Module 02

Accident Causes and

Investigation

© CHSS 2003
Ref: SC/086/V1
 Definitions

 Accident
 An unplanned, unwanted event which
results in a loss of some kind.

 Incident
 An unplanned, unwanted event that had
the potential to result in a loss.

© CHSS 2003
Ref: SC/086/V1
 Accident Triangles

© CHSS 2003
Ref: SC/086/V1
 Accident Triangles
Major Injury 1 Serious Injury
1
Minor Injury
10 Minor Injury
29 Damage Only
30
300 Near Miss 600 Near Miss

Heinrich Bird (1969)

1 Fatal / Serious
1 Major Injury
3 Lost Time

50 First Aid
7 Minor Injury

80 Damage
Near Miss
400 Near Miss 189
Tye & Pearson HSE APAU
(1973) (1993)
© CHSS 2003
Ref: SC/086/V1
 Domino Theory

© CHSS 2003
Ref: SC/086/V1
 Why investigate?
Legal
RIDDOR
Insurance
Statistics
Civil actions
Benefits Agency
Prevent recurrence

© CHSS 2003
Ref: SC/086/V1
 An Effective System

Reporting System
Immediate Risks
Select Level
Gather Information
Record & Analyse
Review Process

© CHSS 2003
Ref: SC/086/V1
 Gathering information

The Scene

Documents

People

© CHSS 2003
Ref: SC/086/V1
 Fault Tree Analysis

The cause of the injury

A man slips and strikes
his head on the floor The direct causes
of the accident

He was hurrying There was oil on The lighting was poor -

the floor he did not see the oil

A1 A2 A3 B1 B2 B3 C1 C2 C3

Underlying or indirect causes

© CHSS 2003
Ref: SC/086/V1
 Recording and analyzing

Terminology
Cause of Injury

Cause of Accident

Type of Accident

© CHSS 2003
Ref: SC/086/V1
 Analysis and Review
 What were the direct causes?
 What were the underlying causes?
 Why did management systems fail?
 Why were the system failures not
identified before the accident?
 How effective were the emergency
procedures?

© CHSS 2003
Ref: SC/086/V1
 RIDDOR
Reporting of

Injuries

Diseases and

Dangerous

Occurrences

Regulations 1995
© CHSS 2003
Ref: SC/086/V1
 RIDDOR
What has to be reported?
 Death, major injury, immediate hospital
treatment, a dangerous occurrence, over three
day absence, acts of violence, suicide on
transport systems and specified diseases.

By Whom?
 The responsible person - in control of the
premises, the employer. But remember some
responsible persons are delegated in law.
• Records kept for three years and all accidents
recorded in the accident book (BI 510).

© CHSS 2003
Ref: SC/086/V1
 RIDDOR
Notification
By the quickest practicable means.

Reporting
written report form within ten days (F2508
& F2508A)
• Death, specified major injuries and dangerous
occurrences
– Fracture (not fingers, thumbs or toes), amputation,
dislocation, loss of sight, chemical or penetrating
injury to the eye...

© CHSS 2003
Ref: SC/086/V1
 RIDDOR
Injuries
 Death, Major Injury, >3 day injury

 Dangerous Occurrences

Dangerous Occurrences
 Failure of lifting machine, contact with overhead
power lines, failure of breathing apparatus.

Reportable Diseases
 Tetanus (contact with soil contaminated by
animals), inflammation, ulceration or malignant
disease due to exposure to ionising radiation.

© CHSS 2003
Ref: SC/086/V1
 HSC discussion document
 Published in November 1998. The HSE
believes it is important for employers to face
up to the responsibility - and to be pro-active
in managing health and safety risks.
 This means taking more of an interest in the
actual root causes of incidents when things go
wrong.
 The HSC would like to consider the merits of placing
a specific duty on employers to take the initiative in
finding out what went wrong and why, and how to
make sure it does not happen again.
© CHSS 2003
Ref: SC/086/V1