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Accident Investigation: In-depth
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Summary
Investigation of workplace accidents and incidents is an essential part of the proactive management of health
and safety. Trend analysis of and accurate information about previous accidents and near misses helps in the
development of improvement objectives to prevent them recurring.
Health and Safety Executive inspectors (or local authority Environmental Health Officers, depending on
jurisdiction) may also carry out an investigation of an accident within their enforcement powers.
This topic discusses what should be investigated and how an investigation should be carried out, and by
whom. It also delves into causation and the necessary training required to ensure those investigating are
competent to do so.
Employers' Duties
There is no explicit legal duty to investigate accidents but certain regulations do imply the need to carry out
accident investigations.
The Management of Health and Safety at Work Regulations 1999

(/reference-articles/law-and-guidance/legislation-tracker/management-health-and-safety-work#DCAM-234814)
imply that investigating the causes of workplace accidents is considered an essential part of good health
and safety management, and of the risk assessment review process. It forms the “check” part of the
Plan, Do, Check, Act approach in the HSE’s HSG65 Managing for Health and Safety.
The Social Security (Claims and Payments) Regulations 1987, as amended, require an employer to take
reasonable steps to investigate the circumstances of every accident that is reported. 
https://app.croneri.co.uk/topics/accident-investigation/indepth?product=140 1/37
Employees' Duties
Employees have a duty to co-operate with employers to enable them to fulfil their statutory duties under
the Health and Safety at Work, etc Act 1974
(/reference-articles/law-and-guidance/legislation-tracker/health-and-safety-work-etc-act-1974-5#DCAM-234835).
This would include reporting:
dangerous occurrences
near misses and accidents whether or not they resulted in injury, damage or disease.
Employees are also required to co-operate in an investigation.
In Practice
Requirements for Investigation
Investigating the cause of accidents is good practice, even though this investigation is only required by a
limited selection of health and safety legislation.
The Health and Safety Executive (HSE) publishes guidance on accident investigation, HSG245 Investigating
Accidents and Incidents — A Workbook for Employers, Unions, Safety Representatives and Safety
Professionals (/topics/accident-investigation/indepth#DCAM-239009).
As a very basic guide to investigation, the guidance features four steps.
1. Gathering information.
2. Analysing information.
3. Identifying risk control measures.
4. Producing and implementing an action plan.
Three levels of accident causation (/topics/accidents-causes-and-prevention/quickfacts#DCAM-2679504) are

identified through this guidance.
1. Immediate causes.
2. Underlying causes.
3. Root causes.
Legal Requirements
A number of statutory instruments place duties on certain sectors of industry to undertake accident
investigations in certain circumstances. These include:
Ionising Radiations Regulations 2017
Railways (Safety Case) Regulations 2000 

Control of Major Accident Hazards Regulations 2015
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR), as it applies
to railways and mines and quarries
Nuclear Installations Act 1965
Safety Representatives and Safety Committees Regulations 1977.
Where no special provision is made, any requirement to investigate accidents is therefore implicit.
The Safety Representatives and Safety Committees Regulations 1977 (as modified by the Management of
Health and Safety at Work Regulations 1999, regulations 7(1) and 8(1)) provide for safety representatives to
investigate potential hazards and dangerous occurrences and to examine the causes of accidents at the
workplace. While employers are required to assist the safety representatives undertaking this function they do
not have any duty imposed on themselves to investigate.
Death or other serious incidents in the workplace may be investigated by the police — in England and Wales
there is a protocol between the Crown Prosecution Service and the HSE. Similar arrangements exist in
Scotland, where the criminal justice system is administered differently.
What Should be Investigated?

Ideally, investigation and review should take place for all accidents and incidents but in practice this is not
always possible. It is important that organisations take a sensible and proportionate approach to the
investigation of accidents, in which case it may not be necessary to fully investigate minor and trivial accidents.
An organisation’s procedures for accident investigation should include a procedure for deciding which
accidents will be investigated and which will not. It may be helpful for organisations to develop a simple “risk
matrix” (such as outlined in the HSE’s HSG245 Investigating Accidents: A Workbook for Employers, Unions,
Safety Representatives and Safety Professionals) to help decide which accidents should be investigated or at
least to help prioritise investigations.
Investigations should always take place for incidents arising in a high-risk environment where risk control
measures need to be robust. High risks may result from the use of equipment or plant, the use of hazardous
substances or work in certain places such as confined spaces.
It is important that near misses with the potential for injury are investigated. These are incidents where an
unplanned event occurs for which there is no resultant injury or damage, but the potential exists for harm to
result if the event occurred under different circumstances.
The time and effort put into the investigation may vary considerably according to the potential severity of injury
and/or damage. Significant incidents will usually require a written report although there may be no need to
document the results in very minor cases.
What Will an Investigation Achieve?

