Element 8 Occupational Incident and Accident

Investigation, Recording and Reporting

Occupational Incident and Accident Investigation,

Recording and Reporting

November 2010 Element 8 Occupational Incident and Accident 1

Investigation, Recording and Reporting
 Accident

An accident is an unplanned, uncontrolled

event which may cause minor or major injury,
disease, illness, death, damage or other loss
such as delays incurring production losses’

November 2010 Element 8 Occupational Incident and Accident 2

Investigation, Recording and Reporting
 Misconceptions about Accidents

• Accidents cannot be prevented

• We don’t have many accidents
• Safety is expensive
• We are insured anyway.

November 2010 Element 8 Occupational Incident and Accident 3

Investigation, Recording and Reporting
 Categories of accident

1. No injury – no property damage

2. No injury – property damage
3. Injury – no property damage
4. Injury and property damage

November 2010 Element 8 Occupational Incident and Accident 4

Investigation, Recording and Reporting
 Bird Triangle

1 Major injuries

10 > 3 day injuries

60 Minor injuries

600 Near misses

November 2010 Element 8 Occupational Incident and Accident 5

Investigation, Recording and Reporting
 Reasons for Investigating Incidents

• To identify the immediate and root causes of the

incident.
- Usually caused by unsafe acts or unsafe
conditions.
- Arise from underlying or root causes.

• To identify corrective action to prevent

recurrence.
- The main reason for investigating.
November 2010 Element 8 Occupational Incident and Accident 6
Investigation, Recording and Reporting
 Unsafe acts/omissions

• Operating without authority

• Using faulty equipment
• Failing to follow instructions
• Horseplay
• Failure to use PPE
• Operating at unsafe speed

November 2010 Element 8 Occupational Incident and Accident 7

Investigation, Recording and Reporting
 Unsafe conditions

• Inadequate/missing guarding
• Poor housekeeping
• Defective equipment
• Inadequate lighting
• Unsuitable/damaged PPE
• Trip hazards
• Badly maintained equipment

November 2010 Element 8 Occupational Incident and Accident 8

Investigation, Recording and Reporting
 Underlying causes

Management: Social:
• Financial restrictions • Group attitudes
• Lack of commitment • Trade customs
• Lack of policy • Tradition
• Lack of standards • Attitudes to risk
• Lack of knowledge taking
• Poor training • Acceptable work
place behaviour
November 2010 Element 8 Occupational Incident and Accident 9
Investigation, Recording and Reporting
 Reasons for Investigating Incidents

• To record the facts of the incident – people do

not have perfect memories and accident
investigation records document factual evidence
for the future.

• For legal reasons – accident investigations are

an unwritten legal duty placed on the employer.

November 2010 Element 8 Occupational Incident and Accident Investigation, 10

Recording and Reporting
 Reasons for Investigating Incidents

• For claim management – if a claim for

compensation is lodged against the employer
the insurance company will examine the
accident investigation report to help determine
liability.

• For staff morale – non-investigation of accidents

has a negative effect on morale and safety
culture because workers will assume that the
organisation does not value their safety.
November 2010 Element 8 Occupational Incident and Accident 11
Investigation, Recording and Reporting
 Reasons for Investigating Incidents

• For disciplinary purposes – though blaming

workers for incidents has a negative effect on
safety culture, there are occasions when an
organisation has to discipline a worker because
their behaviour has fallen short of the acceptable
standard expected.

• For data gathering purposes – accident statistics

can be used to identify trends and patterns; this
relies on collecting quality data.
November 2010 Element 8 Occupational Incident and Accident 12
Investigation, Recording and Reporting
 Types of Incident

• Near miss – an unplanned, unwanted sequence

of events that have the potential to lead to injury,
damage or loss.
• Accident – un unplanned, unwanted sequence
of events that leads to injury, damage or loss.
• Dangerous occurrence – a specified event that
has to be reported to the relevant authority.
• Ill-health – a disease or medical condition hat is
directly attributable to work.

November 2010 Element 8 Occupational Incident and Accident 13

Investigation, Recording and Reporting
Basic Incident Investigation Procedures

• Step 1 – gather factual information.

• Step 2 – analyse that information and draw
conclusions about the immediate and root
causes.
• Step 3 – identify suitable control measures.
• Step 4 – plan the remedial actions.
Before the investigation:
• Secure the scene.
• If it is an injury accident, care for the victim.
November 2010 Element 8 Occupational Incident 14
and Accident Investigation,
Basic Incident Investigation Procedures

The level of investigation will be determined by the

seriousness of the event e.g. minor injury,
fatality, etc.
• A simple investigation for an accident that
caused no injury or little damage and did not
have the potential to be more serious.
• A more in-depth investigation of an incident with
serious outcomes or potential for a serious
outcome.

