Risk Assessment - introduction

Accident and Incident Investigationan introduction Slide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk1Aim of Session To provide an overview of:Accident investigation Human Factors as they relate to accidents and incidentsImmediate causes of accidents and incidentsThe Why? - Because model of root cause analysisResponding to an incident

Slide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk2Explanation ofPreliminary - Original report, but may be converted to a local investigationLocalRole of DCPSpend 1 minute explaining process relative to groupAddress individual concernsAsk GroupIf they know who their DCP isWhat their aspirations of the course are

Introduction Slide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk3Please ExplainThis part of the syllabus concerns why people do things, i.e. make certain decisions

This section will teach candidates the difference between error types.

Remember to mention the Human Factors e-learning program DETAILS BELOW

Human Factors E-learning Tool AVAILABLE ON CONNECTThe Human Factors e-learning tool will be available during the beginning of 2008.The e-learning programme provides information about and learning opportunities concerning: Undertaking an investigative interview and techniques that can be used to optimise information retrieval and error identification In addition there are four case studies that provide an opportunity to apply a human factors approach to an investigation. The modular based approach allows the user to progress through each module as required. There is no formal competence attached to the tool. Why report accidents and incidentsAll accidents and incidents need to be reportedComply with the lawIdentify failings prevent recurrence What is YOUR reporting procedureSome to the Health and Safety Executive (HSE) - RIDDOR

Slide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk4Bryan. Examples from the Manual. Talk through.

RIDDORThe Reporting of Injuries, Diseases and Dangerous Occurrence Regulations 1995DeathMajor injuries e.g. broken legOver-3-day injuriesInjuries to members of the public taken from the scene of an accident to hospitalSome work-related diseases e.g. skin cancer from mineral oilDangerous occurrences e.g. scaffolding collapseSlide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk5Bryan. Examples from the Manual. Talk through.

TerminologyHazardsomething with the potential to cause harmIncidentUnplanned, uncontrolled event .could result in an accidentAccidentUnwanted or unintended sudden event .harmful consequences

Slide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk6Explain the terms

Hazard give examples of hazards e.g. electricity, height, working at a height without adequate protection.Stress the importance of correctly identifying hazards

Accident and Incident refer to NR/L2/INV/002 for the full definition

Explain the Following

Hazards:Give Examples of Hazards, i.e Drilling a hole = Electricity, Swimming in a pool = Water, Working by the Track - Trains

Incident May be termed a near miss / hit. Could become an accident in different circumstances

AccidentAn event that has actually happened, one control or several controls have failed

HazardThe realisation of harmSession 5 30 minutesSafe System of WorkMachine GuardPPEUndesirable eventHarmSlide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk7If you can not explain this model then go back to Old Kent RoadHazardSession 5 30 minutesSafe System of WorkMachine GuardPPEUndesirable eventHarmPut in extra barriersThe realisation of harmSlide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk8If you can not explain this model then go back to Old Kent RoadHazardSession 5 30 minutesSafe System of WorkMachine GuardPPEUndesirable eventHarmIdentify and remove the holes (e.g. latent failures)The realisation of harmSlide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk9If you can not explain this model then go back to Old Kent RoadHuman Factors Slide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk10Please ExplainThis part of the syllabus concerns why people do things, i.e. make certain decisions

This section will teach candidates the difference between error types.

Remember to mention the Human Factors e-learning program DETAILS BELOW

Human Factors E-learning Tool AVAILABLE ON CONNECTThe Human Factors e-learning tool will be available during the beginning of 2008.The e-learning programme provides information about and learning opportunities concerning: Undertaking an investigative interview and techniques that can be used to optimise information retrieval and error identification In addition there are four case studies that provide an opportunity to apply a human factors approach to an investigation. The modular based approach allows the user to progress through each module as required. There is no formal competence attached to the tool. Why Classify the Human FailureIf you understand the human failure, you can start to understand the causation path and what to do about itIf someone has a lapse then training etc. will not help, we should look at the visual clues, process checks and balancesIf it is a mistake then we should look at the training, supervision, data supplied, etc.Slide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk11Different types of human failure require different solutions. Draw on real life examples from your own experience. Ensure you use poor examples of blame culture that this is counter productive.