There is a need for both managers and workers to understand why certain events and outcomes occurred,
even if the severity or consequences of the accident were comparatively minor on that occasion. This will aid
preventing a recurrence of such events.
Employers must be in a position to justify their assessments of risks and any action they have taken or intend
to take after an accident, including the review of any relevant risk assessment. This can only be achieved by
adequate and robust accident investigation.
Accidents cost money; understanding the causes of accidents can assist in preventing unnecessary loss as
well as providing cost-effective solutions.
Many events will have to be reported to the relevant authority under the provisions of RIDDOR. The existence
of a process of accident investigation will enable a better understanding of the events reported. This can
greatly assist in dealing with any enquiries made by the enforcement agencies or in any subsequent
investigation undertaken by an enforcing authority.
The benefits to employers who undertake accident investigation include:
a better understanding of risk and provision of information for use in risk assessment
reducing the risk of accidents and incidents in the future
a powerful vehicle for motivating organisational learning and activating cultural change
a means of understanding and obtaining information on management systems
a useful means of demonstrating the status of safety management in an organisation which in turn can
be used to assist in litigation claims and developing arguments for lowering insurance premiums
providing evidence of any discrepancy between what should be in place, eg safe systems of work
(/topics/safe-systems-work/quickfacts), and what is actually happening.
Cultural Aspects
At the cultural level, if the idea is held that accidents are always a result of negligence and that somebody (an
individual) is always to blame then the progress of the investigation and its outcomes will be limited. A positive
culture of enquiry and continual improvement is more likely to lead to frank and thorough approaches to
investigation.
Prerequisites for Investigation

Before any accident investigation is undertaken, it is essential that the organisation is prepared for both the
process of the investigation and the results of the investigation. Further information on pre-planning is given in
BS 45002-3: Occupational Health and Safety Management Systems — General Guidelines for the Application
of ISO 45001. Part 3: Guidance on Incident Investigation. Specific arrangements include:
selection and training of investigators, taking into account the need for workforce collaboration
assessing what should be investigated in terms of legal requirements and organisational needs

establishing the arrangements for investigations as part of the health and safety policy, including
notification arrangements
the process for reporting and the on-going monitoring of the implementation of recommendations
(remedial treatment).
Accident Investigation Policy

The extent of the policy and the requirements provided by it will depend on the nature and size of the
organisation, as well as the hazards and risks likely to be encountered in the workplace.
The policy should cover:
the responsibilities for accident investigation, including co-operation between various units of
management, as well as trade union safety representatives or other employee representatives (where
they exist)
the support in terms of resources, facilities and personnel that will be or can be made available — this
should include expert assistance where this is foreseeable
the competencies of those tasked with investigation, including training arrangements and skills
development
notification of next of kin, relatives, etc and the support arrangements for dealing with the more traumatic
events
dealing with the media and designating the individuals who should handle such enquiries
dealing with the enforcement authority, especially the identification of those persons with authority to
speak for the organisation and how this should be carried out.
Linking the policy requirements to the legal duties to report accidents under the provisions of RIDDOR will
ensure that, RIDDOR reportable events will be reported.
Who Should Investigate an Accident?

There are differing views on who is best suited to undertake accident investigations. Ideally investigation is
undertaken by a team rather than an individual, but the size of the team is best determined by the complexity
and potential risk associated with the events.
A team comprising safety practitioners and line managers will provide an adequate balance, providing they
have been suitably trained. It is also helpful to include those who can give practical expertise such as those
who routinely perform the work or processes.
In all cases, a properly trained safety professional can act as the focal point for the selection and direction of
investigation methods and processes. In addition, the skills and knowledge of specialist staff or consultants
may be used in the investigation process.