November 2010 Element 8 Occupational Incident and Accident 15

Investigation, Recording and Reporting
 Site Visit - Equipment

• Report form/check list

• Notebook and pens
• Tape recorder
• Cameras - instant/35mm
• Measuring tape
• Specialist equipment e.g. Draeger
tubes, decibel meter

November 2010 Element 8 Occupational Incident and Accident 16

Investigation, Recording and Reporting
 Accident Investigation Procedure

1. Carry out within 24 hours if possible

2. Visit site and take photographs, make
sketches, take measurements etc.
3. Interview witnesses using ‘soft’ interviewing
technique
4. Distinguish fact from opinion
5. Interview the injured person

November 2010 Element 8 Occupational Incident and Accident 17

Investigation, Recording and Reporting
 Accident Investigation Procedure

6. Examine any equipment involved and talk to

maintenance staff
7. Examine written policies, systems of work and
check for compliance
8. Report to the Authorities if necessary
9. Prepare report and discuss findings
10. Issue report

November 2010 Element 8 Occupational Incident and Accident 18

Investigation, Recording and Reporting
 Interviewing Witnesses
• Use a none-threatening place for the interview
• Put the witness at ease
• Explain clearly the purpose of the interview
• Ask easy, open questions which do not lead
• Ask what happened and listen without interruption
• Separate fact from opinion
• Be considerate tolerant and patient!
• Close the interview by explaining what will happen next
• Make notes and ask for signature at end of interview.

November 2010 Element 8 Occupational Incident and Accident 19

Investigation, Recording and Reporting
 Incident Investigation
The report should answer the following questions:
• What was the immediate cause of the
accident/ injury/loss?
• What were the underlying causes?
• What corrective action is required?
• What system changes are needed to prevent a
re-occurrence?
• Do policies and procedures need reviewing?
• What are the estimated costs involved?

November 2010 Element 8 Occupational Incident and Accident 20

Investigation, Recording and Reporting
 Remedial Action

Remedial actions must be allocated to a responsible

person and time limits set.

Example of how this may be presented

Action Priority Timescale Responsible
person
Introduce user Medium 1 month Machine shop
checklist for all manager
machine
operators

November 2010 Element 8 Occupational Incident and Accident 21

Investigation, Recording and Reporting
 Remedial Action
Unsafe conditions cannot be ignored or allowed to
continue.
Dangerous practices and high risks must be dealt
with immediately .
• Dangerous machinery taken out of use.
• High risk activities may have to be suspended.
• Dangerous environments evacuated.
Some circumstances cannot wait for a full
investigation before taking action.
November 2010 Element 8 Occupational Incident and Accident 22
Investigation, Recording and Reporting
 Remedial Action

Where long-term action is required interim

measures must be put in place until a more
suitable solution can be found, but this interim
period must not be indefinite.

Remedies may require some capital expenditure

and effort to develop. This action needs
commitment from management.

November 2010 Element 8 Occupational Incident and Accident 23

Investigation, Recording and Reporting
Recording and Reporting Requirements
Requirements for reporting of incidents should be
described in the Arrangements section of the
organisations Health and Safety Policy. It should
be made clear to employees what type of incident
that has to be reported
• Verbal report to line manager.
• Completion of the appropriate incident form.
• Contractor working in a clients premises may
have to report and incident to the client as well
as their own employer.
November 2010 Element 8 Occupational Incident and Accident 24
Investigation, Recording and Reporting
Recording and Reporting Requirements
Reasons why workers might not report incidents:
• Not described in the policy.
• No reporting system in place.
• Complicated reporting system.
• Too much paperwork to complete.
• Takes to much time.
• Fear of being blamed for the outcome.
• Workers don’t really care, lack of safety culture.
• Lack of training on policy procedures.
November 2010 Element 8 Occupational Incident and Accident 25
Investigation, Recording and Reporting
Recording and Reporting Requirements

It may be necessary to inform the following:

• Company Directors e.g. Managing/Finance
• Line managers/ HRD Staff
• Legal department

• Relevant Authority Inspector

• Insurance company
• Employees/employees representatives
• Family of injured parties
November 2010 Element 8 Occupational Incident and Accident 26
Investigation, Recording and Reporting
 Report should identify

