Investigating, Recording and Reporting Incidents
Reasons for Investigations
Reasons to carry out investigations:
- Identify the immediate and root causes.
- Prevent recurrence.
- Collect and record evidence.
- Legal reasons.
- Insurance purposes.
- Staff morale.
- Disciplinary purposes.
- Data-gathering.
Types of Incident
- Accident.
- Near miss.
- Dangerous occurrence.
- Work-related ill health.
Types of Incident
Accident:
An unplanned, unwanted event which leads to injury, damage or loss.
- Injury accident – where the unplanned, unwanted event leads to some sort of personal injury, e.g., a cut hand.
- Damage-only accident – where the unplanned, unwanted event leads to equipment or property damage but not personal injury, e.g., a wall is demolished.
Near Miss
An unplanned, unwanted event that had the potential to lead to injury, damage or loss but did not, in fact, do so.
Dangerous Occurrence
A specified event that has to be reported to the relevant authority by statute law, e.g., a major gas leak.
Work-Related Ill Health
A disease or medical condition that is directly attributable to work, e.g., dermatitis as a result of exposure to skin irritants.
Level of Investigation
- Minimal – immediate line manager and not excessive time or effort.
- Low – line manager perhaps with some support and more time and effort involved.
- Medium – middle manager with support and significant time and effort.
- High – senior management oversight with team-based approach and significant time and effort.
Group Exercise
Discuss the first thing you should do when arriving at an accident scene and then the later steps.
Consider what type of equipment you may need to assist you.
Basic Investigation Procedures
Safety of the scene:
- Is the area safe to approach?
- Is immediate action needed to eliminate danger before casualties are approached?
Casualty care:
- First-aid treatment.
- Hospitalization.
- Also consider bystanders who may be in shock.
Basic Investigation Procedures
| Step | Action |
|---|---|
| Step 1 | Gather factual information |
| Step 2 | Analyse the information and draw conclusions |
| Step 3 | Identify suitable control measures |
| Step 4 | Plan the remedial actions |
Step 1: Gathering Information
- Secure the scene.
- Identify witnesses.
- Collect factual information.
- Interview witnesses.
- Examine documents.
Witness Interview Technique
- Quiet room, no distractions.
- Establish a rapport.
- Explain the purpose, not about blame.
- Use open questions, e.g. Who? What? Where? When? Why? How?
- Keep an open mind.
- Take notes.
- Ask for a written statement.
- Thank the witness.
Document Examination
- Company policy.
- Risk assessments.
- Training records.
- Safe systems of work.
- Permits to work.
- Maintenance records.
- Previous accident reports.
- Sickness and absence records.
Step 2: Analysing Information
Immediate causes:
- Unsafe acts.
- Unsafe conditions.
Underlying/root causes:
- Reasons behind the immediate causes.
- Often failures in the management system:
- No supervision.
- No PPE provided.
- No training.
- No maintenance.
- No checking or inspections.
- Inadequate or no risk assessments.
Group Exercise
A worker is struck by a load being carried on a pallet by a forklift truck.
Outline possible immediate and underlying causes of the accident.
Forklift Truck Accident
Possible immediate causes:
- Failure to secure the pallet.
- Poor positioning of the truck close to the pedestrian exit.
- Aggressive braking by the driver.
- Inattentive pedestrian steps into the path of the forklift truck.
Possible underlying/root causes:
- No training for the driver.
- Lack of segregation of vehicles and pedestrians.
- Poor driver induction.
- Poor truck maintenance.
- No refresher training.
Step 3: Identifying Suitable Control Measures
For immediate causes:
- Clean up the spill.
- Replace the missing guard.
- Relocate the trailing cable.
For underlying/root causes:
- More difficult.
- Need to make changes in management system.
Step 4: Planning the Remedial Actions
- Dangerous conditions must be dealt with immediately.
- Interim actions may be possible.
- Underlying causes will require more complex actions:
- Will take time, effort, disruption, money.
- Need for Prioritization.
Table:
| Recommended action | Priority | Timescale | Responsible person |
|---|---|---|---|
| Introduce induction training for all new drivers | Medium | 1 month | Warehouse manager |
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Recording and Reporting Requirements
- Reporting is the process of informing people that an incident has occurred:
– can be internally within the organisation, or
– externally to enforcing authorities or insurers. - Recording is the process of documenting the event.
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Internal Incident Reporting
Will depend on the severity:
Table:
| Internal | External |
|---|---|
| – Directors. | – Family of the casualty. |
| – Senior managers. | – External authorities. |
| – Human resources managers. | – Insurance companies. |
| – Health, safety and environmental advisers. | – Public relations advisers. |
| – Worker representatives. |
Group Exercise
What sort of things are likely to hinder good accident and near-miss reporting?
What can an organisation do to make it more likely that incidents will be reported?
Internal Incident Reporting Systems
Barriers to reporting:
- Unclear organisational policy.
- No reporting system in place.
- Overly complicated reporting procedures.
- Excessive paperwork.
- Takes too much time.
- Blame culture.
- Apathy.
- Lack of training on policy and procedures.
Incident Recording and the Accident Book
Minimum standard is the ‘Accident Book’:
- Name and address of casualty.
- Date and time of accident.
- Location of accident.
- Details of injury.
- Details of treatment given.
- Description of event causing injury.
- Details of any equipment or substances involved.
- Witnesses’ names and contact details.
- Details of person completing the record.
- Signatures.
Externally-Reportable Events
Some incidents need to be reported to regulator by law, for example:
- Fatality.
- Major injury.
- Dangerous occurrence.
- Disease.
- Lost-time injuries.
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