Professional Documents
Culture Documents
INVESTIGATION
A course book for the NEBOSH HSE Introduction
to Incident Investigation Award
Edition 1
Version 1
Compassa Ltd, 136 Hawthorn Avenue, Hull, HU3 5PY, United Kingdom
TEL: +44 (0) 1482 739 090
Email:will@compassa.co.uk
www.compassa.co.uk
Contains public sector information licensed under the Open Government Licence v1.0
Every effort has been made to trace copyright material and obtain permission to
reproduce it.
If there are any errors or omissions, Compassa would welcome notification that
corrections may be incorporated in future reprints or editions of this course book.
© Compassa Ltd.
Will is a career health and safety professional and trainer who’s managed health
and safety for several large organisations. A chartered member of IOSH with a BSc
(Hons) in Safety and Environmental Management and several NEBOSH qualifications,
he has 20 years of experience managing health and safety in industry. Furthermore,
he has also undertaken secondments in Lean Six Sigma, Production Management,
and recruitment.
Compassa is a Gold Learning Partner for NEBOSH and an approved course provider
for IOSH.
Element 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Human Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Organisational Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Job Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Individual Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Human Error . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Element 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
What a Good Investigation Looks Like . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
The Levels of Incident Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Pre-Investigation Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Step 1: Gathering Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Getting the Information Organised . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Step 2: Analysing the Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Immediate, Underlying and Root Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Step 3: Identifying Risk Control Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Step 4: The Action Plan and its Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Element 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Introduction to the PEACE Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Planning and Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Engage and Explain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Account, Clarification and Challenge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Barriers to Good Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Unwilling Interviewees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Blame Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Element 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Advanced Incident Investigation Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Element 1:
Reasons to
Investigate
Incidents
An incident is an over-arching
category for multiple words
Definition of an Accident
An accident is a type of
incident
An accident could be described as
an incident which results in injury or
ill health to someone or damage to
property.
A fatality
An accidental fire
The failure of a
pressure vessel
Overturning of a forklift
truck or crane
However, the definitions do matter. Because you will need to encourage people
to report accidents and near misses. And you will need to explain the difference
between them.
However, we have naturally evolved to learn from our mistakes. Thanks to this, we
learn to live, walk, and survive.
Wasted materials
Disciplinary problems
An Example of an
Improvement Notice
An improvement notice served on Dalau Limited in 2020 said: “You have failed
to make and give effect to appropriate arrangements to effectively review your
preventative and protective measures following any near-miss, accident, dangerous
occurrence or ill-health occurrence because you did not have an effective system
to record and investigate such events. The arrangements you have in place do
not allow you to collect sufficient information to ensure that you can carry out a
thorough investigation ...”
As you fix these causes, you break the law less and less, and reduce the chances of
getting prosecuted or sued in the future.
Organisations are legally required, under the Management of Health and Safety at
Work Regulations 1999, to keep their arrangements to keep people safe under review
and up to date.
RIDDOR
If you don’t investigate incidents then you can’t comply with the Reporting of Injuries,
Diseases, and Dangerous Occurrences Regulations 2013. These require certain
incidents to be identified, recorded, and reported to the Health and Safety Executive.
If you are you convicted and found of a health and safety offence,
you may be able to demonstrate that you:
- Took the .
- That you investigated it promptly and .
- And that you acted to reduce the risk of reoccurrence.
This can result in your being reduced by up to .
Cooperate fully
This often leads to having to offer a settlement and paying more compensation than
may be necessary.
At the very least, colleagues will need to clean up and do the work the injured
person was doing. In extreme cases, where the organisation is affected financially,
colleagues may lose their jobs.
Building damage
Manager time
Compensation
Yes
No
The costs are only insured if the organisation has purchased an insurance policy.
• Compensation claims (but not always.) In the UK, only private sector
organisations are required to have Employers’ Liability Insurance. The public
sector often does not have this, and pays the insurance out of its own funds
(ultimately, coming from thetaxpayer).