At least one workforce representative should be involved in the investigation. The level of involvement of
various staff is often dependent upon the organisational arrangements, the type of incident and the potential
risk associated with the incident (eg injuries or damage that reasonably could have occurred).
Great care must be taken to ensure that investigators are not hampered or influenced by internal pressure
from within the management structure. Some organisations prefer to use outside consultants for this reason.
Accident Investigation and Who Becomes Involved When
Staff at supervisory When an incident is reported to them by an employee under their

level supervision, which the employee believes indicates the presence of any
danger to persons, plant or equipment.
Staff at managerial When an incident occurs within the manager’s area of responsibility
level involving the failure of or damage to any part of the premises, plant,
equipment, tool or substance.
When an incident occurs in which an employee or other person within the

manager’s area of responsibility has suffered death or injury.
When an incident occurs within the manager’s area of responsibility which

could have led to the death or injury of persons or to the failure/damage of
any company property.
Health and safety Incidents to be reported to the enforcement authority.

advisor/manager
Incidents involving the death of, or personal injury to, anyone doing
anything with or in relation to any activity carried out by the company.
Incidents which a department manager believes could have led to the

death of, or personal injury to, any person.
Specialists and When specific skills, specialist knowledge or experience are required to
consultants carry out an effective investigation.
Staff representative Any incident in which a member of staff that they represent is involved.
Investigations by Inspectors
An enforcement authority inspector may:
carry out an examination and investigation
direct that the premises or any part of them, or anything on the premises, should be left undisturbed for
the purpose of any examination or investigation

take measurements, photographs and recordings
take samples of any articles or substances
dismantle and/or test any article or substance found in any premises
secure possession of any article or substance for use as evidence
require any persons to give any information relevant to an investigation including giving a statement
which may later be used in legal proceedings
require the production of any books or documents
ask to be afforded such facilities and assistance as are necessary.
If an enforcement officer has carried out a separate accident investigation, it may be appropriate to let them
know the outcome of the company’s own investigation. However, legal advice should be sought before
disclosing this information.
Stages in an Investigation
There are various models which attempt to describe the stages of an accident investigation. They all have the
same principles and commence with the site of the accident itself.
Ensure the site of the accident or incident is safe for the investigation team.
Contain and preserve the evidence.
Carry out initial investigations.
Identify reference material such as procedural documents, training manuals, risk assessments, etc.
Interview witnesses.
Examine equipment, materials, plant and machinery.
Collate evidence and any other relevant information, eg maintenance records, training records.
Share lessons learned from accidents and incidents across sites.
Write a report detailing the findings and drawing conclusions.
Checklist for Accident Investigation

A typical checklist for accident investigation will include the following.
1. Collect, protect and secure evidence, eg:
photographs/video recordings
plan of the scene
list of witnesses
list of equipment and plant
seek forensic/scientific expertise 

take samples
measure distances/sizes
institute immediate control measures.
2. Identify and locate relevant documents, such as:
procedures
manufacturer's/supplier's information
maintenance/service records
training records and content
risk assessments.
3. Interview arrangements:
venue
time/schedule
take statements.
4. Administration backup:
control documents
list witnesses/statements
maintain file
record methods used and maintain results/charts, etc
notification.
Evidence collection
It is vital that the scene of an accident is left undisturbed (once any significant residual risks have been
controlled) until the investigation has been completed or at least until all the physical evidence has been
gathered and accurately recorded.
The earlier an investigation begins, the less chance there is of evidence being destroyed and the scene of the
accident being disturbed. It will not always be possible to interview all witnesses immediately after an event,
but there is great merit in completing the information-gathering process as soon as possible after an accident
has taken place.
When deciding on the amount of resources to commit to any investigation, it is helpful at an early stage to
review the relevant risk assessments in the light of the accident or incident. For example, it may be quite
apparent which risk factors within the earlier assessment should be focused on in any further investigation, or
the discovery of a mistake in the assessment may save time in investigating why certain measures had failed.
The investigator(s) should keep an open mind and not be unduly influenced by what should have happened as
it is important to determine what actually happened. It is important to remember that apportioning blame is not
an objective of the investigation. This may arise as part of the investigation findings, but should not be
emphasised at this stage.

