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
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 Major Injury

3 Lost Time 1
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

A
B C
D

© 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

Th e c a u s e o f th e in ju ry
A m a n s lip s a n d s trik es
h is h e a d on th e floo r Th e d ire c t c a u s e s
o f th e ac c id e n t

H e w a s h u rryin g Th e re w a s o il o n Th e lig h tin g w a s p oo r -

th e flo o r h e d id n ot s e e th e o il

A1 A2 A3 B1 B2 B3 C1 C2 C3

U n d e rlyin g o r in d ire c t c au s e s

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

 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
 Module 03

Risk Management

© CHSS 2003
Ref: SC/086/V1
 Definitions
 Hazard

Something with the potential to cause harm.

 Risk
 The likelihood that the harm
will be realised.
 When assessing risks the
potential severity of the
consequences is also
considered.
© CHSS 2003
Ref: SC/086/V1
 Laws requiring risk
assessment
 Section 2(1) HASAWA 1974
 The Control of Substances Hazardous to
Health Regulations (COSHH) 1999
 The Control of Lead at Work Regulations 1998
 The Construction (Health Safety and Welfare)
Regulations 1996
 The Display Screen Equipment
(Health and Safety) Regulations
1992

© CHSS 2003
Ref: SC/086/V1
 5 Steps to Risk Assessment
 Look for the Hazards
 Decide who might be harmed and
in what circumstances
 Evaluate the risks, and the
adequacy of existing controls
 Record the significant findings
 Review the assessment

© CHSS 2003
Ref: SC/086/V1
 Step 1 - Identify the hazards

 A Hazard is something with the potential

to cause harm
 Physical

 Chemical

 Biological

 Ergonomic

 Psychological

© CHSS 2003
Ref: SC/086/V1
 Hazard Identification
Techniques
 Inspections
 HAZOP
 Job Safety Analysis
 Hazard Books and Contact Schemes
 Fault Tree Analysis Th e cau se of th e in ju ry
A m an slip s an d strikes
h is h ead on th e floor Th e d irect cau ses
of th e accid en t

H e w as h u rryin g Th ere w as oil on Th e lig h tin g w as p oor -

th e floor h e d id n ot see th e oil

A1 A2 A3 B1 B2 B3 C1 C2 C3

© CHSS 2003 U n d erlyin g or in d irect cau ses

Ref: SC/086/V1
 Step 2 - Decide who might be
harmed & how?
 Consider groups who may be
especially at risk
 the disabled, pregnant workers,
children and young workers

© CHSS 2003
Ref: SC/086/V1
 Step 3 - Evaluate the risks

 Consider the likelihood and severity

 Are existing controls adequate?
 Is there anything else that can be
done to make it safer (SFAIRP)?
 Are legal standards met and best
practice followed?

© CHSS 2003
Ref: SC/086/V1
 Risk Assessment Matrix
Severity of Outcome

Slight Serious Major

(1) (2) (3)

Likelihood Low
of Harm 1 2 3
(1)

Medium
2 4 6
(2)

High
3 6 9
(3)

© CHSS 2003
Ref: SC/086/V1
 Hierarchy of Control
Eliminate PPE
Reduce Discipline
Isolate
Safe Safe
Control Place Person

© CHSS 2003
Ref: SC/086/V1
 General Principles of Prevention
 avoiding risks;
 evaluating the risks which cannot be avoided;
 combating the risks at source;
 adapting the work to the individual
 adapting to technical progress;
 replacing the dangerous by the non-dangerous or less
dangerous;
 developing a coherent prevention policy, relating to the
working environment;
 giving collective protective measures priority over
individual protective measures;
 giving appropriate instructions to employees.

© CHSS 2003
Ref: SC/086/V1
 Step 4 - Record significant
findings
 You must decide what the significant
findings are, they may include;
 the significant hazards
 the existing control measures
 identification of workers affected
 reference to other guidance

© CHSS 2003
Ref: SC/086/V1
 Step 5 - Review the
assessment
 The assessment must be reviewed when:
 You believe it is no longer valid

 There has been a significant change in the

matters to which it relates.
• the workplace
• new work rates
• new process or plant
• competency of individuals
• new legal requirements

© CHSS 2003
Ref: SC/086/V1
 Nilsson v. Redditch Borough Council (1994) 12 CL 467, CA

A safe system of work

 “A safe system of work is a formal

procedure which results from a
systematic examination of the task in
order to identify all the hazards. It defines
safe methods to ensure that hazards are
eliminated or risks minimised.”
 Nothing is absolutely safe
 Nilsson v. Redditch Borough Council

© CHSS 2003
Ref: SC/086/V1
 Develop a safe system of work

 Analyse the task

 MEEP

• Materials
• Equipment and Plant
• Environment
• People

 Implement the system

 Monitor the system

© CHSS 2003
Ref: SC/086/V1
 Materials,Equipment,
Environment and People
Environment
Temperature,Lighting,
Noise,Ventilation etc.
People Equipment
Systems Design
Training Ergonomics
Skills Maintenance
Motivation Inspections
etc. Materials etc.
Use
Handling
Storage
Transportation
Disposal etc.

© CHSS 2003
Ref: SC/086/V1
 Permit to Work - Situations
High risk activities including
Confined space entry Just remember - the
failure to manage
permits has cost
Live working lots of lives in the
past - Piper Alpha,
Barry long Sea
Hot/Cold work Outfall,
Carsington...
Hazardous areas
Maintenance operations
Pressurised systems

© CHSS 2003
Ref: SC/086/V1
 Format of a Permit to Work

 Issue
 Receipt
 Clearance and return to service
 Cancellation
Just remember - the
failure to manage
permits has cost lots
of lives in the past -

 Extensions
Piper Alpha, Barry
long Sea Outfall,
Carsington...

© CHSS 2003
Ref: SC/086/V1