The uninsured costs of workplace accidents, ill health, and incidents can be
enormous. These can include:
• First aid.
• Overtime.
• Hiring of temporary staff.
• Investigation time.
• Fines.
A is an which caused ,
ill health, or damage
For example, for a pedestrian to get run over by a car, both the pedestrian and
the driver must fail to pay attention and both need to be in the same place at the
same time.
Their ISO45001 standard is the world’s leading health and safety management
system standard.
Your organisation can work towards getting its health and safety management
system accredited to this standard if its system meet the criteria.
ISO45001 says that incidents are a “non-conformity”. It means you are not
conforming with the standard.
With lagging indicators, there is a time delay between your actions and the result.
The indicator “lags” behind your actions. With leading indicators, you’re trying to
measure the actions you take today which positively influence your results in the
future.
Fill in the gaps with the correct words to complete the explanation of leading and
lagging indicators
Human Factors
Simply put...
Human Factors are things which affect our behaviour and our performance at work.
Organisational
Job
Individual
Organisation = Management
Organisational factors are often called management factors.
They are linked to the culture of the organisation, the quality of its leadership, the
level of investment and resources, work patterns, and the quality of communications.
Culture
Perhaps the organisation, its managers, or even its staff don’t value health and
safety. This could result cutting corners.
For example, if managers don’t wear PPE, this can engender a culture where no one
wears PPE.
A poor health and safety culture, especially amongst management, can often lead
to:
• Poor or no training.
• The wrong materials being delivered.
• Unsuitable equipment being provided, or being poorly maintained.
• Insufficient numbers of people allocated to the job.
This often leads to people cutting corners and making do with what they have.
Poor Communications
Communication may be poor, meaning that priorities or instructions are not clear.
This often means workers have to make their own instructions up or guess what the
priorities are.
Conflicting Goals
Some organisations have conflicting goals. For example, they will say they value
safety, but they will also remove guards from machines to work faster when a
customer wants something delivering the next day.
For example, inadequate risk assessments, or procedures that don’t work or are not
followed.
Organisational Factors =
Common Root Cause of Incidents
Displays or Controls
Some equipment may be poorly designed, and therefore it is not clear how to use
the equipment or read the displays. This can make the task confusing for the
individual which results in errors.
Task
Some tasks that individuals are expected to
undertake may be complicated or physically or
mentally demanding.
PPE
How can PPE affect human behaviour or performance?
For example, if hearing protetion is required in a certain area, try different types with
workers to see which they prefer the most. You may have to provide different types
to different people.
Poor Maintenance
Environment: Temperature
Repetitive Tasks
Attitude
Attitude may be defined as ‘the tendency
to respond in a particular way to a certain
situation’.
Competence
Competence may be defined as ‘skills, knowledge, ability, level of training or level of
experience’.
Complacency
Complacency is extremely dangerous in the workplace. We get so used to things
being done the same way that we do not always see the hazards in our surroundings.
We may also underestimate the risk of tasks that we perform regularly, or fail to notice
a change in our environment when we become complacent in our daily routines.
Risk Perception
• Doing a boring, repetitive job resulting in the lowering of stimulus in the brain
which reduces the individual’s attention.
• Tiredness which may reduce an individual’s attention level and affect their
perception of hazards like moving machinery or vehicles.
• Some hazards may not be as obvious. They may be hidden or difficult to see,
such as electricity or certain gasses like carbon monoxide.
• literacy,
• illness,
• stress,
• health,
• drugs,
• alcohol,
• prescribed medication,
• physical or mental capabilities,
• age,
• gender,
• and language.
• Violations, where the failure is deliberate. Usually, with good intentions. But not
always.
Examples: Slips
‘Your body does something unintended’
• Performing an action in the wrong direction e.g. a MEWP operator pushing the
joystick to the left instead of the right.
• Tripping up over your own feet.
• Picking up a knife by the blade instead of the handle.
• Reaching for something and knocking over a glass of water.
Examples: Lapses
‘Forgetting to do something, or losing your place midway through a task.’
