Fire Precautions
Fire Precautions :– If continuous alarm sounds – leave the building by the nearest exit – Report to the tutor at the assembly point
INTRODUCTION
Tea / coffee facilities Toilets
No smoking
First aid / fire Mobile phone / pagers Trainee introductions Please ask questions at any time
OVERALL AIMS
An understanding of the process and
purpose of investigating incidents
Remember : Includes ill health as well as
injury accidents
An understanding of the legal and
organisational requirements for recording and reporting
2003/04 Statistics
235 fatalities
159,809 RIDDOR reported injuries
An estimated 2.2 million people suffering
from an illness caused or made worse by their current or past work An estimated 39 million working days lost 30 million due to ill health & 9 million due to injury
The Reporting of Injuries, Diseases and dangerous Occurrences Regulations (RIDDOR) 1995
What‟s the point of RIDDOR?
HSE/EHO need to know about the more
serious accidents, diseases and dangerous occurrences at work so they can perform their statutory role.
They can analyse where and how risks
arise and then investigate/enforce.
What needs to be reported?
Death or major injury:
– employee or a self-employed person working on your premises is killed or suffers a major injury (including violence), or; – a member of public is killed or taken to hospital
Over-3-day-injury:
– employee/self-employed off work, or incapacitated for normal work for more than 3 days;
Disease:
– doctor notifies you of reportable work-related disease;
Dangerous occurrence:
– categories of near-misses.
The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995
Reporting procedures cover: fatalities and major injuries incapacity to work for more than three days specified diseases dangerous occurrences 2.1
RIDDOR
Covers: employers employees self-employed trainees other people injured on premises
RIDDOR
Major injuries include: fracture of:
skull, spine, pelvis arm, leg, wrist, ankle
– amputation through any bone
– loss of sight (temporary or permanent
RIDDOR
Major injuries (continued):
certain eye injuries electric shock requiring attention unconsciousness through lack of oxygen acute illness due to exposure to certain materials hospitalisation for more than 24 hours
RIDDOR
Reportable occurrences:
structural collapses
fires and explosions
release of gases or other dangerous substances failure of breathing apparatus while in use scaffold collapse
contact with or arcing of overhead cables
RIDDOR
Reportable diseases: • any disease listed in the regulations as „reportable‟
Social Security Act 1975 and RIDDOR
Every accident involving personal injury to an employee must be entered in the accident book by:
the employee, or someone acting on behalf of the employee The accident book must be kept accessible. An employer must investigate all accidents reported
Reporting to enforcing authorities
Since 01 April 2001, you can report accidents and occurrences to the Incident Contact Centre by: telephone fax e-mail post Reporting accidents and occurrences direct to the local HSE Office, on Form F.2508 or F.2508A, is still acceptable.
Report to enforcing authorities
F.2508 must be sent to the enforcing authorities in cases of:
injury at work resulting in more than three consecutive
days‟ incapacity death of an employee within one year of sustaining a reportable injury a reportable disease when diagnosed by a registered medical practitioner
RIDDOR: Answers
Details of employee injury (normal working Monday to Friday 8.00 am to 5.00 pm)
Days off work Hrs in hospital
Tick if RIDDOR applies
1
Sprained arm (put on „light duty‟ with 5 days off normal job)
1 day
30days
1 day
Nil
No
The „light duty‟ counts as 5 days off work
2 3 4 5
Broken arm
4 hrs
3 hrs 3 hrs
Nil Nil
Any fracture but not toes and fingers
Broken finger
Broken finger
4 days
1 day
This is because of more than 3 days off work
Dermatitis
Only if confirmed by doctor
6
Sprained ankle on Thursday, returns to work on Tuesday
2 days
4 days not available for work (includes Sat and Sun)
RIDDOR: Answers
Details of employee injury (normal working Monday to Friday 8.00 am to 5.00 pm)
Days off work Hrs in hospital
Tick if RIDDOR applies
7 8
Amputation of finger Vibration white finger
2 days
6 hrs
Any amputation Only if confirmed by a doctor 3 days or more off work
nil
nil
9
Twisted ankle
4 days
nil
10 11 12 13
Twisted ankle
1 days
3 hrs
No
No
Over 5 metres high Unconsciousness
Electric shock (not unconscious)
2 days
nil
Electric shock (unconscious)
2 days
25 hrs
Electrical fault causing fire but workshop out of use for only 24 hours 6 metre high scaffold collapses
N/A
N/A
14
N/A
N/A
Accident/Incident Investigation
RIDDOR only requires reporting of
incidents etc. No explicit legal requirement in any H&S legislation to investigate - therefore WHY DO IT?