Human FailureError - action or decision which was not intended and which led to an undesirable outcomeSlip / 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 rightViolation - when a person deliberately breaks the rules and violates a rule, regulation or instruction.

Slide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk12Please Give an Example

Use the example of driving a car

1/ Driving in a 30mph speed limit and your speed gradually increases to 33mph or 34 mph and you suddenly notice and reduce speed. - Slip / Lapse

2/ Driving in a 30mph speed limit when you thing the speed limit is 40mph - Mistake

3/ Driving in a 30mph speed limit when you know you cannot reach your destination in the required time by sticking to the speed limit Violation

Some more information if required.

Initially a split is made in intended and unintended actionsUnintended actions:Slips are usually benign, not so dangerous on their own. Usually you get an immediate reminder that you are doing the wrong thing. Example: if you drive a car in a country with traffic on the other side of the road, you will switch your windscreen wiper on when you want to turn right.Lapses are more dangerous, harder to contain. You forget to do something and are not immediately reminded. Example: You forgot to fill up your petrol tank.Mistakes are even more dangerous, you intend your action and ignore counter-evidence that says that what you are doing is wrong. Example: you are driving along a road which has a speed limit of 100 km/h. Your actual speed is 95 km/h which is within the speed limit. You turn off the road onto another road which looks no different and continue at 95 km/h. However, a police seed trap catches you speeding as the limit on the road you have turned onto has a speed limit of 80 km/h.Violations are deliberate and break a fundamental assumption of a Safety Management System: procedures will be followed. A violation removes a barrier/control and opens the path to disaster. One violation is not necessarily disastrous. However, in combination with another violation from somebody, who also assumes that other barriers will remain in tact, and slips or lapses (holes in barriers) is the recipe for disaster. Example: A pool car has a speed limiter on it set at 80 km/h. A driver gets in the car and finds this frustrating as he has to sit at 80 km/h for a long journey although the road he is driving on is designed for a maximum speed of 80 km/h. He then tampers with the speed limiter by cutting a wire to disengage the speed limiter. He then completes his journey and hands in the car to the car pool. Another driver gets in the following day and drives the car. He goes above 80 km/h and the speed limiter does not engage. While going round a tight bend above 80 km/h he rolls the car and injures himself.

An alternative way to presenting this slide to avoid throwing up the definitions is to ask the participants what they would immediately say to a police officer after a police officer had stopped them for overtaking a police car where the police car was travelling at exactly the speed limit. Get each participant to write down very quickly what they would say to the police officer and then you as the facilitator write them up on a flipchart. Then go through each one and discuss if each is a intended action (violation or a mistake) or a unintended violation (lapse or slip) then bring the definitions into the ensuing discussion.

Identifying the Immediate Causes Slide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk13Remember - an Immediate Cause is the last thing to happened before an event occursAccidents and IncidentsUnsafe actaction likely to result in accidentoccurs immediately prior to the accidentUnsafe conditionarticle, equipment or environment in a condition likely to result in accidentexists prior to the accident

Slide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk14Please explain

Unsafe Act:The very last action to occur prior to event taking place

Unsafe ConditionExisted prior to event taking placeImmediate Causes

Slide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk15UnderlyingCauses Slide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk16Please explain that Underlying causes follow the 1 immediate cause.

There may be several underlying causes

Have been referred to as Basic, and Root Causes in the past, for the purpose of a Network Rail led investigations they are called underling causes.

Give brief details on the Why Because Methodology, mentioning that this has been found to be one of the most useful parts of the course, commented on by candidates.Underlying Causes

Slide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk17Must identify what is in the mind of somebody committing an unsafe act.