Examples: Mistakes
• These can be rule-based or knowledge-based.
• A rule-based mistake: is when you apply a rule or procedure in the wrong
situation. e.g. You evacuate the building when you hear an alarm, but it is a
burglar alarm.
• A knowledge-based mistake: is where you don’t know what to do. e.g. A machine
is not working correctly. So you open the guard and start touching things you
don’t understand in an attempt to fix it.
Examples: Violations
• Scaffolders not clipping their lanyards to a suitable anchor point.
• Construction vehicle drivers not wearing seat belts.
• FLT operators not doing their vehicle pre-use checks.
• A site manager allowing untrained operatives to operate machinery.
- You exceed the speed limit because you are late. This is a .
- Accidentally pressing the accelerator instead of the brake is a .
- You borrowed your partner’s car. You try to use the indicator, but turn on the
windscreen wipers. The controls are on the opposite side in your car.
This is a .
- Forgetting to take a left turn because you were distracted is a .
- You get lost driving to a new location. This is a .
Investigating Accidents
and Incidents
• Risk control measures to deal with the immediate, underlying and root causes.
This sets out a simple decision making process. Depending on the likelihood of
reoccurrence and the potential worst consequence of the event, we will work out the
level of investigation which can be either minimal, low, medium, or high.
Risk Assessment
But you can’t put down death as a consequence for everything, even if it is
technically possible.
You have to be reasonable, and put down the CREDIBLE worst consequence.
Take Notes
In the immediate aftermath, you might want to
make a note of a few things before they change
or disappear.
1. 2.
3. 4.
5.
For example, we want to start investigating before anything gets moved, before
equipment is repaired, before machine guards are replaced, and so on.
We also want to make sure that we get witness statements from people before they
forget the details of what happened.
Physical Evidence
Physical evidence includes anything
at the scene of the incident. This
might be the equipment, machines,
tools, or substances involved.
Environmental Conditions
You should also make a written note of the
environmental conditions at the time.
Because when the witnesses , they will inevitably talk about what
happened and they will each others’ stories.
Written Evidence
This would include the risk assessments,
policies, procedures, maintenance
records, training records, previous
inspections, previous investigations,
disciplinary records, job descriptions,
specifications, instruction manuals,
safety data sheets, and so on.
Make sure you remain open-minded as to all of the possible causes of the incident,
and the role played by the individuals and the organisation.
False
But if lots of people all say the workplace
was untidy, then it’s more believable.
Subjectivity
Be careful!
People have subjective opinions and beliefs. They might describe something as,
“busy” or “tidy”, but their standard of busyness or tidiness might be different to yours.
Asking “Why” repeatedly helps us dig deeper into the causes until we get to the root
causes of the incident.
It’s a simple incident, but you will soon see just how complicated a 5 Whys Analysis
can get.
Let’s say someone has injured themselves by falling off a ladder. We start by defining
the problem we are investigating.
It’s a simple
process, but it is
not easy. It takes
some practice.
2. Be factual. Don’t make assumptions. Base your answers on the information you
gathered.
For the purposes of your assessmen, it’s important that you are able to correctly
identify whether a cause of an incident is either an Immediate, an Underlying, or a
Root Cause.
Immediate Causes
Immediate causes of incidents are the hazards, the unsafe conditions, and unsafe
actions which directly caused the incident.
Root Causes
Root Causes are the initiating event or failing from which all other causes or failings
spring.
• Design flaws.
• The health and safety culture.
• Organisational values and priorities.
• A lack of Senior Management commitment to H&S.
• Inadequate investment in health and safety.
• Failures in management systems.
1. What existing risk control measures should have prevented the incident?
3. Can we implement any risk control measures that are higher up the hierarchy of
controls?
A DSE assessment
Eye tests
You should consider introducing any control measures required by these HSE Codes
of Practice and Guidance as doing so will usually be considered to be proof that you
are legally compliant.
Other Requirements
There may be other standards that you have to comply with:
• Various industry standards.