?
?
Accident/Incident Investigation
HSW Act states - “employers must
ensure….the health, safety and welfare of employees...” etc. Reactive monitoring - to prevent the same or similar from happening again Review/revise risk assessments and associated H&S documentation/working practices
Are you learning the lessons?
?
Do you investigate incidents & accidents in your company?
Do you do it well? Do you find the underlying causes? Do you take corrective action? Do you review your risk assessments as a
result?
Do you do it?
Accident Investigation Law
Explicit legal duty to investigate accidents
HSE on Accident Investigation 1999
Most accidents are not investigated
safety specialists lead rather
than line managers effort determined by severity of the injury rather than potential of the event little employee involvement if line managers do investigate, little training in investigation skills and techniques immediate technical causes only cont’d
29
HSE on Accident Investigation 1999
often stops when someone is found to blame fails to get to underlying causes
Even if there is an investigation:
failure to monitor full implementation of
investigation findings failure to systematically record findings so that lessons can be learnt throughout the organisation Most firms don‟t know why accidents occur !
30
Integrated approach to accident investigation and risk assessment
ie it should be integrated but usually isn’t!!
from HSE CD169/2001
Integrated approach to accident investigation and risk assessment
ie it should be integrated but usually isn’t !!
from HSE CD169/2001
Near misses are important
Powerful advantages
why not take the “free lessons”? equivalent learning opportunity…
…but, without the legal and liability
implications
Team based investigation
RoSPA study - best practice
led by senior managers involving employees, including
safety representatives supported by OS&H professionals acting as facilitators
Team based investigation
Local knowledge, especially operational
Building of trust;
Creates workforce 'champions' for H&S; Check on safety management standards Investigation of lower risk safety issues is
important in creating a positive climate for more structured investigation when major safety failures occur.
Summary
It will help prevent accidents It should fit in with existing risk assessment
practice It should be part of H&S management It will become an explicit legal duty but, most importantly… … Good accident / incident investigation will improve safety
The Cost of Accidents at Work
£££
So why bother with H&S?
Premiums Uninsured losses Reputation Morale Productivity
Pain and suffering Duty to fellow human being
Fines and costs Court time Civil cases Notices
Humane
Prevent suffering and maintain quality of life No-one should be expected to risk life and
limb in return for a contract of employment
The true cost of an accident
To the victim: pain and suffering extra cost, less income continued disability incapacity – for job and other activities the effects on others
The true cost of an accident
To those responsible: worry and stress recrimination and guilt extra work a) reports b) staff replacement loss of credibility
The true cost of an accident
To the working group:
shock and personal grief low morale affected production
Is good health & safety good business?
The true cost of an accident
To the firm: lost working time a) the victim b) others damaged equipment insurance costs prosecution or civil action
“We recognise the importance of costing loss events as part of total safety management. Good safety is good business”
Dr. J Whiston, ICI Group SHE Manager
“Safety is, without doubt, the most crucial investment we can make, and the question is not what it costs us, but what it saves.”
Robert McKee, Chairman Conoco (UK) Ltd.
“Prevention is not only better, but cheaper than cure…Profits and safety are not in competition. On the contrary, safety at work is good business.”
Basil Butler, MD British Petroleum plc
“We saved £750,000 on insurance premiums through improving our systematic management of health and safety.”
Birse Group plc
Accident Costs Iceberg
Insurance Costs
Uninsured Costs
Insurance Costs
Employers Liability Public Liability
Product Liability
Motor Vehicle
Uninsured Costs
Product and material damage
Lost production time
Legal costs Overtime & temporary labour
Investigation time/Administration
Supervisors time Fines
Loss of expertise/experience
Loss of morale Bad publicity
Piper Alpha
167 dead
Estimated cost of over £2 billion
Grangemouth
BP refinery fire in 1987
One person died
Cost £50 million in property damage
Cost further £50 million due to business
interruption
HSE Example
Small engineering firm (15 workers) Workers sleeve caught on rotating drill Both bones in lower arm broken 12 days in hospital Off work for 3 months Admin duties for 5 months Unable to operate machinery for 8 months Managing Director Prosecuted 2 employees made redundant to prevent
company going out of business
Costs to Company
Wages for injured worker over period Lost production/remedial work required Overtime wages to cover lost production Wages for replacement worker Loss of time of manager/MD Legal expenses Fines and court costs Increase in Insurance Premiums = = = = = = = = £10000 £8000 £3000 £7000 £4000 £3000 £4000 £6000
Total cost to business = £45000
Costs of slips and trips in GB
To the individual Lost income, pain, reduced quality of life To employers over £500m p.a. Damages, admin. and insurance, lost production, temporary absences To society over £800m p.a. Loss of potential output, medical costs, social security.