For reasons of safety, only the absolute minimum number of people should be allowed into the accident scene
area. They must be made aware of the unique circumstances that exist during the very important period of time
immediately after the occurrence of an accident.
The following flowchart highlights the normal activities to be undertaken in an investigation.
Figure 1: Procedure to Follow in an Accident Investigation
Witnesses
Anyone who has seen or partly seen the events leading up to or taking place during the accident should be
interviewed to determine what they saw and/or heard. Wherever possible, the investigation method should
provide for confirmation of any evidence — especially any human witness evidence received.
It is useful to use a plan or outline of the area and equipment, etc involved, as well as any available
photographs to prompt the memory processes and assist in locating the evidence both spatially and
temporally.
Witnesses should be handled with care. If traumatised by the incident, it is generally better to obtain just
overview impressions early on, eg by asking witnesses to briefly write down where they were and what they
were doing at the time of the event. They can then be interviewed in depth later on when they have had time to
adjust to the circumstances and reflect on the situation.

Information required
The information required during an accident investigation will include:
location, time and date of the incident
details of persons involved, including any witnesses
details of injuries and ill health
damage to plant and equipment
work activities performed at the time of the incident
control measures and systems of work employed
working conditions at the time of the incident (eg ground conditions, weather, lighting and heating)
the sequence of events leading to the incident
organisational arrangements such as supervision, staff training and work demands (eg production
targets)
the maintenance and cleaning procedures adopted
materials and substances involved
safety equipment that was employed.
To collect this information the investigator will need to:
carry out a visual examination of the scene of the accident or incident
carry out a visual examination of tools and equipment involved
take samples from substances or materials involved
inspect relevant documentation (/topics/accident-investigation/indepth#DCAM-2760627)
interview the injured person, witnesses or others who may have relevant information.
Photographs, videos, sketches and plans are a useful method of recording the physical evidence and
conditions at the location. Samples may also be taken and equipment removed for further investigation and
examination.
Equipment, plant, machinery and other physical examination

Any equipment, etc involved may need to be examined to determine what part it played in the accident. In
some cases, this may not be easily determined in the early stages of the investigation and it is generally good
practice to undertake such examinations as early as possible, even though subsequently the evidence may be
discounted. This is especially so in those cases where evidence may be lost because the plant has to be
brought back on line or destruction has to take place to secure safety, as in the case of a partially collapsed
wall.
Detailed photographs, technical reports and sample examinations may be required and prove useful at a later
stage in the investigation. Expert assistance may be required for this.

When such examinations are undertaken, it is important to advise the supplier/manufacturer of the details of
the examination and invite them to observe this if they so wish. At all times the liabilities of suppliers and
manufacturers must be considered.
This has an important bearing on any action that might subsequently be taken for breaches of contract or third-
party actions.
The Analysis of Evidence

