Health and Safety Investigations Adverse Events

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Health and SafetyInvestigationsAdverse Events

• Alan Strawbridge
• H.S.E. Inspector

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Health and Safety Investigations

• Background
• Legal requirements to investigate
• Why Investigate and how to do it
• Outcome of an Investigation

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The Background

• 241 people killed
• 141,350 3 RIDDOR injuries
• 274,000 Injuries Labour Force Survey
• 2.2 million cases of ill health
• 36 million working days lost
• Cost to business of 2.5 billion

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HSC Response

• Pressure for new Duty to Investigate
• Discussion Document in favour
• Consultative Document on new duty
• Research into current practice
• Dutyholders divided
• HSC - guidance - review progress

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Accident Investigation Research Findings

• Less than 1 in 5 small companies have procedures
  for investigations
• Less than 3 in 4 large companies have procedures
  for investigations
• Of those companies that carry out
  investigations-
• Almost 40 are unstructured and informal
• 50 progress no further than immediate causes

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Accident Investigation Research Findings

• Limited procedures for ensuring that
  recommendations are acted upon
• No linkage between investigation findings and
  risk assessments
• For small companies accidents are rare -
  developing and maintaining investigative skills
  is difficult.
• Need for help guidance for SMEs

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Legal Duty

• No new explicit Duty to Investigate
• Legal Duty already exists!

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Legal Duty

• Management of Health and Safety at Work
  Regulations 1999 reg 3(3) Risk Assessment review
  if-
• There is reason to suspect that it is no longer
  valid
• There has been a significant change in the
  matters to which it relates
• ACoP adverse events . should be a trigger for
  reviewing the original assessment

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Legal Duty

• Management of Health and Safety at Work
  Regulations 1999 reg 5(1) Health and Safety
  Arrangements
• effective planning, organisation, control,
  monitoring and review of the preventative and
  protective measures
• ACoP monitoring includes adequately
  investigating the immediate and underlying causes
  of incidents and accidents to ensure that
  remedial action is taken, lessons learnt and
  longer term objectives are introduced.

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New Guidance
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Improvements

• More SMEs carry out investigations
• Improvement in the number and quality of
  investigations carried out
• Full employee involvement
• Immediate, underlying and management failings are
  all addressed

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Improvements

• Firm recommendations and an action plan result
  from an investigation
• Senior managers and decision makers are involved
  in, and committed to, the action plan
• The action plan is implemented
• The investigation findings feed back into the
  risk assessments.

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Investigate???

• Why?
• What?
• Who?
• How?

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Why Investigate?

• To comply with legal requirements under HSWA
• Civil Action Woolfe Report companies expected
  to make full disclosure.
• Insurance Companies/Solicitors need something to
  work with.

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Why Investigate?

• To prevent further adverse events
• To learn specific and more general lessons
• Adverse Events provide a snapshot of how things
  really are.
• The skills of investigation can be applied to
  other areas of the business
• Cost

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What to Investigate?

• Accidents

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What to Investigate?

• Near Misses

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What to Investigate?

• Undesired
• Circumstances

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Undesired Circumstancesand Near Misses
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Undesired Circumstances
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Undesired Circumstances Base of Accident Pyramid
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Do I need to Investigate?

• All adverse events are potential candidates for
  investigation
• Consider worst consequences what could
  (reasonably) have happened
• Frequency of the adverse event
• Members of Public

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Who should Investigate?

• Essential that both the workforce and the
  management are involved.
• Depending on the size and nature of the
  investigation-
• supervisors
• line managers/HS Officers
• Managers/Partners/Directors
• Union safety Reps/Employee reps

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How to Investigate?A good Investigation -

• Is suitable for purpose
• Is thorough systematic and structured
• Is carried out with prevention in mind NOT
  apportioning blame.
• Investigations that simply conclude operator
  error are unlikely to be adequate.
• Follows the causal chain all the way up to
  Management level

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How to Investigate?

• To get rid of weeds you must dig up the root. If
  you only cut off the foliage the root will grow
  again.
• Essential Steps in an Investigation-
• Information gathering
• Analysis
• Risk control measures
• Action plan AND implementation

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Investigation - Methods

• Wide variety of methods
• HSE doesnt endorse any one method
• Suitable for purpose
• SMEs difficult to develop an expertise

I keep six honest serving men(They taught me all
I knew)Their names are What and Why and
WhenAnd How and Where and Who.
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Why?.because. Method
Why?
Why?
Why?
Why?
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Analysis output

• Whichever method you use, your analysis will have
  identified the failings which allowed the adverse
  event.
• You now need to determine what you can do to
  remedy these failings.

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Risk Control Measures

• Identify a range of risk control measures that
  address the failings identified in the analysis
• Compare with standards
• Identify what additional risk control measures
  (if any) you intend putting in place
• Where else might the lessons of the investigation
  be applicable

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Action plan Implementation

• Set SMART objectives (Specific, Measurable,
  Agreed, and Realistic with Timescales)
• Ensure that the people who can make it happen
  are part of the decision process
• Monitor progress against the Action Plan
• Review relevant Risk Assessments and Safe Working
  Procedures

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Manual Handling Undesired Circumstance?
Depends on your point of view!!
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END