• Your customer’s requirements.
• Your own internal standards.
It makes sense for you to implement whatever risk control measures these standards
require.
Elimination
Engineering Controls
Fill in the gaps with the correct words to make a list of Engineering Controls.
Asking office workers to take regular breaks while using Display Screen Equipment
• Reducing the time workers are exposed to hazards (e.g. job rotation).
• Prohibiting the use of mobile phones in hazardous areas.
• Warning signs.
PPE
PPE is the control measure of last resort. This is only to be used after all the previous
measures have been found to be insufficient or unreasonable.
For example, where you cannot eliminate or prevent a fall, use PPE (a fall arrest
system) to minimise the distance and consequences of a fall.
5. Release the scene of the incident back to the operational unit of the organisation.
The person reading the action must be able to understand exactly what is required.
You should be able to hand the action plan to someone who can read it and know
exactly what you want them to do.
Measurable: Instead of “train more first aiders on the night shift”, you might
decide to “train 4 extra first aiders on the night shift”.
Action
Next we need to identify
whether it’s an immediate,
underlying or root cause. In
this case it’s an underlying
cause. So we write a “U” in
the 2nd column.
And finally, we have to specify the priority. Which is essentially a timescale. Sourcing
a suitable safety knife is usually a quick, easy, and cheap job, so we should be able
to get that done within a month. So we’ll put a priority of “1” here.
2nd Action
Then we
continue
through all of
our actions,
adding whose
who are
responible
and priorities
until all of our
actions have
been added to
the action plan.
You might also need to update other risk assessments and standard operating
procedures with any new hazards, risks, or controls you are introducing.
Your system should check the result of the system to make sure it is delivering the
result you intended and has truly fixed the cause of the incident.
Frontline workers
Introduction to The
PEACE Model
The PEACE model is not a health and safety interview model. It was developed by the
Police and it has been adopted by Police forces and government agencies all
around the world. It is a fantastically effective tool to help you get the best out of
your witness interviews.
Soft Skills
Interviewing people requires good people and communication skills, humility,
openness, and being willing to challenge your own bias and prejudice about what
happened.
The first thing we need to do is decide what we want to achieve from the interview.
A List of Questions
The interview
plan will include
a list of questions
that you need
to ask. You need
to confirm that
what you think
you know is
actually true,
and you want to
uncover any
information you
don’t know.
Have a timeline of events prepared. You can refer to this in your interview. This would
help both of you remember key details like timings, sequence of events, locations,
what actions people took and so on.
private disturbed
Meeting Rooms
Having interviews in a meeting
room is often a good idea because
it can help control interruptions.
But, sometimes, the formality of a
meeting room can make frontline
operatives feel uneasy.
This can be reassuring to the interviewee, because it makes it harder for you to twist
their words or try to bully them in any way.
But don’t take too long. Take breaks if either you or the interviewee are getting tired.
If the incident was particularly serious, recounting what happened may lead to
the interviewee needing some time out to compose themselves. You might need
to take a break.
You must always have a timeline of events before carrying out an interview.
Always carry out interviews near the scene of the incident.
An interview plan will include questions to ask, things to say, things to find, and
maybe even a timeline of event.
If we can build rapport, that increases the chances of getting useful and accurate
information.
Ask the interviewee if you can count on them to help you discover the facts of what
happened.
Closed Questions
After getting the initial information, we can use closed questions to determine
specific facts. Such as: “where exactly were you standing?” or “were
you standing next to the door or next to the control panel?”.
These invite short answers which are much more detailed and establish specific
facts.
Open Question
Leading Question
Closed Question
Active Listening
Active listening is one of the most important skills someone can learn, and not just
for incident investigation.
Active listening means really listening and trying to understand what the person
means.
You listen without thinking about what you’re going to say next. And you avoid
jumping to conclusions about what they’re saying.
Or maybe you’ve misunderstood. “Assume Ignorance Before Malice”. Simply point out
the contradiction and ask them to explain it.