1. Age and sex of victim

2. Work location and group
3. Immediate causes
4. Root/underlying causes
5. Hazards/risks
6. Nature of injuries/illness

November 2010 Element 8 Occupational Incident and Accident 27

Investigation, Recording and Reporting
 Report should identify

7. Parts of body injured in detail

8. Any treatment given
9. Details of equipment damage
10. Details of property damage
11. Details of any chemical or biological
substances involved
12. Any existing control measures

November 2010 Element 8 Occupational Incident and Accident 28

Investigation, Recording and Reporting
 Data Collection, Analysis and
Communication
Helps to identify trends and reassess targets for
improvement.
• Trend in accidents over previous 5 years.
• Common accidents.
• Common injuries.
• Time of accidents.
• Part of the body affected.
• Department / area where accidents happen.
• Accident/ incident rates for departments.
November 2010 Element 8 Occupational Incident and Accident 29
Investigation, Recording and Reporting
 Record Keeping

Accident forms kept for at least three years.

Time, place & date of dangerous occurrence
Name, occupation & nature of injury for persons
injured at work and a brief description of the
accident
Name, status & nature of injury for non-
employees
Time, date authorities informed and by what
method e.g. telephone, fax.

November 2010 Element 8 Occupational Incident and Accident Investigation, 30

Recording and Reporting
Reporting of Events to External Agencies
All countries have a procedure for reporting:
• Major injuries e.g. amputation.
• Dangerous occurrences e.g. failure of a hoist.
• Occupational diseases e.g. cancer.

The ILO have published standards on reporting

procedures with the main reference being the
Protocol to the Occupational Safety and Health
Convention 1981.
November 2010 Element 8 Occupational Incident and Accident 31
Investigation, Recording and Reporting
 Finally

Safe place Safe person

• Workplace • PPE
• Equipment • Information,
• Environment instruction, training
• Safe behaviour

November 2010 Element 8 Occupational Incident and Accident 32

Investigation, Recording and Reporting
 Causes of workplace accidents

• Pure chance theory

• Biased liability theory
• Accident proneness theory
• Domino theory
• Multi-causality theory

November 2010 Element 8 Occupational Incident and Accident 33

Investigation, Recording and Reporting
 Pure chance theory

All accidents are Acts of God and everyone has

an equal chance of having an accident.

Therefore any steps to prevent accidents are a

waste of time.

November 2010 Element 8 Occupational Incident and Accident 34

Investigation, Recording and Reporting
 Biased liability theory

Once a person has had an accident the

probability of the same person having another
accident is decreased (Burned Finger
Hypothesis)
or
the chance is increased (Contagion
Hypothesis).

November 2010 Element 8 Occupational Incident 35

and Accident Investigation,
 Accident proneness theory

Some people are more susceptible to accidents

than others – not proven by research

November 2010 Element 8 Occupational Incident 36

and Accident Investigation,
 Domino theory

Social Personal Unsafe act, Accident Injury, damage

Environment Fault omission or near miss
condition

Heinrich 1959 – emphasis on individual failure

November 2010 Element 8 Occupational Incident 37
and Accident Investigation,
 Accident causation - Heinrich

• 88% caused by unsafe acts or omissions

• 10% by mechanical failure or physical
conditions
• 2% by Acts of God
• If middle domino is removed the sequence
would be interrupted and most accidents
prevented

November 2010 Element 8 Occupational Incident 38

and Accident Investigation,
 Updated domino theory

Lack of Unsafe Unsafe acts, Accident Injury, damage

Management underlying omissions near miss
Control causes or conditions

Emphasis on management failure rather than individual failure

November 2010 Element 8 Occupational Incident 39
and Accident Investigation,
 Multicausality theory (Tree)

Underlying causes Unsafe Acts ➔


Accident Injury/loss


Underlying causes Unsafe conditions

November 2010 Element 8 Occupational Incident 40

and Accident Investigation,
 Tye/Pearson Triangle

1 Fatal /serious accident

3 Minor injury

50 First aid injury

80 Property damage
400 Near misses

November 2010 Element 8 Occupational Incident 41

and Accident Investigation,
 Near misses

• Important to identify, record and analyse

• How do you do this in your organisation?