Must identify if the act was intentional

Why? Because ModelIncidentPerson fell down the stairs due to tripping on a training cableWhyWhy was the trailing cable at the top of the stairs?BecauseThe contractor had put it thereWhyThe contractor had put it there?BecauseHe was not aware of the Safe System of Work on Trailing CablesWhyHe was not aware of the Safe System of Work on Trailing Cables?BecauseHe had not been briefed by the supervisorWhyHe had not been briefed by the supervisor?BecauseThe supervisor had become sloppy and failed to brief the contractorSlide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk18Explain this is a systematic methodology to determine what happened.

Remember stress the person asking the questions must know when to stop has the underlying course been identified?Use as open questioning

Please ExplainThis a systematic methodology to determine what happened:

Know when to stop i.e. when it identifies a systemic failure

RememberYou can change your line of questioning to identify other underlying causes i.e. you might want t ask why the injured party was not using insulated tools. Model of Causal Analysis

Slide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk19Give overview of the whole processRoot Causes

Slide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk20Whichever type of human failure - there are influencing factors.

Look at our examples we can almost see organisational factors contributing to the cause of the incident.

e.g. After maintenance came back in house we still have the contractor interpretation of the rules. This is organisational or management issue.

Excellent starting checklistSection 2, HASAWA* 1974 Employers duties to employeesSo far as is reasonably practicable

Safe plant and systems of workSafe storage, handling, use and transportation of articles and substancesInformation, training, instruction and supervisionSafe access and egressSafe working environment and adequate welfare facilities

* Health and Safety at Work etc. Act 194Slide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk21Refer delegates to the appropriate page within the notes. Outline the main points.

Responding to an Incident

Slide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk22Please explain

Prior to this point in the module all information has been theoretical:

This session explains how a Local Investigation fits within the hierarchy of the investigation process.Response to the IncidentPreserve InformationGather EvidenceDont make assumptionWhat 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 - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk23Please Explain

Information is evidence

You may discard 80% of information, but it is better to have to discard than have Information Gaps

2 types of evidence - Perishable - Evidence that can dissipate such as brake readings, a pool of water etc.

Non perishable, such as reports, written records etc. Conducting an InterviewOrganise the interviewGreet and PersonaliseExplain aim and objectivesInitiate Free ReportingAsk open questionsEncourage retrievalSummarise get agreementExplain next step Slide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk24Please Explain

Organise - Try to pick neutral location, Somewhere not intimidating, suitable environment.Greet and personalise - Go to where they are waiting, introduce yourself, your role, engage in small talk, try to prepare individual.Aim - To establish the facts. Objective - To prevent re-occurrenceInitiate Free Reporting - Let them talk uninhibited, try not to interrupt, let it flowAsk open questions - i.e. Then what happened?, What do you think went wrong?, What would you have done differently?Encourage retrieval - Ask the interviewee if there is anything else, minor details, fill in the timeline.Summarise - Get Agreement - Make sure you are both agreed on the detail, its no good after the event. It may cause problems even delaying the completion, or worst case scenario re-interviewing. Remember this is a Local Investigation, records of interviews are not included, just held on file.Explain next step - Thanking interviewee for their time and honesty, advising them that the information they have given will assist the completion of the report, still other people to interview. A report will be completed in 5 days and forwarded to the DCP, this interview is not part of the disciplinary procedure Sequence of EventsDetermine the chronological listing of events that gave rise to the incidentBefore incidentIncidentAfter the incidentSlide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk25Please Explain

That the sequence starts as far back as when the last significant event occurred that may have contributed to the incident.