The analysis of evidence is based on the methods employed in any investigation. A number of methods are
available. It is essential to use a robust method to achieve:
a good understanding of the sequence of events and circumstances involved in the accident
the collection, collation and analysis of evidence.
Before being able to say what caused any accident or what gave rise to the circumstances in which an
accident occurred, it is necessary to know, as far as possible, the sequence of events leading up to and
including the observable outcome(s). This is regardless of whether the outcome was a minor injury, a major
injury or a fatality.
In fairly simple accidents, the sequence may be derived from the collation of witness statements and writing
down a commentary of the accident events as if replaying them. For anything more than the simple cases it is
important to have a rigorous methodology to analyse the sequence of events. Information obtained in any
investigation may sometimes be contradictory, the observations of witnesses are subject to vagaries and
inconsistencies and the information provided must be checked and cross referenced for verification wherever
possible.
A method based on sequential timed event plotting (STEP) for devising a sequence of events may be helpful to
investigators. A timeline is constructed which “maps” the sequence of events, from a point prior to the accident
to a point considered by the investigator to be the last evidence necessary to explain the events which have
occurred.
A plot is made listing all the witnesses and “players” in the accident down the side. Across the top, the times at
which various events occurred or were seen are listed in sequence. This type of event plotting not only assists
in determining a clear picture of the sequence but also provides a means of ascertaining corroboration of
evidence and the identification of further areas for investigation.
Drawing Conclusions
The major purpose of accident investigation is to establish what has happened in order to reduce the risk of
recurrence. The conclusions arising from any accident investigation must be presented in a form which allows
management to create appropriate action plans.
In drawing conclusions, the apportioning of blame should be avoided. The results of investigations should
solely be to create opportunities for prevention and identify causes for which a solution can be found. Reports
and their conclusions should be concise, clear and relevant. 
One particular conclusion that must be drawn is the underlying, or root cause of the incident. The HSE has
published a comprehensive literature review on the use of root cause analysis techniques — Contract
Research Report CRR325/2001 Root Causes Analysis: Literature Review. The report outlines the principles,
structure and application of each identified technique and groups these into classes.
Investigation Documentation
During any investigation, it is important to have adequate administration procedures in place that can keep
control of any documentation produced. This will include witness statements, information on items of plant and
equipment, etc and any communication with employee safety representatives and enforcement officers. It is
also important to keep track of any briefings held with senior managers and any details provided to the press
and other outside bodies.
The continuity of evidence is maintained if a written statement is provided each time an item of evidence is
collected or passed from one person to another, eg an item of equipment given to a specialist technical
examiner.
Relevant documentation
There are many pieces of documentation that may be helpful in accident investigations and these may include
the following.
Risk assessments of the work carried out at the time of the accident.
Training records for the work being done.
Safe working procedures or safe operating procedures relating to the activity.
Method statements (if applicable).
Any special arrangements in place, such as permits to work or emergency safety procedures.
Commissioning, repair and maintenance records for any machinery or equipment being used at the time
of the accident.
Personal protective equipment (PPE) records.
Personal records for the individuals involved, such as health, discipline, etc.
Clock cards or other time-recording records.
A computer audit trail to pinpoint specific timings relevant to the accident.
Telephone records (where available) indicating calls made from particular extensions (especially useful
to establish the time the accident was reported).
Investigation Interviews
Interviews should be conducted in a very positive manner with utmost care for the witness, especially where
they may have been traumatised by the event. 
It is best to start by allowing the witness to describe events as they remember them before asking questions.
Questioning should be “open” so as to assist the witnesses to give their evidence. Leading questions should
be avoided. It does not necessarily matter that facts are given out of sequence providing that the sequence
itself can be pieced together. It is generally better to let witnesses tell their own story assisted by questions,
such as:
what happened next
what did you see
could you explain that?
Interviews should be conducted separately and as privately as possible. Interviews should be held as soon as
is practicable after the event being investigated. It may be useful to have available photographs/sketches of
the scene so that witnesses can relate themselves to it and locate themselves with respect to the accident and
the events.
The interviewer must bear in mind that not all witnesses will have an accurate memory of the incident or be
helpful and co-operative. Some may be hostile, and deliberately misleading. Some may be trying to pursue a
false claim or be attempting to cover up their own actions involved in the accident or be worried that they are
getting a colleague in trouble. Those being interviewed may wish to be accompanied by a colleague or
representative and this should be permitted.
When performing an investigation interview, the following three guiding principles should be followed.
1. Be sure of the purpose of the interview. When interviewing an individual, determine what aspects of the
investigation they will be able to assist with and structure the interview questions to ensure that the
nature and amount of information they provide is relevant.
2. Keep an open mind. Assumptions as to the cause of any accident should be avoided.
3. Get the person to talk. The interviewer must appreciate the pressures that they may feel during a formal
interview.
In the interview, investigators should:
show concern
explain clearly to the witness the nature and purpose of the interview
establish the facts surrounding the accident, for example find out:
what normally happens
what procedures are in place
who is responsible for them
establish the sequence of events on the day of the accident
start the questioning with a general, easy, open question (eg “Please could you tell me what happened
on the day of the accident?”)
follow up by asking a more detailed question relating to a specific part of the answer (eg “Could you tell
me a little more about the way the machinery in question functions?”) 
probe the answer to check factual details (eg “So was the noise that you describe normal?”)
then ask more about specific detail (eg “Was the guard fitted to the machine?”)
summarise and seek agreement (eg “So it was normal for two people to operate the machine, but on
that day you were on your own, the machine started making a funny noise and one of the guards was
missing — is that right?”)
start the sequence again but relating to a different topic
explain when closing that the witness can come back to the investigator if they think of any further
information, and that investigators may need to go back to cross check information with the witness from
other sources
close on a positive note by thanking any witness for their time and help.
Statements should be signed by the witness with the date and time of the interview included.
Determining the Accident/Incident Causes

