NVQ Study Guide for

City & Guilds NVQ Diploma in Occupational Health and

Safety

Knowledge Unit A 5
Managing Health & Safety
Loss Causation & Incident Investigation

Written by Mr Darren Platts CMIOSH MCMI

CEO Ordosafe Consultants

Edited & Unitised by Mike Watson CMIOSH Dip RSA MIIRSM FlnstLM
Chairman Specialist Vocational Training Ltd

1
 Element A 5 :

Loss causation and

incident
investigation

Unit A:
Managing Health & Safety 2 December 2016
Element A5: Loss causation and incident investigation
Learning Outcomes
Upon completion of this element, you should be able to:

 Outline the theories/models and use of loss causation techniques

 Explain the use of quantitative methods in analysing loss data
 Explain the significance and use of statutory and internal reporting of loss events
 Explain the reasons for loss and near miss investigations and the procedures to be followed
References used for this element and further reading

Statutory instruments
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013
Link:
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (Northern Ireland) 1997 (as
amended)
Link:
Other relevant references
Bird F E, 1974. Management guide to Loss Control, Institute Press, Atlanta, Georgia, USA
Link: N/A
Reporting accidents and incidents at work, INDG453
Link:
Investigating accidents and incidents – a workbook for employers, unions, safety representatives and safety
professionals, HSG245
Link:
Other references/ websites

http://www.cgerisk.com/knowledge-base/risk-assessment/the-bowtie-methodology
OHS Body of BoK Knowledge - Models of Causation: Safety, Australia
http://www.ohsbok.org.au/wp-content/uploads/2013/12/32-Models-of-causation-Safety.pdf
http://www.hse.gov.uk/humanfactors/topics/core2.pdf

INTRODUCTION
It is quite likely at some stage or another that an organisation may be faced with an incident or accident. If,
and when they are, it is key that they understand the methods for carrying out a thorough investigation.
During this element, we will look at the methods you can use to assist you when analysing and comparing loss
and incident data, and look at the ways in which the information can be represented. We will also look at the
different methods for investigating incidents to identify the root causes.

DEFINITIONS
Accident

An unplanned, unwanted event which resulted in loss. Loss is not just confined to personal injury, this could
extend to loss of revenue.

Near Miss

An unplanned event that could have but did not result in injury, illness or damage but had the potential to do
so.

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A5.1 THEORIES, MODELS AND THE USE OF LOSS CAUSATION TECHNIQUES
Accident ratio studies, their use and limitations

In 1969 Frank E Bird Jr. conducted a study of industrial accidents based on previous research conducted by
H.W. Heinrich. The result was the following ratio triangle:

Serious or disabling injury

1
Minor Injuries (First aid)
10
Damaging accidents
30
600 Accidents with no damage and near miss accidents

Heinrich’s Accident triangle

Major or lost time

1
Minor
29
300 No injury accidents

What does this triangle ratio represent and show?

 Near misses and non-injury accidents can be useful in assisting to predict an organisation accident
potential.
 For every fatality, there are multiple major injuries and a larger multiple of less serious injuries.
Some triangles show minor injuries and no injury accidents (near misses),these are again
multiples of the category immediately above them.
 That near miss and minor accidents can predict more serious accidents and therefor should be
investigated.
 All these events are failures of control, and so by investigating them we can learn from them and
prevent more serious accidents as a result.
There are several limitations to this data that should also be considered:

 We must see that not every occurrence has the potential to be a fatality or a major accident.
Problems can arise when using ratios as a means of predicting an organisations accident rates and
comparing its performance against others.
 For the triangles (ratios) to work effectively you need data that is representative of a large group. If
you only have a small organisation, then this statistic may not be of use and may not allow for a useful
conclusion to be draw.

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BIRDS DOMINO AND MULTI-CAUSALITY THEORIES

Herbert William Heinrich developed his original theory in 1929 called the domino theory. This theory has
been modified and expanded and shows accident causation labelled on five ‘dominos’. The original theory
was modified by Bird and Loftus in 1974 to include the role of management. This revised model of the theory
takes the stand that incidents begin by a lack of management control.

Bird and loftus suggested a different sequence of events:

I. Lack of management control

II. Basic underlying causes
III. Immediate causes
IV. Accident
V. Resulting in loss
ACCIDENT DOMINO SEQUENCE – Bird & Loftus

Heinrich and Bird suggest that an injury that is preventable is the culmination of a sequence of events or
circumstances that happen in a certain order. In the image above, imagine that the left domino falls to the
right, this would cause the next one to fall until all dominos have fell. The theory suggests that if one element
is removed then the sequence or chain of events would be halted.

