Accident Reporting and Investigation

Accident Reporting &
Investigation
Paul Craythorne
Health, Safety & Environmental Advisor
Investigation
 Course Objectives
 to understand:
 accident definition
 accident causation
 accident costs
 accident prevention
 accident reporting/notification
 accident investigation
Investigation
 Common Uninformed Comments
 accidents just happen

 we don’t have many accidents
 safety is expensive
 the insurance will pay
 safety is just common sense
Investigation
 Accident Definition
 what is an accident?
 unplanned & uncontrolled event
that led to, or could have led to:
• injury to persons, damage to
property/plant/equipment, impairment
to the environment or some other loss
to the company
Investigation
 Accident Definition
 accident types
• minor dangerous occurrence
• near miss
• plant/equipment damage
• minor injury
• lost time injury
• disablement/fatality
Investigation
 Accident Definition
 Frank Bird (Accident Triangle)

• 600 near misses
• 30 property damage
• 10 minor injuries
• 1 serious injury (lost time or fatal)
Investigation
 Accident Causation
 environment
 personal fault
 unsafe act
 unsafe condition
 accident
 injury/damage
Investigation
 causal factors
• individual
• job
• organisation
Investigation
 causal factors
• individual
– knowledge
– skills
– training
– experience
– personality
– attitude
– risk perception
Investigation
 causal factors
• job
– task
– workload
– equipment
– controls
– procedures
– environment
Investigation
 causal factors
• organisation
– culture
– leadership
– resources
– work patterns
– communications
Investigation
 Kings Cross Fire (1987) - 31died

• discarded cigarette
• accumulation of rubbish
• poor cleaning regime
• wooden escalator
• failure of fire fighting equipment
• lack of emergency training
• poor safety culture
Investigation
 Herald of Free Enterprise (1987) -

189 died
• failure to close bow doors
• no checking/reporting system
• commercial pressures
• internal friction
• disease of sloppiness
Investigation
 Clapham Junction (1988) - 35 died

& 500 injured
• signal failure
• incorrect maintenance
• degradation of working practices
• training problems
• communication problems
• poor supervision
• excessive working hours
• failure to learn lessons
Investigation
 Piper Alpha (1988) - 167 died

• maintenance error
• inexperience
• poor maintenance procedures
• communications breakdown
• permit to work system fault
• safety procedures not practised
Investigation
 Automotive Supplier (1999) - 1

died
• poor safety culture
• lack of guarding
• lack of training
• poor perception of risk
• no safe systems of work
• no risk assessment programme
• no effective accident system
• no communication
Investigation
 Accident Costs
 insured costs
 uninsured costs
Investigation
 Accident Prevention
 reasons
• humane
• economic
• legal
Investigation
 Accident Prevention
 control measures
• safety procedures/work instructions
• adequate training
• effective communications
• good housekeeping
• guards/safety devices/warning signs
• adequate working environment
• regular safety inspections
• risk assessment
Investigation
 Accident Reporting/Notification
• internal report form

• HSE RIDDOR report
• injury claim requirement
Investigation
 Accident Investigation
 reasons
• identify root causes
• identify faults
• identify corrective/preventative action
• prevent recurrence
Investigation
 investigation team
• supervisor
• safety rep
• engineer
• manager
• safety officer
Investigation
 investigation objectives
• establish chain of events
• identify faults
Investigation
 investigation techniques
• attend promptly
• ensure medical attention
• leave scene undisturbed
• take photographs/sketches
• take measurements
• take samples
• gather documentation
• interview witnesses
Investigation
 investigation techniques
• interviewing witnesses
– explain purpose
– their version of events
– do not listen to ‘hear say’
– ask open questions
– avoiding leading or implying
– do not apportion blame
– express appreciation
Investigation
 investigation report
• identify team
• summarise consequential events
• describe other weaknesses
• allocate responsibility & timescale

Accident Reporting and Investigation

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Accident Reporting and Investigation

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Accident Reporting &

 accidents just happen

 Frank Bird (Accident Triangle)

 Kings Cross Fire (1987) - 31died

 Herald of Free Enterprise (1987) -

 Clapham Junction (1988) - 35 died

 Piper Alpha (1988) - 167 died

 Automotive Supplier (1999) - 1

• internal report form

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