By careful analysis of the information collected, the investigator (or team) will be able to identify the causes of
the accident. The causes that lead directly to the accident or incident are called the immediate causes.
According to the HSE, immediate causes can be placed into four sectors as follows:
1. Place or premises where the incident occurred. Causes under this heading will include:
inadequate access and egress
workplaces that are unsuitable (eg due to lack of space) or are being used incorrectly
poor work environment and ergonomics
poor segregation of people from hazards
lack of warning signs and information.
2. Plant, equipment and substances. Causes under this heading will include:
use of unsuitable plant, equipment and substances
poor maintenance of plant and equipment
improper use and poor guarding of plant and equipment
misuse and poor storage of substances and materials
incorrect or lack of personal protective equipment

(/topics/personal-protective-equipment-principles-use/quickfacts).
3. Process and procedures. Causes under this heading will include:
safe working procedures not being in place or out of date or inadequate
lack of supervision of procedures
lack of training in procedures and processes.
4. People involved. Causes under this heading include: 

use of unsuitable staff
use of poorly trained and supervised staff
deliberate violation of procedures by those involved
lapse due to fatigue, poor motivation, distraction, pressure of work, etc.
Secondary causes
Underlying causes are the unsafe acts or conditions that lead directly to each immediate cause and are
sometimes called the secondary causes. These can be grouped under the following headings.
1. Control
Was there a lack of supervision and monitoring?
Were people held accountable for their performance?
Were contractors controlled?
2. Co-operation
Were staff and their representatives involved in ensuring health and safety?
Was information shared among those involved in the accident?
3. Communication
Were duties and responsibilities set out and understood?
Was information passed on in respect of health and safety?
Were written safe procedures available?
How good was internal communication?
4. Competence
Were those involved competent?
Was suitable safety training provided?
Was training effectively delivered?
Was the competence of contractors checked?
5. Design
Were the workplace, equipment and controls well designed and set out properly?
6. Implementation
Were suitable and sufficient plant, equipment and materials available?
Was suitable labour available?
Were cleaning and maintenance arrangements adequate?
Were there adequate means to report defects, near-misses, safety concerns, etc?
Was there adequate monitoring and health surveillance? 

7. Risk assessment
Were adequate assessments carried out?
Were controls in place as a result of the assessment?
The use of an investigation checklist (/topics/accident-investigation/resources#DCAM-244370) may assist in

answering these questions.
Root causes
The root causes relate to organisational and management control of health and safety; these allow the
underlying and immediate causes to occur. Common examples are:
poor communication
lack of management commitment (often demonstrated by a lack of resource provision).
It is vital to drill down to identify root causes during an investigation, because if corrective actions can be
effectively implemented, these are likely to reduce the risk of future harm throughout the organisation.
Identifying causes
Causes are identified when an analysis of the accident is made using a number of available methods to
ascertain the various factors involved. A good understanding of the sequence of events and an overview of all
the evidence is necessary for success. The causes of an accident will include immediate, underlying and root
causes. The extent to which these are analysed will depend both on the experience and skills of the
investigator, as well as the policy and approach adopted by the organisation. It is essential that the
root/underlying causes of the incident are identified and dealt with otherwise it is likely that the immediate
causes will reoccur in the future.
Report of Accident Investigation Findings

The initial details of any accident should be recorded in the accident book.
The investigation report supplements this, although the amount of detail required in a report depends upon the
severity or potential severity of the outcome, and the use made of the investigation and report.
The report should contain:
time, date and location of the accident/incident
a summary of what happened
a summary of events leading up to the accident
information collected during the investigation
details of those injured, those who assisted and witnesses
details of the outcome of the accident (ie injury, loss or damage)
conclusions including the causes of the event and probability of recurrence 

recommendations and costing of remedial actions
supporting material (copies of witness statements and interviews, photographs and sketches)
the date of the investigation
the signature of the person carrying out the investigation.
Additional information may be requested to facilitate notifications within and outside the company (eg relatives,
the HSE, insurers and, if applicable, the police).
The results of the investigation should be widely circulated (taking into account the General Data Protection
Regulation) to ensure that there is no risk of a recurrence of a similar incident in other areas of the operation.
Copies of the investigation findings may need to be circulated to a number of different parties as follows:
managers, supervisors, employees and other departments who have similar equipment or processes
maintenance or engineering departments who may have to carry out repairs and/or modifications
planning or production control departments who may have to change job instruction or control
documentation
HR/training departments who may need to implement new or refresher training
the safety department for inclusion in statistical reports and review of safety procedures
the department responsible for keeping incident records, completing statutory reports and notifying the
organisation’s insurers
safety representatives and safety committee members
the employee or employees who were involved in the accident
the organisation’s insurer.
The accident investigation policy (/topics/accident-investigation/accident-investigation-policy#DCAM-242631)