Let us use this analogy in terms of an accident sequence. If one of the factors above was eliminated from the
sequence, then theoretically there would be no loss occurrence as an accident would have been prevented.

Now consider how to eliminate an accident and loss event from happening using the theory and the factors
within. Probably the most effective factor in the theory to consider for control would be the immediate and
underlying causes. Immediate causes can be better defined as unsafe acts and unsafe conditions.

Immediate Causes

Unsafe acts

Unsafe acts are behaviours of individuals that can be both errors or violations arising from lack of skill,
knowledge, boredom, distractions etc. A more specific definition is that an unsafe act is any act that deviates
from a generally recognised safe way or specified method of doing a job and increases the potential for an
accident.

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Example of Unsafe Acts:

 Using unsafe equipment

 Horseplay (fooling around)
 Failure to lockout/tagout
 Failure to wear PPE
 Disabling safety devices
Unsafe conditions

An unsafe condition is an unsatisfactory physical condition existing in a workplace environment immediately

before an accident that was significant in initiating the event. It is a condition where something exists that
varies from the normal accepted safe condition and can result in injury, death or property damage if not
properly controlled.

Examples of Unsafe Conditions:

 Absence of the required guarding on a piece of machinery

 Inadequate lighting
 Poor housekeeping
Underlying / root Causes

Unsafe acts and unsafe conditions can often be caused by a range of underlying causes. Underlying causes are
the less obvious system or organisational reasons for the even occurring. This can come from deficiencies or
inadequacies in the management systems or organisational failings.

Examples of Underlying/Root Causes:

 Poor maintenance of equipment and machinery

 Inadequate instruction or training
 Unsatisfactory safe system of work
MULTI-CAUSATION

Incidents and indeed accidents may usually have multiple causes made up of a chain or combination of
events.
This can be said for major accidents; however, simple accidents may only have a single cause. During the
investigation of an accident we must identify all related causes. The multi-causation model allows us to
identify causes that occur not only in sequence but also at the same time.

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REASON’S MODEL OF ACCIDENT CAUSATION (SWISS CHEESE MODEL)

By analysing everyday slips and lapses Reason developed his model of accident causation. Reason addresses
two kinds of errors: active and latent. Reason accepted that accidents were not solely due to individual
operator error (active errors) but lay in the wider systemic organisational factors (latent conditions) in the
upper levels of an organisation.

Active Failures

Active failures have an immediate consequence and are usually made by front-line people such as drivers,
control room staff or machine operators and are the acts or conditions precipitating the incident situation. In
a situation where there is no room for error these active failures have an immediate impact on health and
safety and can often be prevented by design, training or operating systems.

Latent Failures

Latent failures are made by people whose tasks are removed in time and space from operational activities,
e.g. designers, decision makers and managers. Latent failures are typically failures in health and safety
management systems (design, implementation or monitoring).

Examples of latent failures are:

 Poor design of plant and equipment

 Ineffective training
 Inadequate supervision
 Ineffective communications
 Inadequate resources (e.g. people and equipment)
 Uncertainties in roles and responsibilities.

Latent failures provide as great, if not a greater, potential danger to health and safety as active failures. Latent
failures are usually hidden within an organisation until they are triggered by an event likely to have serious
consequences.

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FAULT TREE ANALYSIS (FTA)

Fault Tree analysis is a deductive reasoning method (from generic to specific information) for determining the
causes of an incident.

A Fault Tree is a vertical graphic model that displays the various combinations of unwanted events that can
result in an incident. The diagram represents the interaction of these failures and events within a system.
Fault Tree diagrams are logic block diagrams that display the state of a system (Top Event) in terms of the
states of its components (basic events). A Fault Tree diagram is built top-down starting with the Top Event
(the overall system) and going backwards in time from there. It shows the pathways from this Top Event that
can lead to other foreseeable, undesirable basic events. Each event is analysed by asking, “How could this
happen?” The pathways interconnect contributory events and conditions, using gate symbols (AND, OR). AND
gates represent a condition in which all the events shown below the gate must be present for the event
shown above the gate to occur. An OR gate represents a situation in which any of the events shown below the
gate can lead to the event shown above the gate.

