Accident and

Incident
Investigation
an introduction

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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

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Introduction

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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

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RIDDOR

The 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

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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

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The realisation of harm

Hazard

Machine Guard

Safe System of Work

PPE

Undesirable event
Harm

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Session 5 30 minutes
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The realisation of harm

Hazard

Put in extra barriers

Machine Guard

Safe System of Work

PPE

Undesirable event
Harm

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Session 5 30 minutes
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The realisation of harm

Hazard

Machine Guard

Safe System of Work

Identify and remove

the holes (e.g.
latent failures)

PPE

Undesirable event
Harm

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Session 5 30 minutes
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Human Factors

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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.

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wrong action (slip)

Human
Failure to carry
or omitting
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

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Identifying the
Immediate
Causes

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Unsafe act

action likely
to Incidents
result in
Accidents
and
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

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Immediate Causes

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Underlying
Causes

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Underlying Causes

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Why? Because Model

Incide
nt

Person fell down the stairs due to tripping on a

training cable

Why

Why was the trailing

cable at the top of
the stairs?

Becaus
e

The contractor had put it

there

Why

The contractor had

put it there?

Becaus
e

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?

Becaus
e

He had not been briefed

by the supervisor

Why

He had not been

briefed by the
supervisor?

Becaus
e

The supervisor had

become sloppy and
failed to brief the
contractor

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Model of Causal Analysis

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Root Causes
Individual
Competence, personality,
attitudes, risk
perception

Job
Task, workload,
equipment, displays,
controls, procedures

Organisation
leadership, resources,
work patterns,
communications

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Excellent starting check

Section 2, HASAWA* 1974
Employers duties to
employees
So 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

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Responding to an
Incident

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Response to the Incident

Preserve Information
Gather Evidence
Dont 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?

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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

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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

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Identifying what went wrong

Barriers in place
What should have happened
Which barrier failed
Human failure
Underlying causes

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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

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Produce SMART Actions

Specific
Measurable
Agreed / Achievable
Realistic / Reasonable
Timescale / Time based

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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 peoples names
Do not use the terms violation
lapse, mistake in the report

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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

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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

Accident and Incident Investigation an Inroduction Issue 1.0 Augu

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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

Accident and Incident Investigation an Inroduction Issue 1.0 Augu

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