accident investigation - uk-hse
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Slide - 1 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
www.uk-hs.co.uk
Accident and Incident
Investigationan introduction
Slide - 2 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
www.uk-hs.co.uk
Aim of Session • To provide an overview of:
– Accident investigation – Human Factors as they relate to
accidents and incidents– Immediate causes of accidents
and incidents– The “Why? - Because” model of
root cause analysis– Responding to an incident
Slide - 3 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Introduction
Slide - 4 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Why report accidents and incidents
• All accidents and incidents need to be reported• Comply with the law• Identify failings – prevent recurrence
• What is YOUR reporting procedure• Some to the Health and Safety
Executive (HSE) - RIDDOR
Slide - 5 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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RIDDORThe Reporting of Injuries, Diseases and Dangerous Occurrence Regulations 1995
• Death• Major injuries – e.g. broken leg• Over-3-day injuries• Injuries to members of the public taken
from the scene of an accident to hospital• Some work-related diseases e.g. skin
cancer from mineral oil• Dangerous occurrences – e.g. scaffolding
collapse
Slide - 6 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Terminology
• Hazard- something with the potential to cause
harm• Incident
- Unplanned, uncontrolled event …….could result in an accident
• Accident- Unwanted or unintended sudden
event ….harmful consequences
Slide - 7 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Hazard
The realisation of harm
Session 5 30 minutes
Safe System of Work
Machine Guard
PPE
Undesirable eventHarm
Slide - 8 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Hazard
Session 5 30 minutes
Safe System of Work
Machine Guard
PPE
Undesirable eventHarm
Put in extra barriers
The realisation of harm
Slide - 9 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Hazard
Session 5 30 minutes
Safe System of Work
Machine Guard
PPE
Undesirable eventHarm
Identify and remove the holes (e.g. latent failures)
The realisation of harm
Slide - 10 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Human Factors
Slide - 11 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Why Classify the Human Failure• If you understand the human
failure, you can start to understand the causation path and what to do about it– If someone has a lapse then
training etc. will not help, we should look at the visual clues, process checks and balances
– If it is a mistake then we should look at the training, supervision, data supplied, etc.
Slide - 12 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Human Failure• Error - action or decision which
was not intended and which led to an undesirable outcome
– Slip / Lapse - performing the wrong action (slip) or omitting to carry out a step in the process (lapse) (Forgets)
– Mistake - a person does the wrong thing while believing it to be the right
• Violation - when a person deliberately “breaks the rules” and violates a rule, regulation or instruction.
Slide - 13 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Identifying the Immediate Causes
Slide - 14 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Accidents and Incidents• Unsafe act
– action likely to result in accident
– occurs immediately prior to the accident
• Unsafe condition– article, equipment or
environment in a condition likely to result in accident
– exists prior to the accident
Slide - 15 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Immediate Causes
Immediate Causes
Unsafe ActsUnsafe
Conditions
Slide - 16 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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UnderlyingCauses
Slide - 17 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Underlying Causes
Immediate Causes
Unsafe ActsUnsafe
Conditions
Underlying Causes
Human Failure
Slips/Lapses, Mistakes or Violations
Missing or Inadequate
Control Measures
Slide - 18 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Why? Because ModelIncide
ntPerson fell down the stairs due to tripping on a
training cable
Why Why was the trailing cable at the top of the stairs?
Because
The contractor had put it there
Why The contractor had put it there?
Because
He was not aware of the Safe System of Work on ‘Trailing Cables’
Why He was not aware of the Safe System of Work on ‘Trailing Cables’?
Because
He had not been briefed by the supervisor
Why He had not been briefed by the supervisor?
Because
The supervisor had become sloppy and failed to brief the contractor
Slide - 19 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Model of Causal Analysis
Identify Facts and Failures
Immediate Causes
Unsafe ActsUnsafe
Conditions
Underlying Causes
Human Failure
Slips/Lapses, Mistakes or Violations
Missing or Inadequate
Control Measures
Identify Root Causes
Influencing Factors
Personal
Influencing Factors
Job or Organisational
Slide - 20 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Root Causes
OrganisationJob
Task, workload, equipment, displays, controls, procedures
Competence, personality, attitudes, risk perception…
leadership, resources, work patterns,
communications
Individual
Slide - 21 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Excellent starting checklistSection 2, HASAWA* 1974 Employer’s duties to
employeesSo far as is reasonably practicable
• Safe plant and systems of work• Safe storage, handling, use and
transportation of articles and substances• Information, training, instruction and
supervision• Safe access and egress• Safe working environment and adequate
welfare facilities
* Health and Safety at Work etc. Act 194
Slide - 22 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Responding to an Incident
Slide - 23 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Response to the Incident• Preserve Information• Gather Evidence
• Don’t make assumption• What was the Safe System of
Work in place?• What equipment was being used?• Were people competent?• What supervision was in place?• Is something FACT or OPINION?
Slide - 24 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Conducting an Interview
• Organise the interview• Greet and Personalise• Explain aim and objectives• Initiate Free Reporting• Ask open questions• Encourage retrieval• Summarise – get agreement• Explain next step
Slide - 25 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Sequence of Events
• Determine the chronological listing of events that gave rise to the incident- Before incident- Incident- After the incident
Slide - 26 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Identifying what went wrong
• Barriers in place• What should have happened • Which barrier failed• Human failure• Underlying causes
Slide - 27 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Identify what needs to be done to address failings
• Can include- Individual action plans- Group initiatives to address
culture issues- Improvement plans
• Should include- Monitoring
Slide - 28 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Produce SMART Actions
• Specific • Measurable• Agreed / Achievable• Realistic / Reasonable• Timescale / Time based
Slide - 29 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Writing the Report• Use the correct terms• Use of speech marks to ‘quote’• Vocabulary• Clear and to the point• Do not use people’s names• Do not use the terms violation
lapse, mistake in the report
Slide - 30 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Writing the Report - Some Guidance
• Immediate Cause– The last event to occur prior to the Accident /
Incident and is either an unsafe act or unsafe condition
• Underlying Causes– must cross reference with the problem issues
discussed in the “Factors for Consideration” and demonstrate their contribution to the Accident / Incident
• Action Plans– The controls to prevent re-occurrence– Make sure they are SMART
Slide - 31 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
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Your Report – basic checklist• Have you?
– Described Accident - Nature or Description
– Identified Hazards– Determined the Sequence of events– Determined the Control Measures or
Barriers– Determined Failures and where in the
sequence of events– Identified Unsafe Acts and/or Unsafe
Conditions– Identified Unsafe Act immediately prior
to the accident is the Immediate Cause– Identified Unsafe Condition exists prior
to the accident
Slide - 32 Accident and Incident Investigation – an Inroduction Issue 1.0 August 2008
www.uk-hs.co.uk
Aim of Session • Do you have an overview of:
– Accident investigation – Human Factors as they relate to
accidents and incidents– Immediate causes of accidents and
incidents– The “Why? - Because” model of
root cause analysis– Responding to an incident
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