FTA analysis is mainly used in the fields of safety engineering and reliability engineering mainly to:

 Understanding how systems can fail

 Identifying the best ways to reduce risk
 Determine or get an idea of event rates of a safety accident.
This method is mostly used in high hazard industries such as: Nuclear power, chemical and process,
petrochemical and pharmaceutical.

FTA analysis involves five steps:

1. Define the undesired event to study

Definition of the undesired event can be very hard to catch, although some of the events are very easy and
obvious to observe. An engineer with a wide knowledge of the design of the system or a system analyst with
an engineering background is the best person who can help define and number the undesired events.
Undesired events are used then to make the FTA, one event for one FTA; no two events will be used to make
one FTA.

2. Obtain an understanding of the system

Once the undesired event is selected, all causes with probabilities of affecting the undesired event of 0 or
more are studied and analysed. Getting exact numbers for the probabilities leading to the event is usually
impossible as it may be very costly and time consuming to do so. Computer software is used to study
probabilities. For the event, all causes are then numbered and sequenced in the order of occurrence and then
are used for the next step, constructing the fault tree.

3. Construct the fault tree

After selecting the undesired event and having analysed the system so that all the causing effects are known
(and if possible their probabilities) the fault tree can be constructed. Fault tree is based on AND and OR gates
which define the major characteristics.

4. Evaluate the fault tree

After the fault tree has been assembled, it is evaluated and analysed for any improvement or in other words
study the risk management to find ways for system improvement. The final step is to control the hazards
identified.

5. Control the hazards identified

After identifying the hazards, all possible methods are pursued to decrease the probability of occurrence.

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*INSERT EXAMPLE IMAGE

EVENT TREE

The Event Tree analysis method is used to analyse event sequences following an initiating event.

Event Trees help in creating a holistic picture of the risks and rewards associated with each possible course of
action. The method is popular due to its simplicity.

It uses a bottom-up inductive method. It makes use of general information to analyse specific information.
The diagram that is built gives a horizontal graphical representation of the logic model that identifies the
possible outcomes following an initiating event. The event sequence is influenced by either success or failure
of the applicable barriers or safety functions/systems. The event sequence leads to a set of possible
consequences. Each combination of successes or failures of barriers leads to a specific consequence or event.
The method can also be used quantitatively to calculate the probability of each outcome or consequence
giving the failure probability of each barrier.

The use of event tree analysis as a tool for risk assessment can help to prevent negative outcomes from
occurring.

An Event Tree begins with an initiating event. Examples are:

1. Fire
2. Increase in temperature/pressure
3. Release of a hazardous substance

The consequences of the event are followed through a series of possible paths. The paths represent the
failure or success modes of the assigned barriers for the event. Each barrier can be assigned a probability of
failure. Examples of barriers are:

1. Ignition prevention
2. Isolation
3. Emergency response

The cumulative failure probability of the various barriers per path gives the probability of occurrence for each
outcome or consequence. Examples of consequences are:

1. financial losses
2. Explosion
3. Environmental damage

 INSERT EXAMPLE IMAGE

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BOWTIE MODEL

The Bowtie contains information about the ways incidents can happen and the ways in which to prevent
them. Therefore, to add information about actual incidents has a lot of added value. The information can
‘prove’ the effectiveness of barriers and the prevalence of Threats, Top Events and Consequences. Incidents
can also point out if there are any holes in the risk analysis; if all the scenarios are covered.

All information is presented in what looks like a “Bow tie”, hence the name.

The method combines two analysis methods; Bowtie risk analysis and Tripod incident analysis. The method
brings the advantages of both worlds together. The information from the Bowtie analysis can be used as input
for the incident analysis, viewing it from a broader perspective and making sure all the possible scenarios are
considered. The input from the Tripod incident analysis can be used to make the Bowtie analysis more
realistic and up to date, using real-life data. It creates an extra layer in the Bowtie diagram, making it possible
to add more specific information to the risk analysis. The two methods have an important similarity in the
analysis technique; the barriers. For both methods barriers are used to show what is done to prevent
incidents or events (Bowtie) or to show where the failures lie (Tripod). To build an ‘Incident Bowtie’ diagram
the items from both methods are connected on the level of the barriers, making it possible to collect
information about those barriers from two viewpoints.

An incident can be mapped on an existing or developed Bowtie risk analysis diagram. Bowtie risk analysis is a
proactive method that maps different risk scenario’s making a visual representation of a hazard and how you
can lose control over the hazard. The diagram contains a left side which represent all the scenarios (the
Threats) that can lead to the Top Event, which is the moment control is lost over the Hazard. The right side of
the diagram represents all the scenarios that can lead from the Top Event (the Consequences). For each
scenario barriers are used to show how loss of control is prevented. Control measures show how Threats can
be prevented and recovery barriers show how Consequences can be prevented.

