1. Investigating accidents and incidents HSG 245 Brian Hagyard CMIOSH Technical Officer Heal & Safety Harrogate Borough Council

2. Why Investigate Accidents

3. Ethical Obligation.

4. 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Safety at Work Regulations 1999: Any risk assessment shall be reviewed if: (a) There is reason to suspect that it is no longer valid; Legal Reason

5. 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 TimeLegal costs –Extra wages/overtimeDamage to plant etc. –Sick payClearing site –Production delaysInvestigation Time –FinesExcess on claim –Loss of contractsloss of reputation

6. 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

7. HOW?

8. HSG245 Investigating accidents and incidents. A workbook for employers, unions, safety representatives and safety professionals £9.50 from HSE Books. Free Download.

9. 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.

10. Steps to take EMERGENCY RESPONSE Prompt emergency action (eg first aid) Make the area safe (in some case’s this may be 1 st )

11. Steps to Take INITIAL REPORT. Preserve the scene Note people, equipment involved and any witnesses Decide what level of investigation is needed.

12. Decision to Investigate

13. 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)

14. 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.

15. 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

16. 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

17. 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.

19. Decision to Investigate

21. Part 2

22. Decision to Investigate

24. What caused The Accident Norman Did Something He Should Not Have Done!

26. 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

27. To get rid of weeds you must dig up the roots. If you only cut off the foliage, the weed will grow again

28. Part 3 To be completed as appropriate by investigation team So What did the Team Think about Mr Brown,s Accident?

36. Adverse event analysis Immediate cause