November 2010 Element 8 Occupational Incident 42

and Accident Investigation,
 Fatal Accidents

A Falls from heights

B Struck by moving vehicle
C Struck by moving object
D Contact with machinery
E Trapped by collapse
F Electricity
G Harmful substance

November 2010 Element 8 Occupational Incident and Accident 43

Investigation, Recording and Reporting
 Reported injuries
A Manual handling
B Slips, trips & falls
C Struck by moving object
D Fall from height
E Crushed against object
F Machinery
G Harmful substance
H Moving vehicle
November 2010 Element 8 Occupational Incident and Accident 44
Investigation, Recording and Reporting
 Accident Iceberg

Insured costs
£1

Uninsured costs
£8 - £36

The Costs of Accidents at Work - HS(G)96

November 2010 Element 8 Occupational Incident and Accident 45
Investigation, Recording and Reporting
 Costs of accidents

Insured costs

• Injury - employers liability insurance

• Illness
• Damage to vehicles, plant, buildings
etc.

November 2010 Element 8 Occupational Incident and Accident 46

Investigation, Recording and Reporting
 Cost of accidents
Uninsured costs
• Product/material damage • Investigation time
• Plant/building damage • Supervisors time
• Tool/equipment damage • Clerical effort
• Legal costs • Fines
• Site clearance • Loss of expertise
• Production delays • Loss of experienced
• Overtime workers
• Additional labour costs • Damage to company
image
November 2010 Element 8 Occupational Incident and Accident 47
Investigation, Recording and Reporting
 Categories of accident

1 No injury, no property damage

2 No injury, property damage
3 Injury, no property damage
4 Injury, property damage

November 2010 Element 8 Occupational Incident and Accident 48

Investigation, Recording and Reporting
 RIDDOR 1995

• Duties on employers & self employed

• Responsible persons to report
• Responsible person normally the employer
• On building sites the main contractor should
ensure that the reports are made.

November 2010 Element 8 Occupational Incident 49

and Accident Investigation,
 Injuries

• Deaths and major injuries by quickest

practicable means

• F2508 within 10 days

• Major injuries listed in RIDDOR

November 2010 Element 8 Occupational Incident 50

and Accident Investigation,
 Major injuries

• Fractures – not fingers, toes or thumbs

• Amputations
• Dislocations of hips, knee, shoulder etc.
• Temporary loss of sight
• Electric shock requiring resuscitation
• Chemical, hot metal or penetrating injury to the
eye.

November 2010 Element 8 Occupational Incident 51

and Accident Investigation,
 Major injuries

• Loss of consciousness by asphyxia, chemical or

biological agent
• Hypothermia, heat induced illness or
unconsciousness
• Any injury requiring hospitalisation for more than
24 hours

November 2010 Element 8 Occupational Incident 52

and Accident Investigation,
 Minor injuries

• More than three days away from work or unable

to carry out normal duties

• Send in F2508 within 10 days

November 2010 Element 8 Occupational Incident 53

and Accident Investigation,
 Non Consensual Violence

• Resulting in death, major injury or more than 3

day injury

• In connection with work

• Reportable

November 2010 Element 8 Occupational Incident 54

and Accident Investigation,
 Injuries to non-employees

Only reportable if the non-employee goes

directly to hospital by whatever means e.g. taxi,
private car or ambulance

November 2010 Element 8 Occupational Incident 55

and Accident Investigation,
 Reportable diseases

• Report in writing within 10 days using form

F2508A
• Diseases listed in RIDDOR 1995
• Common diseases include occupational
dermatitis or asthma

November 2010 Element 8 Occupational Incident 56

and Accident Investigation,
 Examples of reportable diseases
• Various WRULDs’ e.g. Carpal Tunnel
Syndrome, Hand-arm Vibration Syndrome
• Biological infections e.g. Hepatitis, Tetanus,
Legionellosis
• Poisoning e.g by arsenic or lead
• Cancers
• Occupational Dermatitis & Asthma

November 2010 Element 8 Occupational Incident and Accident 57

Investigation, Recording and Reporting
 Dangerous Occurrences

• Report by quickest practicable means followed

by F2508 within 10 days

• Gas incidents use form F2508G

• Balfour Beatty tunnel collapse at Heathrow

resulting in fine in excess of £1.2 million

November 2010 Element 8 Occupational Incident 58

and Accident Investigation,
 Examples of dangerous occurrences

• Collapse of a crane or hoist

• Overturning of a fork lift truck
• Failure of a pressure system
• Fire/explosion from an electrical short circuit
• Collapse of a scaffold
• Major gas leak
• Collapse of a building.

November 2010 Element 8 Occupational Incident 59

and Accident Investigation,
 Benefits for those injured at work

• Industrial injuries disablement benefit

• Constant attendance allowance
• Severe disablement benefit
• Above are non-taxable
• Statutory sick pay - taxable

November 2010 Element 8 Occupational Incident and Accident 60

Investigation, Recording and Reporting