Besides the basic Bowtie diagram, management systems should also be considered and integrated with the
Bowtie to give an overview of what activities keep a Control working and who is responsible for a Control.
Integrating the management system in a Bowtie demonstrates how Hazards are managed by a company. The
Bowtie can also be used effectively to assure that Hazards are managed to an acceptable level (ALARP)

By combining the strengths of several safety techniques and the contribution of human and organisational
factors, Bowtie diagrams facilitate workforce understanding of Hazard management and their own role in it. It
is a method that can be understood by all layers of the organisation due to its highly visual and intuitive
nature, while it also provides new insights to the HSE professional.

METHOD

Hazard

The start of any Bowtie is the Hazard. A Hazard is something in, around or part of the organisation which has
the potential to cause damage. Working with hazardous substances, driving a car or storing sensitive data are
for instance hazardous aspects of an organisation, while reading this article on your computer is not. The idea
of a Hazard is to find the things that are part of your organisation and could have a negative impact if control
over that aspect is lost. They should be formulated as normal aspects of the organisation. The rest of the
Bowtie is devoted to how we keep that normal but hazardous aspect from turning into something unwanted.
The first step is always the hardest, and this is also the case here. Normally, starting with for instance a HAZID
is a good way to get a long list of all possible Hazards. Bowties are then done only for those Hazards with a
high potential to cause extensive harm. Normally, 5 to 10 Hazards is a good starting point.

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Top event

Once the Hazard is chosen, the next step is to define the Top Event. This is the moment when control is lost
over the Hazard. There is no damage or negative impact yet, but it is imminent. This means that the Top Event
is chosen just before events start causing actual damage. The Top Event is a choice though, what is the exact
moment that control is lost? This is a subjective and pragmatic choice. Often, the Top Event is reformulated
after the rest of the Bowtie is finished. Don’t worry too much at the beginning about formulation. You can
start with a generic “Loss of control” and revisit it a couple of times during the Bowtie process to sharpen the
formulation.

Threats

Threats are whatever will cause your Top Event. There can be multiple Threats. Try to avoid generic
formulations like “Human error”, “Equipment failure” or “Weather conditions”. What does a person do to
cause the Top Event? What piece of equipment? What kind of weather or what does the weather impact?
You can be too specific as well, but generally people tend to be too generic.

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Consequences

Consequences are the result from the Top Event. There can be more than one Consequence for every Top
Event. As with the Threats, people tend to focus on generic categories instead of describing specific events.
Try not to focus on Injury/fatality, Asset damage, Environmental damage, Reputation damage or Financial
damage. Those are broader categories of damage rather than specific Consequence event descriptions. Try to
describe events like “Car roll over”, “Oil spill into sea” or “Toxic cloud forms”. Besides containing more specific
information, you’re also helping yourself to think more specifically when coming up with Barriers. Think how
you want to prevent “Environmental damage” versus “Oil spill into sea”. The second is an actual scenario
which makes it much easier to come up with specific Barriers.

Barriers: controlling unwanted scenarios

Now that unwanted scenarios have been identified, it’s time to look at how to control them. This is done
using Barriers.

Control and Recovery Barriers

Barriers appear on both sides of the Top Event. Barriers interrupt the scenario so that the threats do not
result in a Loss of Control (the Top Event) or do not escalate into an actual impact (the consequences)

There are different types of Barriers, which are mainly a combination of human behaviour and/or
hardware/technology. Once the Barriers are identified, you have a basic understanding about how risks are
managed. You can build on this basic barrier structure further to deepen understanding of where the
weaknesses are. Barriers can be extended besides Barrier types to include for instance Barrier effectiveness.
This lets you assess how well a Barrier performs. After that you can look at the activities you have to
implement and maintain your Barriers. This essentially means mapping the Safety Management System on

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the Barriers. Also, determining who is responsible for a barrier and assessing the criticality are things you can
do to increase your understanding.

Escalation factors & Escalation factor barriers

Barriers are never perfect. Even the best barrier can fail. Given this, what you need to know is why a Barrier
will fail. This is done using the Escalation factor. Anything that will make a Barrier fail can be described in an
Escalation factor.

