inspectorates;
(b)
the scope of the statistics, particularly in respect of categories

of persons, branches of economic activity, occupations, size
of the enterprise, constituent states of a country or regions;
(c)
the definitions used;
(d)
the methods used for recording and notifying occupational

accidents, occupational diseases, commuting accidents and
dangerous occurrences, and for compiling the statistics;
(e)
the quality of the statistics;
(f)
the prior statistics, where available.
In designing or revising the concepts, definitions

and methodology used in the collection, compilation and
publication of such statistics, the competent authority
should take into account the latest standards and
guidelines established under the auspices of the ILO or

other relevant international organisations.
In designing or revising the concepts, definitions
and methodology used in the compilation and publication
of such statistics, the competent authority should consult
the most representative organisations of employers and
workers.
When publishing statistical data on occupational
accidents, occupational diseases and dangerous
occurrences, the competent authority should arrange for
the frequency rate, incidence rate and severity rate,
where appropriate, to be computed for major divisions of
economic activity (see classification in paragraph
3.2.1(a) of the code), occupation (see classification in
paragraph 3.2.1(b) of the code), age group, sex and
other groups to be specified.
Recording and notification of more detailed information in a progressive manner.
National laws or regulations should provide for the

specification of progressively more detailed information to
be included in records and the notification of occupational
accidents, occupational diseases, commuting accidents
and dangerous occurrences.
Before specifying requirements for more detailed
information, the competent authority should consult the
most representative organisations of employers and
workers.
The competent authority should allow a reasonable

time, as specified by national laws or regulations, for
employers to be able to provide the more detailed
information required for records and notifications of
occupational accidents, occupational diseases and
dangerous occurrences.
1.11
Statistics of Occupational Accidents, Occupational
Diseases and Dangerous Occurrences: Classifications
General.
The statistics of occupational accidents, occupational
diseases and dangerous occurrences should be classified
at least according to branch of economic activity and, as
far as possible, according to:
(a)
significant characteristics of workers,

such as status in employment, sex, age or
age group; and
(b) significant characteristics of the

enterprise.
1.11.1
Occupational Diseases
Statistics of occupational diseases published by the

competent authority should give the total number of
cases reported for each of the diseases included in the
list of occupational diseases prescribed by the competent
authorities.
The period covered by the statistics of occupational
diseases should not exceed a calendar year.
Statistics on occupational diseases for selfemployed persons should be shown separately.
1.11.2
Dangerous Occurrences
The competent authority should publish statistics of
the numbers and types of dangerous occurrences that
have been notified.
1.12
Investigation of Occupational Accidents, Occupational
Diseases, Commuting Accidents, Dangerous
Occurrences and Incidents
At national level.
In furtherance of national policies on occupational safety,

occupational health and the working environment, and of national
policy on the prevention of occupational accidents and diseases, the
competent authority should arrange for the investigation of a sufficient
number and variety of types of occupational accidents, occupational
diseases, commuting accidents and dangerous occurrences in order to be
able to:
(a)
verify the effectiveness of those policies;
(b)
determine whether changes are necessary to those

policies, or to national laws or regulations; and
(c)
verify the effectiveness, at both national and

enterprise levels, of the arrangements for recording
and notification of occupational accidents,
occupational diseases, commuting accidents and
National laws or regulations concerning occupational safety and

health - and the working environment - should specify that the
competent authority must establish adequate arrangements and
appropriate systems of investigation of occupational accidents,
occupational diseases, commuting accidents and dangerous occurrences.
The competent authority should arrange for investigations to be
carried out by labour inspectorates or by other authorised agencies.
Representatives of the employers, and of the workers of the enterprise,
should have the opportunity to accompany the investigators, unless the
latter consider, in the light of the general instructions of the competent
authority, that this may be prejudicial to the performance of their duties.
Where the investigation is not entrusted to an institution
authorised by the competent authority or to a government department
responsible to the legislature, national laws or regulations should
specify arrangements for the participation of the most representative
organisations of employers and workers - and of public authorities - in
the planning of the investigation, and for the participation in the
investigations of the representatives of the employers and of the workers
affected, as specified in the paragraph above.
The competent authority should hold inquiries - and publish