What contributes to the slip / trip risk?
Floor Environment Slip/ trip Potential People Contamination Obstacles
Footwear
Unsafe people
Unsafe conditions
Accidents
Some common causes of accidents
Not knowing or not using safe work methods Lack of testing, inspection and maintenance Unsafe manual handling Working too fast or cutting corners Overloading equipment
cont’d
Some common causes of accidents
Not using: guards, scaffolds, platforms, etc. Ignoring or disregarding: warning signs statutory notices Untidiness or carelessness Horseplay
Safety in the workplace requires
Safe systems of work and good
organisation
Good defect reporting and maintenance
arrangements
Careful, safety-based work planning The correct tools and equipment for the job
in hand
cont’d
Safety in the workplace requires
Knowledge of, and compliance with, safety
law Adequate information, training, instruction and supervision Common sense and a mature attitude
Reporting accidents
An accident book should be available in all work situations The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 reportable injuries three days or more off work certain listed injuries No report: no proof no future safeguard
Reporting accidents
Dangerous occurrences: Collapsed or overturned items of plant Explosion or bursting of closed vessels Reportable diseases: Certain diseases associated with specified work activities
THE LAW AND HEALTH & SAFETY
Oberon: “This is thy negligence - thou mistakest or else commit’st thy knavery wilfully”
Shakespeare
UK legal system
Criminal
By HSE or LA Leads to a fine/imprisonment Not insurable
Civil
By injured person Leads to award of damages Must be insured
EXERCISE
You are going to work by bus. You buy a ticket (a “contract” with the bus co). During the journey, the driver collides with another vehicle and you suffer minor cuts and bruises. By the time everything is sorted out, you are very late for work. You sprint from the bus stop and trip over a paving stone, breaking your arm. Who is, if anybody, is liable for your injuries?
COMMON & STATUTE LAW
Common law is unwritten being derived from local & customary laws and the decisions of judges but is nevertheless binding
It evolves continuously as precedents are established
decisions of a lower court can be overturned by a higher court
Statute law is passed by Parliament, approved by the Sovereign & is written (published law)
It takes precedent over all other forms of Law (Common Law)
etc
Some Statute law is derived from decisions of the European
Union (Directives etc)
BURDEN OF PROOF
Criminal Law exists to punish offenders
and guilt must be established “beyond reasonable doubt” Civil Law is concerned with compensation and redress: the burden of proof is “the balance of probability” This is a lower standard of proof and a civil action may succeed where a criminal case has failed
CIVIL COURTS (ENGLAND & WALES)
The County Courts deal with Civil cases. The
judge normally sits alone though a Jury may sometimes be empanelled The High Court of Justice may also deal with civil cases The Court of Appeal (Civil Division) hears appeals from the lower courts Once again, the House of Lords is the ultimate court of appeal Civil cases are often settled out of court
CIVIL ACTION
If an accident occurs and somebody suffers injury or loss and negligence or breach of statutory duty can be proved damages may be recoverable
Documents, including accident reports, risk assessments etc must be disclosed on request
TIME LIMITATIONS
Actions for personal injury claims etc
normally have to be brought within 3 years of the accident In the case of a disease such as asbestosis the limitation is 3 years from the diagnosis of the condition Courts have the discretion to allow time barred cases to proceed in some circumstances
NEGLIGENCE
Donoghue v Stevenson (1932) must take reasonable care
to avoid acts/omissions which you can reasonably foresee would be likely to injure your neighbour”
This duty of care is owed to people who are closely &
directly affected by your acts/omissions (e.g. employers, employees, contractors, visitors, suppliers)
defences against actions include: no duty owed, duty not
breached, breach did not lead to damage, risk accepted voluntarily,contributory negligence
Bradford vs Robinson‟s Rentals (1967): employer liable for reasonably foreseeable frostbite injuries to B
SAFE SYSTEM OF WORK
Wilson & Clyde Coal v English 1938 A leading case which established an Employer‟s duty of care towards employees “Master‟s duty to a Servant” Safe premises Safe plant & equipment Competent fellow workers Adequate supervision (cf Health & Safety at Work etc Act)