Behavioural root cause analysis

Although 'Root Cause Analysis often identifies the behaviours involved, it is rare for investigators to follow
through to identify the 'true' drivers for these behaviours. Behavioural root cause analysis is a method that
specifically examines the motivations for people's behaviour that can be used in all areas of human activity.
Combined with the other Root Cause Analyses it is an extremely powerful tool. As such it can be used as an
adjunct to complement existing methods, or as a 'stand-alone' investigation method.

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Unit A:
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A5.2 THE QUANTITATIVE ANALYSIS OF ACCIDENT AND ILL-HEALTH DATA
METHODS OF CALCULATING LOSS RATES FROM RAW DATA

Around the world there are many different calculations used for establishing various loss rates. Some of the
more commonly used are:

 Accident/Incident frequency rate

 Accident incident rate
 Accident severity rate
 Ill-health prevalence rate

Although definitions vary, the mechanism used for calculations is largely the same. Often it is the hours used
for the calculations that change. For example, the UAE insists that organisations use 1,000,000 as the
standard number for the calculations whereas some oil and gas companies insist on the use of 200,000. The
end goal remains the same; Identify the trend pattern and/or ratios related to information.

Accident/Incident frequency rate (AFR)

To establish the frequency rate for accidents and incidents organisations can use the following calculation:

A/IFR = Number of accidents/total man hours x 100,000

So, we establish the number of accidents/incidents, divide that by the number of man-hours and times that
by the number used (determined by some countries i.e. UK 100,000, UAE 1,000,000), so as an example:

A company had 5 incidents in one month. They work 300,000 man hours per month. The calculation would
be:

5/300,000 x 100,000 = 1.6

This figure can be used to benchmark the organisation with other similar companies or indeed to self-
benchmark its performance to continually improve.

Accident/Incident rate (AIR)

This is probably the most widely used formula, and is the number of defined accidents, in a period per
thousand employees.

AIR = Number of defined accidents/Average number employed x 1,000

Accident severity rate (ASR)

The severity rate can be described as the total number of days lost during a set period per 100,000 man hours
worked. It is a good indicator to monitor trends within an organisation in terms of time lost due to injury
along with the number of accidents occurred.

ASR = Number of days lost/man-hours worked x 100,000

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METHODS OF PRESENTING AND INTERPRETING LOSS DATA

There are many ways in which loss event data can be represented whether using pie charts, line graphs, or
indeed simple numerical formats. Whichever the format used the end objective is the same, data and trend
analysis. Let’s look at some of the options for representing this data.

Numerical Format

Numerical format and representation of data can sometimes be very simple, say for a small organisation, or
very complex for a larger business. Numerical data is usually the rawest form of loss data and is easy for
practitioners to interpret, however, this does not mean that it may be easy for the organisations leaders. The
below example shows the numerical loss data represented in a simple XL.

Line graphs

The data that was shown in the previous image could be better represented by using a line graph. Taking the
data from the XL table making a line graph would be a simple exercise but a beneficial one. Organisations can
better see the increase or indeed the decrease in trends and the organisations overall performance against its
targets.

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As can be seen in the line graph, the numerical information is far easier for management to understand. Not
only does it show that the organisation had an incident but it also shows that there is a clear positive trend as
the rate decreases. I personally prefer line graphs for this type of data as it gives me the best view for trend
analysis and to present to management and leadership.

Considering the same information from the original table, line graphs can be further used to show incidents
by their type, what month they occurred etc. Again, this representation of the information allows for a clearer
picture of the organisations loss data and can be easily understood by all.

Pie Charts

Pie charts are a circular statistical graph. They are usually divided into slices to show a numerical proportion.
These numerical slices usually vary in size which represent how much of one input data element exists, the
bigger the slice, the more of that data element exists. So, as is shown on the chart below; A study was
conducted to determine the percentage of safe and unsafe behaviours existed in the organisation. The pie
chart shows the two parameters “Safe” and “Unsafe”. It can be determined from the chart that almost half of
the sample of behaviours taken where unsafe. A good visual chart but from experience it is rarely used for
data representation.

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Principles of statistical variability, validity and the use of distributions

Variability
Variability refers to how spread out a set of data is. Variability gives you a way to describe how much data
sets vary and allows you to use statistics to compare your data to other sets of data. A good example of this
would be the monitoring of a lost time injury frequency. This data varies from month to month and is
unpredictable in nature.

Validity

Validity implies precise and exact results acquired from the data collected. Valid results could be gained from
number of inspections for example. We know this is valid data and would be precise.