Clarification
Engaging with Interviewee and asking for their Account
Challenge
TRUE or FALSE?
You don’t need to get every interviewee to sign their statement.
True
False
Tell them you will carry out some interviews, review the evidence, draw some
conclusions and formulate some recommendations for management.
It’s possible that new information will come to light and we might need to ask them
about it.
Considerations
One witness might speak to the next witness, and may comment negatively about
your interview style or approach. This might lead to future witnesses being less
cooperative.
You don’t need to check their contact details if you already have them.
You thank them simply because it’s polite.
When summarising, always use their own words.
Compare it against the other available evidence: does it confirm or support the other
evidence? Or does it contradict the other evidence?
Conclusion
Always Remember:
Language Barriers
If the interviewee does not speak your language very well, you are going to
struggle. They may not fully understand what your questions mean.
Leading Questions
Avoid asking questions which encourage, manipulate, or pressure the interviewee to
give you a certain answer. Avoid putting words into their mouth.
Asking leading questions may lead to the interviewee becoming reluctant to answer
and not talking.
Furthermore, be careful of rumours. Interviewees may repeat what they have heard
as facts.
Remember to ask: “how do you know this?” or “what makes you think that?”
to determine whether it is a rumour or not.
turning up refusing
Some people don’t want to be interviewed or fail to cooperate with the interview
process. This might look like:
Not for the interview.
Being passive .
Being .
Claiming not to key details.
Insisting on a despite clear evidence to the contrary.
Openly to answer questions.
And there is clear scientific evidence that shows that people will dig in their heels on
their beliefs or opinions when they feel attacked. Even if you have
definitive proof they are wrong.
Show Understanding
Show complete support and acceptance for the person’s feelings and opinions.
You can do this by actively listening to any objections they have and repeating back
in their own words.
Put yourself into their shoes and explain why it is understandable they may be
resistant.
If the person seems reluctant, it’s good to ask them directly how they feel about
being interviewed.
You can then follow up and repeat back to them how they feel, to show you have
listened.
Stating things they might identify with will help build rapport.
A blame culture is the tendency to look for one person who can be
held entirely responsible.
Almost all of us have failed to take responsibility for our mistakes (at some time).
This is an ancient problem, which even gets mentioned in the Bible: “let he who is
without sin cast the first stone”.
If you focus on the why, you will develop a Learning Culture where organisations can
learn and improve over time.
In Blame Cultures, witnesses often keep quiet or try to deflect blame onto others.
Minor accidents and near misses probably won’t even get reported.
And we must hold people to account when they have failed to adhere to health and
safety standards. Any punishment must be proportionate to the part they played in
the incident.
Proportionate Punishment
Ignorant or Malicious
Consider the motivation behind their behaviour. They may have acted maliciously, in
which case severe punishment may be warranted. But in most cases, people were
not malicious. They had good intentions. They may even have been trying to help. So
temper the punishment in such cases.
Bias is bad for investigations because it can mean that important evidence and
causes of incidents either receive too much attention, are dismissed too quickly, or
get completely ignored.
There are literally dozens of types of bias. And we’re going to focus on 3 types:
1. Self-serving bias
2. Fundamental attribution error
3. Cherry picking bias
Cherry-Picking Bias
Fundamental Attribution Error
Self-Serving Bias
Advanced Incident
Investigation Techniques
Each rib of the fish is a type of cause. You can choose your own types and these
do vary between industries. In manufacturing, the causes are usually Machines,
Methods, Materials, Measurements, the Environment, and People.
This is a
technique
usually
reserved for
complex
industrial
activities or
processes
such as
nuclear power
plants,
petrochemical
reactions, etc.
It starts with
an initiating
event
Which leads
to a result.
Which sets
in motion
a chain of
events
With this method you begin at the top with the ‘undesired
event’, which is the incident.
In this example:
AND
In this example:
No Water Supply
OR
Compassa Ltd
136 Hawthorn Avenue
Hull
HU3 5PY
United Kingdom