reports on those inquiries - into cases of occupational accidents,
occupational diseases, commuting accidents, dangerous occurrences and
incidents which appear to reflect serious situations in terms of actual or
potential risk to workers or the public.
The competent authority should require employers to carry out
investigations of specific occupational accidents, occupational diseases,
commuting accidents, dangerous occurrences and incidents, and to
report on the action taken to prevent a recurrence.
The competent authority should require employers to assist them
in carrying out investigations and holding inquiries.
At the level of the enterprise.
The employer should investigate all reported

occupational accidents, occupational diseases, dangerous
occurrences and incidents.
The employer should ensure that a competent person,

as specified by the competent authority, is identified within
the enterprise to carry out thorough investigations of
Where the employer lacks the necessary expertise

within the enterprise to carry out a thorough investigation,
he or she should call upon the assistance of a person with
appropriate expertise, if necessary from outside the
enterprise.
The employer should arrange for the site of an

occupational accident or a dangerous occurrence to be left
undisturbed before the start of the investigation, apart
from the requirements for first aid or to prevent further
risk to persons.
Where for reasons of first aid, or to prevent further

risk to persons, it is necessary to disturb the site before
the start of the investigation, the employer should arrange
for a competent person to make a record of the site,
including where necessary photographs, drawings and the
identities of eyewitnesses prior to any intervention.
The employer should ensure that the investigations of

dangerous occurrences should, as far as possible:
(a)
(b)
establish what happened;

determine the causes of what happened;
and
(c)
identify measures necessary to prevent a
recurrence.
The employer should ensure that arrangements are in

place at the enterprise for an immediate investigation of
reported occupational accidents, occupational diseases,
dangerous occurrences and incidents.
The employer should ensure that the report required

under paragraph 10.1.6 of the code is sent to the
competent authority by the quickest practicable means.
The employer should make the results of

investigations available to workers and their
representatives with a view to preventing similar
occurrences and so that they may assist the employer in
the more effective implementation of his or her policy on
occupational safety and health.
Workers and the investigation of occupational

accidents, occupational diseases, dangerous
occurrences and incidents.
Whenever an employer investigates under the code an

occupational accident, an occupational disease, a
commuting accident or a dangerous occurrence, workers'
representatives should have the right, the facilities and the
necessary time, without loss of pay, to participate in such
investigations.
Workers in the course of their work should assist the

employer and persons acting on his or her behalf in the
investigation of occupational accidents, occupational
diseases, dangerous occurrences and incidents.
2.0
Summary
This summary will now refer you back to the learning outcomes for this lesson and give
a summary of the information.
Explain the purpose of and procedures for investigating accidents at work
Why do we investigate accidents and incidents?
The simple answer is to ascertain why the accident happened and put measures in place
to ensure that the same - or similar - accidents do not happen again.
It is, however, much more complicated than that. Finding the root cause of an accident
and ensuring that measures are put in place to ensure that it cannot happen again is a
vital part of any investigation.
Basic accident investigation procedures:
interviews;
plans;
photographs;
relevant records;
checklists;
identifying immediate causes (unsafe acts and conditions)
and root or underlying causes (management system
failures);
Identifying remedial actions.
Describe the requirements for the statutory reporting of fatalities and

specified injuries, diseases/ ill-health conditions and dangerous occurrences
What is RIDDOR
It stands for the Reporting of Injuries, Diseases and Dangerous Occurrences
Regulations 1995. Sometimes referred to as RIDDOR 95, or RIDDOR for short, these
Regulations came into force on 1 April 1996 .
It is important that you make reference to the full title: Reporting of Injuries, Diseases
and Dangerous Occurrences Regulations 1995, when answering a question that refers to
RIDDOR in your NEBOSH examination.
Persons who are employers, the self-employed or are in control of work premises have
duties under RIDDOR. The regulations apply to all work activities.
There is little to do when reporting incidents and accidents under RIDDOR. For most
businesses, a reportable accident, dangerous occurrence or case of disease is a
comparatively rare event.
Why should I report?

Reporting accidents and ill-health at work is a legal requirement.
When to Report
In the event of a death or major injury.

If there is an accident connected with work.
An employee, or a self-employed person working is killed or
suffers a major injury (including as a result of physical
violence).
A member of the public is killed or taken to hospital.
Those with responsibilities to report under the regulations must

notify the enforcing authority without delay (e.g. by telephone). Brief details
are required such as:
Name and address.