Use of distributions

The table below shows the frequency of an event, for example there were 20 safe acts, 2 unsafe acts and 10
unsafe conditions in January each with a different outcome. This is known as a frequency distribution.

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This is represented in graphical form as per the below image. Distributions allow for multiples in data to be
collated and are very useful as a practitioner.

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A5.3 REPORTING AND RECORDING OF LOSS EVENTS (INJURIES, ILL-HEALTH AND
DANGEROUS OCCURRENCES) AND NEAR MISSES
Reporting Requirements and Procedures

Within the UK there are specific reporting requirements as laid out and required by law through the Reporting
of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR). A guidance document
(INDG453) is best for understanding each reporting requirement and procedure. Next, we take a look at the
reporting requirements.

Deaths and injuries

If someone has died or has been injured because of a work-related accident this may have to be reported.
Not all accidents need to be reported, other than for certain gas incidents, a RIDDOR report is required only
when:

 the accident is work-related

 it results in an injury of a type which is reportable
 Types of reportable injury
 The death of any person

All deaths to workers and non-workers, with the exception of suicides, must be reported if they arise from a
work-related accident, including an act of physical violence to a worker.

Specified injuries to workers

The list of ‘specified injuries’ in RIDDOR 2013 replaces the previous list of ‘major injuries’ in RIDDOR 1995.
Specified injuries are (regulation 4):

 fractures, other than to fingers, thumbs and toes

 amputations
 any injury likely to lead to permanent loss of sight or reduction in sight
 any crush injury to the head or torso causing damage to the brain or internal organs
 serious burns (including scalding) which:
 covers more than 10% of the body
 causes significant damage to the eyes, respiratory system or other vital organs
 any scalping requiring hospital treatment
 any loss of consciousness caused by head injury or asphyxia
 any other injury arising from working in an enclosed space which:
 leads to hypothermia or heat-induced illness
 requires resuscitation or admittance to hospital for more than 24 hours
 For further guidance on specified injuries is available.
 Over-seven-day incapacitation of a worker

Accidents must be reported where they result in an employee or self-employed person being away from
work, or unable to perform their normal work duties, for more than seven consecutive days as the result of
their injury. This seven-day period does not include the day of the accident, but does include weekends and
rest days. The report must be made within 15 days of the accident.

Over-three-day incapacitation

Accidents must be recorded, but not reported where they result in a worker being incapacitated for more
than three consecutive days. If you are an employer, who must keep an accident book under the Social
Security (Claims and Payments) Regulations 1979, that record will be enough.

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Non-fatal accidents to non-workers (eg members of the public)

Accidents to members of the public or others who are not at work must be reported if they result in an injury
and the person is taken directly from the scene of the accident to hospital for treatment to that injury.
Examinations and diagnostic tests do not constitute ‘treatment’ in such circumstances.

There is no need to report incidents where people are taken to hospital purely as a precaution when no injury
is apparent.

If the accident occurred at a hospital, the report only needs to be made if the injury is a ‘ specified injury’ (see
above).

Occupational diseases

Employers and self-employed people must report diagnoses of certain occupational diseases, where these are
likely to have been caused or made worse by their work: These diseases include (regulations 8 and 9):

 carpal tunnel syndrome;

 severe cramp of the hand or forearm;
 occupational dermatitis;
 hand-arm vibration syndrome;
 occupational asthma;
 tendonitis or tenosynovitis of the hand or forearm;
 any occupational cancer;
 any disease attributed to an occupational exposure to a biological agent.
 Further guidance on occupational diseases is available.
 Specific guidance is also available for:
 occupational cancers
 diseases associated with biological agents

Dangerous occurrences

Dangerous occurrences are certain, specified near-miss events. Not all such events require reporting. There
are 27 categories of dangerous occurrences that are relevant to most workplaces, for example:

 the collapse, overturning or failure of load-bearing parts of lifts and lifting equipment;
 plant or equipment coming into contact with overhead power lines;
 the accidental release of any substance which could cause injury to any person.

Further guidance on these dangerous occurrences is available on the UK’s HSE website.

Gas incidents

Distributors, fillers, importers & suppliers of flammable gas must report incidents where someone has died,
lost consciousness, or been taken to hospital for treatment to an injury arising in connection with that gas.
Such incidents should be reported online.

Significance of Internal Reporting and Recording

Internal reporting is important within an organisation for a number of reasons.