BREACH OF STATUTORY DUTY
Damages can be recovered if it can be proved that
loss occurred because of the defendant‟s failure to comply with a statutory requirement May be easier to prove than negligence, especially if the breach has been established by a criminal prosecution Main defences: duty not breached, injured party not protected by statute, harm not of type statute designed to protect, contributory negligence Some statutory duties are absolute
VICARIOUS LIABILITY
Employers are vicariously liable for the
actions of their employees provided that the employees were acting in the course of their employment (sometimes even if the activity was expressly forbidden) Limpus vs London Omnibus Co. (1862) Employer Liable for accident caused by negligent employee
DUTIES OF EMPLOYEES
Employees may also be sued. They have a
duty to: - To carry out duties with reasonable care - To avoid loss to Employer (cf Health & Safety at Work etc Act) NB. Employers not liable for activities that do not form part of employees‟ employment “servant‟s frolic of his own” Storey v Aston (1869) Employer not liable for accident caused during unauthorised detour
REASONABLE PRACTICALITY
Edwards v National Coal Board (1949) Risk must be
insignificant in relation to sacrifice (time, effort & expense): NCB claimed unsuccessfully that it was not reasonably practicable to shore up all mine roads
Marshal v Gotham & Co (1954) If something is practicable,
courts will not lightly hold that it is nor reasonably practicable
Adsett v K&L Steelfounders & Engineers Ltd (1953) The
standard of practicality is that of current knowledge not having sufficient resources is no excuse for inaction
DEFENCE OF NECESSITY
A defendant may claim that his/her actions
arose from necessity (e.g. to prevent a more serious accident) ESSO Petroleum Co v Southport Corporation (1955) A captain of an oil tanker jettisoned oil in bad weather to safeguard the crew: ESSO convinced the court that this was a necessary act and not negligence
CONSENT:“VOLENTI” DEFENCE
“Volenti non fit injuria”: cannot expect redress if
you consent to an act likely to result in injury or loss Cutler v United dairies (1933) Cutler failed to recover damages after being injured trying to restrain a bolting horse: it was held he consented to the risk Haynes v Harwood (1935) A policeman was able to recover damages after being injured restraining a bolting horse: he had a legal duty to protect life & property and was not held to have consented willingly to the action
CONTRIBUTORY NEGLIGENCE
Where a person suffers damage or loss Partly his/her fault Partly the fault(s) of other person(s) Damages may still be recoverable but the amount will be reduced in proportion to the claimant‟s responsibility Saywer vs Harlow UDC (1958) Contributory negligence was accepted after a woman was injured when she put her foot on a revolving toilet roll while trying to get out of a cubicle
OCCUPIER‟S LIABILITY ACTS (1957 & 1984)
Duty of reasonable care to lawful visitors
(invitees, licensees, contractors & those with a right under law) Need to ensure premises are reasonably safe. Dangerous defects must be repaired and warning notices displayed as necessary Should expect children to be less careful than adults Common Law duty not to cause trespassers intended harm
TRESPASS: CASE LAW
Tichener v British Railways Board (1984)
BRB not liable for injuries to teenage girl hit by a train even though fence was not maintained (Girl frequently & willingly took risk) British Railways Board vs Herrington (1972) BRB liable for injuries to a 6-year old child who had strayed onto the line Bird vs Holbrook (1828) Landowner liable for injuries to a trespasser caused by a spring loaded gun (trespasser unaware of risk)
THE WOOLF PROTOCOL
Lord Woolf (the Lord Chief Justice) drew
up a Personal Injury Pre-action Protocol aimed at simplifying & streamlining claim procedures Claims must proceed to a strict timetable Defendants must investigate claims & disclose relevant documents within the timetable If the protocol is not complied with, Courts may impose tough sanctions
CRIMINAL COURTS (E&W)
All criminal cases are first dealt with by Magistrates Courts.
these can try summary offences and can commit people accused of indictable offences (& commit people for sentencing) to the Crown Court.
The Crown Court tries Indictable offences. Trial is before a
Judge (with a Jury in contested cases. Can also hear appeals from Magistrates Courts.
The High Court of Justice hears appeals from Magistrates &
some appeals from Crown Courts.
