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Factsheet - Accident Investigation

Investigation Terminology
Adverse Event:
  1. An accident (an event that results in injury or ill health) or an incident or near miss (an event that, while not causing harm, has the potential to cause injury or ill health).
  2. Dangerous occurrence, as listed in the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR).
Consequence:
  1. Work related fatality.
  2. Specified injury as defined in RIDDOR.
  3. Minor injury.
  4. Damage only to property and equipment.
Likelihood of event being repeated:
Certain: it will happen again and soon.
Likely: it will reoccur, but not as an everyday event.
Possible: it may occur from time to time.
Unlikely: it is not expected to happen again in the foreseeable future.
Rare: so unlikely that is not expected to happen again.
Risk: The level of risk is determined from a combination of the likelihood of a specific undesirable event occurring and the severity of the consequences. Risk control measures: are the workplace precautions put in place to reduce the risk to a tolerable level?
Root Cause: An initiating event or failing from which all other causes or failings spring. Root causes are generally management, planning or organisational failings.
Why Investigate
Adverse events need to be investigated for the following reasons: legally to ensure that you are meeting H&S management requirements; to understand why things went wrong; to prevent similar events occurring; an improvement in employee morale and attitude towards health and safety and the development of managerial skills which can be readily applied to other areas of the organisation.
Investigation Process
Emergency Response - deal with injured and make area safe.
Initial Report - preserve scene, note names, witnesses and equipment, report to management.
Initial Assessment - report under RIDDOR if appropriate.
FULL INVESTIGATION
FULL INVESTIGATION
Step 1 - Gather information, including what, when, how and why the adverse event occurred. What were the immediate and root causes?
Step 2 - Analysis of information, involves examining all the facts, determining what happened and why. All the detailed information gathered should be assembled and examined to identify what information is relevant and what information is missing.
Step 3 - Identifying risk control measures. The methodical approach adopted in the analysis stage will enable failings and possible solutions to be identified. These solutions need to be systematically evaluated and considered for implementation.
Step 4 - Action Plan and Implementation. At this stage, senior management, who have the authority to make decisions and act on the recommendations of the investigation team, should be involved. An action pan for the implementation of additional risk control measures is the desired outcome of a thorough investigation.
Root Cause: Each domino represents a failing or error which can combine with other failings and errors to cause an adverse event. Dealing with the immediate cause (B) will only prevent this sequence. Dealing with root causes (A) can prevent a whole series of adverse events. (Source HSG 254 Investigating Accidents)
factsheet dominos

AFS 0011 - Accident Investigation© Arinite Limited. Website www.arinite.co.uk Tel: 0207 947 9581

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