First, and foremost it allows the organisation to build a picture and understanding of occurrences which can
be identified and controlled. If the organisation was not reporting and recording but having many accidents,
then this could signal a bad culture. Through internal reposting organisations can also ACT. Using trends
analysis areas for improvement and control can be identified to prevent recurrence of the same or similar in
the future.

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Not only this but also there may be a legal requirement for the recording of accidents/incidents. It is good
practice in most countries to report and record minor through to major incidents i.e. first aid cases.

The reporting, recording and indeed analysis of near misses can be very useful to an organisation.
Remembering that near misses are pre-cursers to an incident then we can look to control any emerging
trends before they turn into an incident.

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A5.4 LOSS AND NEAR MISS INVESTIGATION
Many countries have requirements to report loss events and indeed health issues. This comes in the form of
codes of practice or indeed is incorporated into law. Within the UK organisations must comply with the
Management of Health and Safety at Work Regulations 1999, regulation 5 requires employers to plan,
organise, control, monitor and review their health and safety arrangements. Health and safety investigations
form an essential part of this process.

Reasons for Carrying Out Investigations

1. Legal Reasons

To ensure that your organisation is complying with, and operating within the laws of the place that they are
operating. Many countries have legislation in place to ensure that incidents, accidents, near miss, dangerous
occurrence and ill health are reported and investigated.

 To ensure you are operating your organisation within the law.

 UK Management of Health and Safety at Work Regulations 1999, regulation 5, requires employers to
plan, organise, control, monitor and review their health and safety arrangements. Health and safety
investigations form an essential part of this process.

Following the Woolf Report on civil action, you are expected to make full disclosure of the circumstances of
an accident to the injured parties considering legal action. The fear of litigation may make you think it is
better not to investigate, but you can’t make things better if you don’t know what went wrong!

The fact that you thoroughly investigated an accident and took remedial action to prevent further accidents
would demonstrate to a court that your company has a positive attitude to health and safety. Your
investigation findings will also provide essential information for your insurers in the event of a claim.

2, Information & Data gathering

To understand what happened and to prevent recurrence you can only begin to understand when all
information and data regarding the accident is gathered. The data will allow a practitioner to piece together
information to allow a picture to be built of what went wrong and why. On the other hand, gathering such
information will allow the organisation to identify any trends that may be appearing from other, similar
accidents. Such data is vital when carrying out an investigation.

When gathering information, the investigator should try to use open questions considering;

Who? What? Where? When? How?

Example questions:

 Who was the person injured and who was involved?

 What were you doing at the time of the incident?
 Where did the incident occur?
 When did the incident occur?
 How did it happen?

3. Establish the Root, Underlying and Immediate Causes

Only through effective investigation can the root causes of an accident or incident be identified. It’s important
to find out what happened but also why it happened.

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

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Immediate causes – unsafe actions or lack of action (for example, operating equipment with missing guards
and bypassing interlocks, using the wrong personal protective equipment) and unsafe conditions (for
example, damaged tools and equipment, or high noise and low lighting levels)

Underlying causes – factors that allow the unsafe actions and conditions to happen. The majority of these are
related to the way the organisation manages health and safety and how people perceive risk.

Among the many contributory factors to an accident or incident, there’ll be root causes. A root cause is a
factor that may cause conditions that could result in an undesirable event. If the problem were corrected, it’d
prevent the undesirable event from happening. In other words, a root cause is an event from which all other
causes spring.

Benefits of carrying out an Investigation

One of the main benefits of carrying out investigations is to prevent similar events occurring again.

Organisations that investigate incidents may see an improvement in employee morale and attitude towards
health and safety. If the management is seen to take care, involve them in investigations and decisions
whereby they can see conditions improved and problems dealt with then improvement in employee morale
would be almost certain.

Other benefits

 The prevention of business losses due to disruption, stoppage, lost orders and the costs of criminal
and civil legal actions.
 An improvement in employee morale and attitude towards health and safety. Employees will be more
cooperative in implementing new safety precautions if they were involved in the decision and they
can see that problems are dealt with.
 The development of managerial skills which can be readily applied to other areas of the organisation.

HSG245 INVESTIGATING ACCIDENTS AND INCIDENTS

HSG245 is the UK’s Health and Safety Executive guide regarding the investigation of accidents.

- Initial report
- Decide whether further investigation is required
- Gather information
- Identifying risk control measures
- Produce and implement an action plan
Step 1: Gathering the information

Gathering information is an important and critical step in any investigation. This should begin straight away or
as soon as possible after the incident. This stops it from being contaminated or corrupt, e.g. Items
removed/moved. Work must cease unauthorised access should be prohibited. In some international
countries, the police may prohibit the HSE staff from carrying out an investigation until they have completed
theirs.