should specify who is to receive copies of the report. The investigation team will determine who else needs to
receive copies or other information relevant to the incident.
In the main, the findings will be communicated in writing but in certain cases it can be verbal, ie briefings for all
other employees.
It is recommended that the accident report and investigations should be kept for at least 3 years or, if exposure
to substances has occurred, for at least 40 years.
Remedial Action Following Accident Investigation

Actions should be taken to remedy all of the identified deficiencies. If the actions are not completed, all the
resources invested during the investigation have been wasted.
When remedial action is required to prevent recurrence, staff should be fully consulted on any issues that will
impact on the activities taking place. Information, instruction and training in any additional control measures,
systems of work or protective equipment will have to be considered, along with the potential costs of the
remedial action. 
It is essential that progress on the identified remedies is closely monitored to ensure that they do not get
unnecessarily delayed or even forgotten. There should be a follow-up review to ensure that the actions taken
are effective and do not create other unforeseen hazards.
Records (/topics/accident-investigation/resources#DCAM-244370) should be kept of all investigations and any

existing remedial action.
Management Monitoring
Senior managers should monitor the accident and incident investigation procedures. In particular they should:
receive regular reports the progress of remedial action s following investigation report recommendations
review “trend analysis” of previous accidents/incidents that may highlight the need for wider systemic
changes
ensure that investigation procedures are subject to necessary audits and reviews.
Training
It is important that any investigator should be well trained and have sufficient authority to be able to undertake
investigations.
As a minimum, this training should address the principles of investigation and provide skills in both the
methodologies and the techniques of investigation.
The training provided to those who will carry out an investigation should cover:
the purpose of an investigation
the accident and near-miss investigation policy and procedures
roles and responsibilities of those expected to carry out investigations
the information that needs to be gathered and recorded following an accident
interview techniques
the main theories of accident causation and an understanding of basic, underlying and root causes of
accidents
the role of human factors in accidents
report-writing techniques.
A record of staff who are trained to carry out accident investigations should be maintained.
List of Relevant Legislation

Health and Safety at Work, etc Act 1974

(/reference-articles/law-and-guidance/legislation-tracker/health-and-safety-work-etc-act-1974-5#DCAM-234835)
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013

(/reference-articles/law-and-guidance/legislation-tracker/reporting-injuries-diseases-and-dangerous-1#WKID-
201306271133420692-85882059)
Social Security (Claims and Payments) Amendment Regulations 2013
Management of Health and Safety at Work Regulations 1999

(/reference-articles/law-and-guidance/legislation-tracker/management-health-and-safety-work#DCAM-234814)
Social Security (Claims and Payments) Regulations 1987
Health and Safety (First-aid) Regulations 1981

(/reference-articles/law-and-guidance/legislation-tracker/health-and-safety-first-aid-regulations-1981#DCAM-
234773)
Safety Representative and Safety Committee Regulations 1977

(/reference-articles/law-and-guidance/legislation-tracker/safety-representatives-and-safety-committees#DCAM-
234772)
Further Information
Publications
HSE Publications
The following are available from the HSE website (http://www.hse.gov.uk).
CRR325/2001 Root Causes Analysis: Literature Review
CRR344/2001 Accident Investigation — The Drivers, Methods and Outcomes
HSG48 Reducing Error and Influencing Behaviour

(https://app.croneri.co.uk/system/files/hsop-hsg_0048_14674.pdf)
HSG65 (https://app.croneri.co.uk/system/files/hsop-hsg_0065_12882.pdf)Managing for Health and Safety

(https://www.hse.gov.uk/pubns/priced/hsg65.pdf)
HSG245 Investigating Accidents and Incidents: A Workbook for Employers, Unions, Safety
Representatives and Safety Professionals (https://app.croneri.co.uk/system/files/hsop-hsg_0245_23192.pdf)
L146 Consulting Workers on Health and Safety. Safety Representatives and Safety Committees
Regulations 1977 (as amended) and Health and Safety (Consultation with Employees) Regulations
1996 (as amended). Approved Code of Practice and Guidance
(http://www.hse.gov.uk/pUbns/priced/l146.pdf)
Other Publications
Civil Procedure Rules, Ministry of Justice