There may also be important lessons to learn after the event, it could be how the incident was dealt with, what emergency actions worked well and which didnt. It may also identify some training or reporting issues. Identifying what went wrongBarriers in placeWhat should have happened Which barrier failedHuman failureUnderlying causes

Slide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk26Please explain

Barriers are controlsIf a barrier is in place why did it not workWas a barrier inadequateHuman Failure is an unsafe act

If a Preliminary investigation, then the investigator may identify further investigation may be required, i.e the need to re-interview people or if event has far reaching connotations, the DCP may decide a Local or Formal Investigation is needed.Identify what needs to be done to address failingsCan includeIndividual action plansGroup initiatives to address culture issuesImprovement plansShould includeMonitoring

Slide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk27Please explain

Local Actions can be aimed at a Group or Individual.

Cultural issues may be classed as Custom and Practice

Monitoring may be by Audit, Inspection, checks and examinations.

Monitoring can be carried out using the tools in place such as Planned Inspections, Competency Management Systems etc. No need to re-invent the wheel.

Produce SMART ActionsSpecific MeasurableAgreed / AchievableRealistic / ReasonableTimescale / Time based

Slide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk28Please Explain:

Specific - Who do they apply to and who will carry them out.

Measurable - Will they be measured by audit, checks inspections etc.

Agreed / Achievable & Realistic / Reasonable are the same - They must be able to be carried out, its no good putting in an action plan that is not achievable. People will get annoyed.

Timescale / Timebased - They must have a target that the person accountable can identify with.

Writing the ReportUse the correct termsUse of speech marks to quoteVocabularyClear and to the pointDo not use peoples namesDo not use the terms violation lapse, mistake in the report

Slide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk29Correct Terms - i.e Class 08 Shunting Locomotive not Jocko, Route Indicator not Feather etc.

Speech Marks - Inverted commas for when somebody has made a statement.

Vocabulary / Clear and to point - use ABC, Accurate, Brief, and Clear dont use 10 words when 3 will do.

Peoples Names - Do not use, these may be held in evidence files, use Driver, Signaller, Track Worker # 1, Track Worker # 2 etc. Also need to produce as part of the Investigation a Names document.

Terms - Violation is too confrontational, people reading the report may not have your knowledge, can use Lapse of Concentration. Made a mistake in that they thought. Instead of violation - Broke the rule knowingly.

Avoid unnecessary capitalisationDefine objectives

Writing the Report - Some GuidanceImmediate CauseThe last event to occur prior to the Accident / Incident and is either an unsafe act or unsafe condition Underlying Causesmust cross reference with the problem issues discussed in the Factors for Consideration and demonstrate their contribution to the Accident / IncidentAction PlansThe controls to prevent re-occurrenceMake sure they are SMARTSlide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk30Your Report basic checklistHave you? Described Accident - Nature or DescriptionIdentified HazardsDetermined the Sequence of eventsDetermined the Control Measures or BarriersDetermined Failures and where in the sequence of eventsIdentified Unsafe Acts and/or Unsafe ConditionsIdentified Unsafe Act immediately prior to the accident is the Immediate CauseIdentified Unsafe Condition exists prior to the accidentSlide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk31Aim of Session Do you have an overview of:Accident investigation Human Factors as they relate to accidents and incidentsImmediate causes of accidents and incidentsThe Why? - Because model of root cause analysisResponding to an incident

Slide - # Accident and Incident Investigation an Inroduction Issue 1.0 August 2008www.uk-hs.co.uk32Explanation ofPreliminary - Original report, but may be converted to a local investigationLocalRole of DCPSpend 1 minute explaining process relative to groupAddress individual concernsAsk GroupIf they know who their DCP isWhat their aspirations of the course are

Immediate Causes

Unsafe Acts

Unsafe Conditions

Immediate Causes

Unsafe Acts

Unsafe Conditions

Underlying Causes

Human FailureSlips/Lapses, Mistakes or Violations

Missing or Inadequate Control Measures

Identify Facts and Failures

Immediate Causes

Unsafe Acts

Unsafe Conditions

Underlying Causes

Human FailureSlips/Lapses, Mistakes or Violations

Missing or Inadequate Control Measures

Identify Root Causes

Influencing Factors Personal

Influencing FactorsJob or Organisational