Transcript HSG245 - Harrogate District Health & Safety Forum

Investigating accidents and
incidents
HSG 245
Brian Hagyard CMIOSH
Technical Officer Heal & Safety
Harrogate Borough Council
Why Investigate Accidents
Ethical Obligation.
Legal Reason
Regulation 3(3) Management of Health
and Safety at Work Regulations 1999:
Any risk assessment shall be reviewed
if:
(a) There is reason to suspect that it is
no longer valid;
Financial Obligation.
•
•
•
HSE Leaflet INDG355:
Reduce risks – cut Costs; The real costs of accidents and ill health at
work.
Insurance policies don’t cover everything. Uninsured cost include:
– Lost Time
Legal costs
– Extra wages/overtime
Damage to plant etc.
– Sick pay
Clearing site
– Production delays
Investigation Time
– Fines
Excess on claim
– Loss of contracts
loss of reputation
Annual cost to Employers In
Harrogate From all Health and
Safety Failures
• Low Estimate - £10,000,000
• High Estimate- £20,000,000
• This was 5 years ago
HOW?
HSG245
Investigating accidents and incidents.
A workbook for employers, unions,
safety representatives and safety
professionals
£9.50 from HSE Books.
Free Download.
Aim of publication
• This guide will help you to adopt a
systematic approach to determining why
an accident or incident has occurred
and the steps you need to take to make
sure it does not happen again.
Steps to take
EMERGENCY RESPONSE
Prompt emergency action (eg first aid)
Make the area safe (in some case’s this may
be 1st)
Steps to Take
• INITIAL REPORT.
• Preserve the scene
• Note people, equipment involved and
any witnesses
• Decide what level of investigation is
needed.
Decision to Investigate
Likelihood
recurrence
Certain
Likely
Possible
Unlikely
Rare
Risk
Investigation
Level
of
Potential worst consequence of adverse event
Minor
Serious
Major
Fatal
Minimal
Minimal
level
Low
Low
level
Medium
Medium
level
High
High
level
Terms Used
• Dangerous occurrence: as defined by RIDDOR.
• Hazard: potential to cause harm.
• Consequence:
– Fatal: work-related death.
– Major injury/ill health – RIDDOR Schedule 1
– Serious injury/ill health – over 3 day
– Minor injury – all other injuries
– Damage only – damage to property only (not dealt with by
HSG245)
• Likelihood that an adverse event will happen:
– Certain: will defiantly happen
– Likely: will happen, but not everyday event.
– Possible: may occur from time to time
– Unlikely: not expected in foreseeable future
– Rare: so unlikely that not expected.
• Risk: combination of likelihood, and severity of the
event.
Level of Investigation
• Minimal – relevant supervisor will look
at circumstances to learn lessons and
prevent recurrence
• Low- Short investigation by supervisor
or line manager in circumstances
immediate underlying and route
Level of Investigation
• Medium – detailed investigation by
supervisor or line manager safety
advisor and employee reps to identify
causes
• High – Team based investigation all
above people under supervision of
senior manager to identify causes
Worked Example
Norman Brown was trying to fix a problem on
the edge gluer when the machine started
cutting Norman’s hand badly and had to go to
hospital.
Part 1 should be completed immediately by the manager/supervisor for the work
activity involved.
Reported by:
Incident
Date/Time of adverse event
Ill health
Minor injury
Serious injury
Major injury
Brief details (What, where, when, who and emergency measures taken)
Forwarded to:
Date
Time
Decision to Investigate
Likelihood
recurrence
Certain
Likely
Possible
Unlikely
Rare
Risk
Investigation
Level
of
Potential worst consequence of adverse event
Minor
Serious
Major
Fatal
Minimal
Minimal
level
Low
Low
level
Medium
Medium
level
High
High
level
Part 2
To be completed by person responsible for health and safety.
Type of event
Actual/potential for harm
Accident
Ill health
Near-miss
Undesired
circumstances
Fatal or major
Serious
Minor
Damage only
Riddor reportable?
Entry in accident book
High Level
Medium Level
Y/N
Y/N
Date/time reported
Date entered/reference
Low level
Basic
Initial assessment carried out by
Further investigation required? Y/N
For investigation by:
Date
Priority
Decision to Investigate
Likelihood
recurrence
Certain
Likely
Possible
Unlikely
Rare
Risk
Investigation
Level
of
Potential worst consequence of adverse event
Minor
Serious
Major
Fatal
Minimal
Minimal
level
Low
Low
level
Medium
Medium
level
High
High
level
What caused The Accident
Norman Did Something He
Should Not Have Done!
• Immediate cause: most obvious reason for injury
• Root cause: initial event from which other causes
spring, generally management, planning or
organisational failings
• Underlying cause: less obvious reason
• To get rid of weeds
you must dig up
the roots. If you
only cut off the
foliage, the weed
will grow again
Part 3
• To be completed as appropriate by investigation
team
• So What did the Team Think about Mr Brown,s
Accident?
Adverse event analysis
Immediate cause
Were the access and egress
adequate?
Were the access and egress points
being used?
Was the workplace suitable for the
task in hand?
Was there sufficient space for the task
in hand?
Was the workplace being used as
intended?
Were people segregated from
hazardous areas, processes,
machinery?
Was the work environment (lighting,
temperature and ventilation) suitable?
Did the ergonomics of the workstation
suit the person using it?
Was the work area clean and tidy?
(Routine cleaning programme and
dealing with spills.)
Were weather conditions a factor?
Were the noise levels within
acceptable levels?
Were the appropriate warning signs in
place?
Were contractors provided with
adequate information on access,
egress and the hazards within the
premises?
Risk assessment
Implementation
Design
Competence
Communication
Co-operation
Control
1
The place or premises where the incident happened
If there was anything about the
condition of the workplace that
contributed to the adverse event,
answer the following question, which
will suggest other areas to consider. If
not, go to ‘Plant, equipment and
substance.
Risk Assessment
Implementation
Design
Competence
Communication
Co-Operation
Control
Work Place
Was there sufficient space for work in hand?
Were people segregated from hazardous areas/processes/machinery
x
x
x
x
x
Plant & Equipment
Were the plant and equipment suitable for the job?
x
Were the plant and equipment being properly used?
x
x
x
x
x
Were there adequate controls or guards for the safe use of the
equipment
x
x
x
Process/procedures
Were there safe working procedures and instructions for the tasks under
consideration
x
If there were safe working procedures and instructions were the correct
one followed
x
If there were safe working procedures were they policed?
x
x
x
X
x
x
People
Were the people involved suitable for their job?
x
x
X
Competence (Skilled, Knowledgeable and experienced)
If it was a violation, i.e. Rule breaking or taking short cuts consider
x
x
x
x
x
x