Guidance on Investigating and Analysing Human and Organisational Factors Aspects of Incidents and
Accidents, Energy Institute
BS 45002-3 Occupational Health and Safety Management Systems — General Guidelines for the
Application of ISO 45001. Part 3: Guidance on Incident Investigation
Organisations
Health and Safety Executive (HSE)
http://www.hse.gov.uk (http://www.hse.gov.uk)
The HSE is responsible for the regulation of the risks to health and safety arising from work activity in
England, Scotland and Wales, except in certain businesses (regarded as lower risk), which are the
responsibility of local authorities. Its roles are to prevent work-related death, injury or ill health.
Health and Safety Executive for Northern Ireland (HSENI)

http://www.hseni.gov.uk (http://www.hseni.gov.uk)
The HSENI is responsible for the regulation of the risks to health and safety arising from work activity in
Northern Ireland.
Royal Society for the Prevention of Accidents (RoSPA)

https://www.rospa.com (https://www.rospa.com)
RoSPA is a registered charity that provides information, advice, resources and training in order to
promote safety and prevent accidents in all areas of life. Members can gain access to a wide range of
published guidance, including an extensive library of safety reports and RoSPA’s journal, Occupational
Safety and Health (OSH).
Last reviewed 23 February 2022
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
This page covers
Summary
Employers' Duties
Employees' Duties
In Practice
Requirements for Investigation
What Should be Investigated?
Prerequisites for Investigation
Accident Investigation Policy

Who Should Investigate an Accident?
Investigations by Inspectors
Stages in an Investigation
Checklist for Accident Investigation
The Analysis of Evidence
Drawing Conclusions
Investigation Documentation

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The Management of Health and Safety at Work Regulations 1999

Employees are also required to co-operate in an investigation.

As a very basic guide to investigation, the guidance features four steps.

3. Identifying risk control measures.

4. Producing and implementing an action plan.

Three levels of accident causation (/topics/accidents-causes-and-prevention/quickfacts#DCAM-2679504) are

Ionising Radiations Regulations 2017

Railways (Safety Case) Regulations 2000 

Control of Major Accident Hazards Regulations 2015

Nuclear Installations Act 1965

Safety Representatives and Safety Committees Regulations 1977.

What Should be Investigated?

What Will an Investigation Achieve?

The benefits to employers who undertake accident investigation include:

reducing the risk of accidents and incidents in the future

a means of understanding and obtaining information on management systems

Prerequisites for Investigation

Accident Investigation Policy

The policy should cover:

Who Should Investigate an Accident?

Accident Investigation and Who Becomes Involved When

Staff at supervisory When an incident is reported to them by an employee under their

When an incident occurs in which an employee or other person within the

When an incident occurs within the manager’s area of responsibility which

Health and safety Incidents to be reported to the enforcement authority.

Incidents which a department manager believes could have led to the

carry out an examination and investigation

take measurements, photographs and recordings

take samples of any articles or substances

dismantle and/or test any article or substance found in any premises

secure possession of any article or substance for use as evidence

require the production of any books or documents

ask to be afforded such facilities and assistance as are necessary.

Contain and preserve the evidence.

Carry out initial investigations.

Examine equipment, materials, plant and machinery.

Share lessons learned from accidents and incidents across sites.

Write a report detailing the findings and drawing conclusions.

Checklist for Accident Investigation

1. Collect, protect and secure evidence, eg:

plan of the scene

list of equipment and plant

seek forensic/scientific expertise 

institute immediate control measures.

2. Identify and locate relevant documents, such as:

training records and content

record methods used and maintain results/charts, etc

The following flowchart highlights the normal activities to be undertaken in an investigation.

Figure 1: Procedure to Follow in an Accident Investigation

location, time and date of the incident

details of persons involved, including any witnesses

details of injuries and ill health

damage to plant and equipment

work activities performed at the time of the incident

control measures and systems of work employed

the sequence of events leading to the incident

the maintenance and cleaning procedures adopted

materials and substances involved