The injured person's details.
About the accident.
Within ten days of making the telephone call, this must be followed
up with a completed accident report form (F2508). Again, you will see that
the form asks for basic information.
Over-Three-Day Injury
If there is an accident connected with work (including an act of physical
violence) and an employee, or a self-employed person working on the
premises, suffers an over-three day injury, form F2508 must be completed
and sent to the enforcing authority within ten days.
An over-three-day injury is one which is not major but results in the injured
person being away from work, or unable to do the full range of their normal
duties, for more than three days (including any days they would not
normally be expected to work such as weekends, rest days or holidays), not
counting the day of the injury itself.
So in simple terms, if someone suffers a major injury, including death or a
major incident occurs, then the enforcing authority must be notified
immediately, normally by telephone. This must be followed on within 10
days of the telephone call by completing the F2508 form.
Major injury or Incident
Amputation.
Acute illness requiring medical treatment.
Injury resulting from an electric shock or burn.
Loss of sight (temporary or permanent), and so
on.
Failure of industrial radiography equipment.
Plant in contact with overhead power lines.
Explosion or fire causing suspension of normal
work for over 24 hours.
Failure of load-bearing parts of lifting
equipment.
Reportable diseases.
Some skin diseases, infections such as
legionellosis.
Lung diseases such as occupational asthma.
Disease
If a doctor notifies an employee that they are suffering from a reportable workrelated disease, the employer must send a completed disease report form (F2508A)
to the enforcing authority.
A full list of these reportable diseases is included in 'the guide to the Regulations'. It
is also possible to contact the H.S.E Information Line to check whether a disease is
reportable.
Dangerous Occurrence
If something happens which does not result in a reportable injury but which clearly
could have done, it may be a dangerous occurrence which must be reported
immediately (e.g. by telephone) to the enforcing authority.
Again, within ten days of reporting the incident by telephone, this must be followed
up with a completed accident report form F2508.
Incident Investigation
Congratulations - end of lesson reached

UNit 7 Incident Investigation

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1.

1.0 Unit 7: Incident Investigation, Recording and

the need for an organisation to have a system for internally reporting,

Specific learning outcomes.

explain the purpose of and procedures for investigating accidents and

Tuition time: 4 hours.

Why do we investigate accidents and incidents?

The last thing that any manager wants to do

you may feel that you or your safety

you may worry that reporting accidents

However, we know that as part of your accident

Below is the detail of how and why we need to

Setting the Scene

The incident took place on a large project that

Consider the type of work activities that this might

The employees were working as painters and

The Site Supervisor had followed the procedure; he

The Project Manager needed to telephone the injured

The Painting & Decorating team on the site were

The scene of the accident was a corridor just off the

The input of members of the team was then solicited

The team member who was with the injured person at

The time of the accident was 2.30.

A sketch of the immediate area of the accident was

What Had Happened?

Employees A and B tried to find the step ladders but

Employee A placed the fixed leg chair on the table and

The enforcing authority at the time was the HSE. They

It is not always possible immediately to do carry out the

Within three days of the accident, employee A's

The documents were filed and the data processed. What

All parties blamed each other. Employee A blamed

After the accident, a toolbox talk was given on correct

Why is it important to sketch or photo graph the scene of an accident?

? all the above

? in case the scene is disturbed

Interviews, plans, photographs, relevant records,

Accident Investigation Process

Accident investigations are conducted to

The investigation can also be used to

Near-miss accidents should also be

Who Undertakes the Investigation?

Ideally, an investigation would be conducted by someone

Was the worker distracted?

As discussed earlier, as little time as possible should be

Was a safe work procedure used?

or most of these questions, an important follow-up

question is "If not, why not?"

To seek out possible causes resulting from the equipment and

Was there an equipment failure?

Again, each time the answer reveals an unsafe condition, the

The physical environment, specifically sudden changes to

What were the weather conditions?

Were workers experienced in the work being done?

Were safety rules communicated to - and

Were unsafe conditions corrected?

Were Regular Safety Inspections Carried Out?

How Are the Facts

The steps in accident investigation are simple: the accident

The most important immediate tasks - rescue operations,

Physical evidence is probably the most non-controversial

positions of injured workers;

You may want to take photographs before anything is moved,

Although there may be occasions when you are unable to