Accident

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Accident Incident Management and
Investigation
PRINCIPAL PEOPLE with John Norton-Doyle BSc MSc
DEH FRSH FCIEH CFIOSH
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When someone loses their life in a serious
work-related incident, organisations can be in a
state of shock and disbelief. Invariably, where a
death occurs in the workplace or as part of a
work-related incident, the police on behalf of
the coroner will be involved as part of their
duty to investigate unexpected death. On a few
occasions, this investigation may need to be more
extensive if questions of culpability arise. All
those involved at the initial stages of an
incident must be aware of the need to preserve
and gather information and keep everyone safe.
This will allow others to make well-founded
decisions as to what led to the workers
death. Thankfully, for most employers, workers
and health and safety advisers, work-related
deaths are rare. But preparation and cooperation
are key to successful investigations and knowing
who does what and when can be invaluable. The
important issue here is finding out the truth of
what happened Steve Watts MSc DPM D.Crim (Cantab)
FCIM Assistant Chief Constable Hampshire
Constabulary Forward to IOSH Learning the
Lessons
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What assumptions can we make therefore about
Preparedness and the impact a serious event will
have on the individuals and organisation as a
whole. How can you be sure you are not culpable
and if you are what should you being doing?
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• Accident conveys the meaning of something
  which is
• Unplanned
• Unexpected

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• Before
• During
• and
• After

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• Before
• Accident and Incident investigation is
• Part of management system
• About reactive actions
• Resilience
• Affects risk assessment
• and
• Overall monitoring

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SAFE PERSON - PLACE - PRACTICE

Compliance
Risk
Audit
Policy
Accident Investigation
3 SPs
Training
MIS
Procedures
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• Requires
• Commitment
• from top management
• and
• from everybody

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• Implications and consequences
• support
• time scales
• action plans
• priorities
• open style

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• Resources
• investigators
• skills
• aptitude
• competence
• administration support

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Requirements strategic and front end
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• Standards
• Type
• Quality and quantity of report
• method of investigation

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Control of information internal the
organisation colleagues external family and
friends the regulator?
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• During
• So once the incident or accident occurs who is
  going to handle it and what should they do?
• Who will be first on the scene
• Who will take charge
• What do they need to do

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• Key stakeholders
• Regulators Police, HSE Local Authority
  EHO
• Insurers
• Managers. Colleagues, relatives
• Press
• Shareholders
• Etc etc.

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One of the key issues in the IOSH Guidance is
that organisations need to ensure they have
people competent to manage and do the
investigations. But where does this competence
begin? what does it entail? and how do you
get it ?
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Investigation is an Art experience and
skills and a science specific and technical
knowledge
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Major events are rare experience is therefore
hard to obtain and it needs to be focussed
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Senior management needs to be confident in the
investigation process results
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• Provide a professional approach
• deal with external influences
• Moral hazard

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• PRINCIPLES OF INVESTIGATION
• To IDENTIFY
• What happened
• How it happened
• Why it happened

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• PRINCIPLES OF INVESTIGATION
• Could it happen again?
• What can be done to prevent this?
• How can this be achieved?

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• Need to know
• how to run and manage an investigation,
• how to deal with the potentially conflicting
  needs of stakeholders
• Understand accident causation
• and
• Have a toolkit to unravel the causation

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Think about collecting evidence What is
evidence, where can it be found, how is it
validated and what are the pitfalls and
cautionary approaches that need to be
followed? dealing with witnesses Who and what
are witnesses, how should they be dealt with and
how do you determine fact from fiction? developin
g the sequence of events. If you do not know what
has happened you cannot determine what caused it.
Developing the sequence of events is an essential
for any Investigation.
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• Most importantly how do you analyse the
  evidence
• Whole bag of approaches available but how do you
  select and apply the right one and how good at
  it do you need to be
• for example
• Sequence of events techniques
• Known precedent
• Hartford EMP Equipment, Material and People
• Multilinear Events Sequencing
• Technique of Operations Review (TOR)
• Change Analysis

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• Other key issues
• Finding and Controlling evidence
• Dealing with the stakeholders
• Keeping stakeholders informed without
  compromising the investigation
• Understanding the risk issues.

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• Some Other Issues
• Managing expectations
• Each of the stakeholders has a different view of
  the accident and may have differing uses for your
  report, how should these expectations be managed?
  
• Conflicts of interest
• A number of conflicts of interest can arise
  during an investigation - the nature and
  importance of these need to be determined

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• After
• It is useful to think of accidents as occurring
• as a management failure
• as an exposure to risk

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• as a management failure
• may be
• absence of a system entirely
• less than adequate system
• defective system

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an accident is an exposure to risk identify
the risk
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as an exposure to risk may be known
risk inadequate analysis / assessment
/control unforeseen risk new risk or hidden
risk
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Accidents tend to be multi factorial in
nature, that is not one single cause
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• Consider
• All accidents are events
• Not all events are accidents

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• Consider
• Not all injuries result from accidents
• All accidents do not result in injuries

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And finally Become a learning organisation.
Embed accident and incident management into the
culture and seek to learn from every deviation.
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Protect your Organisation from Surprises.
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THANK YOU