The amount of time spent gathering information should be proportionate to the level of investigation.

When gathering information, the investigator should try to use open questions considering;

Who? What? Where? When? How?

Example questions:

 Who was the person injured and who was involved?

 What were you doing at the time of the incident?
 Where did the incident occur?
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  When did the incident occur?
 How did it happen?
 What activities were being carried out at the time?
 Was there anything unusual or different about the working conditions?
 Were there adequate safe working procedures and were they followed?
 What injuries or ill health effects, if any, were caused?
 If there was an injury, how did it occur and what caused it?
 Was the risk known? If so, why wasn’t it controlled? If not, why not?
 Did the organisation and arrangement of the work influence the adverse event?
 Was maintenance and cleaning sufficient? If not, explain why not.
 Were the people involved competent and suitable?
 Did the workplace layout influence the adverse event?
 Did the nature and shape of the materials influence the adverse event?
 Did difficulties using the plant and equipment influence the adverse event?
 Was the safety equipment sufficient?
 Did other conditions influence the adverse event?

Step 2: Analysing the information

An analysis involves looking at all the associated facts and determining what happened and why. The
information gathering in step one and the analysis in step two in practice are often run side by side. As the
analysis progresses, further lines of enquiry requiring additional information may develop. To be thorough
and free from bias, the analysis should be carried out in a systematic way, so that all possible causes and
consequences of the adverse event are considered.

Formal methods such as Event Tree/factor Analysis could be used to assist in identifying gaps and organising
the information.

The main purpose of the analysis is to identify what were the immediate, underlying and root causes.

What happened and why?

It is only by identifying all causes, and the root causes that you can learn from past failures to assist in
prevention of future repetitions. The causes of adverse events often relate to one another, sometimes only
influencing events and at other times having an overwhelming impact, due to their timing or the way they
interact. Analysis must consider all possible causes. Keep an open mind. Do not reject a possible cause until
you have given it serious consideration. The emphasis is on a thorough, systematic and objective look at the
evidence.

The first step in understanding what happened and why is to organise the information you have gathered.
The simple technique of asking 'Why' over and over, until the answer is no longer meaningful, is a useful
approach.

Once all the possible immediate causes of the adverse event have been identified then for each of these
immediate causes, an underlying cause should be identified and any root causes of the management system
will become clear

Step 3: Identifying risk control measures

During step 2, thorough analysis will have enabled failings and possible solutions to have been identified. This
will have given you the immediate, underlying and root causes for which suitable control measures can be
applied.

Step 4: The action plan and its implementation

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  provide an action plan with SMART objectives (Specific, Measurable, Agreed, Realistic and Timescale);
 ensure that the action plan deals effectively not only with the immediate and underlying causes but
also the root causes;
 include lessons that may be applied to prevent other adverse events, eg assessments of skill and
training in competencies may be needed for other areas of the organisation;
 provide feedback to all parties involved to ensure the findings and recommendations are correct,
address the issues and are realistic;
 should be fed back into a review of the risk assessment. The Approved Code of Practice attached to
the Management of Health and Safety at Work Regulations 1999 regulation 3 (paragraph 26), states
that adverse events should be a trigger for reviewing risk assessments);
 communicate the results of the investigation and the action plan to everyone who needs to know;
 include arrangements to ensure the action plan is implemented and progress monitored.

The last three steps, though essential, are often overlooked. But, without them, the full benefits of the
investigation will not be realised and in the long term nothing will change.

Sharing of information/lessons learned to prevent recurrence

Many organisations conduct investigations for their own benefit, sometimes only sharing information from
the incident with its management. The sharing of information and the lessons learned are key to
communicating the ways in which an incident can be avoided in the future.

Organisations in the oil and gas sector are known to share lessons learned from incidents globally and openly
to allow organisations to identify where their operations may benefit and indeed require some of the lessons
learned to implement for their own operations to be safeguarded.

CASE STUDY

I have investigated many incidents in many different countries. The legal requirements differ slightly in each,
but the process and intentions of each remains the same. Investigations are only as good as the data that is
gathered. On one occasion, a simple “near miss” investigation that I conducted highlighted serious managerial
failings. The investigation of all incidents and not just the injurious or fatal can have significant and valuable
lessons learned which could help you to avoid a serious accident in the future.

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TOP TIPS & KEY POINTS

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END…………………………..

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