Accidents and incidents investigations

Purpose:

Every year people are killed or injured at work. Over 40 million working days are lost annually through work-related accidents and illnesses. Recent figures show that an average of 250 employees and self-employed peopleare killed each year as a result of accidents in the workplace.1 A further 150 000 sustain major injuries or injuries that mean they are absent from work for more than three days. Over 2.3 million cases of ill health are caused or made worse by work.

According to the Labour Force Survey, over 40 million working days are lost through work-related injuries and ill health, at a cost to business of £2.5 billion.

The same accidents happen again and again, causing suffering and distress to an ever-widening circle of workers and their families. The investigation and analysis of work-related accidents and incidents forms an essential part of managing health and safety. However, learning the lessons from what you uncover is at the heart of preventing accidents and incidents. Identify what is wrong and take positive steps to put it right. This guide will show you how.

Carrying out your own health and safety investigations will provide you with a deeper understanding of the risks associated with your work activities. Blaming individuals is ultimately fruitless and sustains the myth that accidents and cases of ill health are unavoidable when the opposite is true. Well thought-out risk control measures, combined with adequate supervision, monitoring and effective
management (ie your risk management system) will ensure that your work activities are safe.

An effective investigation requires a methodical, structured approach to information gathering, collation and analysis. The findings of the investigation will form the basis of an action plan to prevent the accident or incident from happening again and for improving your overall management of risk.

language of investigation:

Certain key words and phrases will be used regularly throughout this guide.

‘Adverse event’ includes:

• accident: an event that results in injury or ill health;
• incident:

near miss: an event that, while not causing harm, has the potential to cause injury or ill health. (In this guidance, the term near miss will be taken to include dangerous occurrences);
undesired circumstance: a set of conditions or circumstances that have the potential to cause injury or ill health, eg untrained nurses handling heavy patients.

Dangerous occurrence: one of a number of specific, reportable adverse events, as defined in the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR).

Hazard: the potential to cause harm, including ill health and injury; damage to property, plant, products or the environment, production losses or increased liabilities.

Immediate cause: the most obvious reason why an adverse event happens, eg the guard is missing; the employee slips etc. There may be several immediate causes identified in any one adverse event.

fatal: work-related death;

major injury/ill health: (as defined in RIDDOR, Schedule 1), including fractures (other than fingers or toes), amputations, loss of sight, a burn or penetrating injury to the eye, any injury or acute illness resulting in unconsciousness, requiring resuscitation or requiring admittance to hospital for more than 24 hours;

serious injury/ill health: where the person affected is unfit to carry out his or her normal work for more than three consecutive days;

minor injury: all other injuries, where the injured person is unfit for his or her normal work for less than three days;

damage only: damage to property, equipment, the environment or production losses. (This guidance only deals with events that have the potential to cause harm to people.)

causes of adverse events:

Adverse events have many causes. What may appear to be bad luck (being in the wrong place at the wrong time) can, on analysis, be seen as a chain of failures and errors that lead almost inevitably to the adverse event. (This is often known as the Domino effect.)

These causes can be classified as:

• immediate causes: the agent of injury or ill health (the blade, the substance, the dust etc);
• underlying causes: unsafe acts and unsafe conditions (the guard removed, the ventilation switched off etc);

root causes: the failure from which all other failings grow, often remote in time and space from the adverse event (eg failure to identify training needs and assess competence, low priority given to risk assessment etc).

To prevent adverse events, you need to provide effective risk control measures which address the immediate, underlying and root causes.