The Court of Appeal (Criminal Division) hears appeals from
Crown Courts it can amend or reverse decisions or remit cases to lower courts
The House of Lords is the ultimate court of appeal
HEALTH & SAFETY AT WORK ETC ACT 1974 (HSAWA)
Section 2: duty to ensure, so far as is reasonably practicable the health safety & welfare of employees safe workplace & safe working practices information, training & supervision adequate welfare facilities health & safety policy safety representatives & committees
Section 3: employers to conduct undertakings so as to ensure so far as is reasonably practicable that persons not in his employment are not exposed to risks to their health & safety
HSAWA - (ii)
Section 4: duty of those in control of premises to
non-employees Section 6: duties of manufacturers & suppliers (includes provision of safety information) Section 7: duty of employees to take reasonable care for their health & safety and that of others affected by their acts/ omissions and to co-operate with employer Section 8: no person to intentionally/ recklessly interfere with or misuse anything provided for health, safety or welfare
Section 9: no charge to employees for H&S items
HSAWA - (iii)
Section 36: where the commission of an
offence is due to the default of another person - that person shall be guilty of the offence Section 37: Directors are responsible (as well as the body corporate) for offences committed with their consent/connivance or attributable to any neglect on their part
HEALTH & SAFETY REGULATIONS
Made under the Health & Safety at Work etc
Act 1974 Often required by European Directives Consultative Documents issued by Health & Safety Commission Signed by the Secretary of State Laid before Parliament Have coming into force (CIF) dates Most may be cited in “breach of statutory duties” actions (but not HSAWA or MHSWR)
REGULATIONS !
Management of H&S at Work * Workplace Health, Safety & Welfare * Working time * Provision & Use of Work Equipment * Personal Protective Equipment at Work * Display Screen Equipment * Manual Handling Operations * Safety Signs & Signals * Pressure Systems * Electricity at Work * First Aid at Work * Control of Substances Hazardous to Health * Control of Asbestos at Work * Genetic Modification (Contained Use) Regulations * Dangerous Substances & Explosive Atmospheres * Ionising Radiations * Genetic Modification * Reporting of Accidents, Incidents & Dangerous Occurrences
MANAGEMENT OF HEALTH & SAFETY AT WORK REGULATIONS
Assessment of risks
planning, organisation, control monitoring &
review health surveillance competent H&S personnel emergency procedures information & training co-operation with other employers serious dangers/shortcomings
PROVISION & USE OF WORK EQUIPMENT REGULATIONS
Work equipment suitable for use
maintained in good repair information, instruction & training
machine guarding
precautions against specified hazards controls, isolation, stability, lighting markings & warnings mobile work equipment & power presses
CONTROL OF SUBSTANCES HAZARDOUS TO HEALTH REGULATIONS
Risk assessment elimination or control of risk
maintenance of equipment
environmental monitoring health surveillance emergency procedures information, instruction & training
APPROVED CODES OF PRACTICE
ACOPs are prepared by the Health & Safety
Commission Although they are not laid before Parliament, they have a legal status They set out how Regulations may be complied with You do not have to follow the ACOP but if you do not you may have to prove that you complied with the Regulations by other means
ENFORCEMENT OF H&S LAW: POWERS OF INSPECTORS (HSE etc)
Entry to premises Involvement of police
Make necessary examinations & investigations
To direct premises are undisturbed To take photographs, measurements & samples
To order plant to be dismantled
Require witness statements Inspect documents etc
HSE ENFORCEMENT POLICY
See HSE Enforcement Policy Statement Proportionality: relating enforcement to how far the duty holder has fallen short of legal requirements Targeting: concentrating on the most serious risks Consistency: taking a similar approach in similar circumstances Transparency: telling duty holders what is expected of them
NOTICES & PROSECUTION
A Prohibition Notice prohibits an activity (e.g. use of a
dangerous machine)
An Improvement Notice requires improvements (usually
within a time scale)
Organisations can appeal against notices to an Industrial
Tribunal
The HSE “names and shames” offenders Enforcing Authorities can prosecute offenders for breaches
of HSAWA or Regulations made under HSAWA
MAX PENALTIES UNDER HSAWA
Failing to comply with an Improvement/ Prohibition
Notice: Lower court £20,000 and/or 6 months in prison Higher court unlimited fine and/or 2 years in prison Breaches of sections 2-6 of HSAWA Lower court £20,000; higher court unlimited fine Breaches of regulations etc Lower court £5,000; upper court
unlimited fine
R v ASSOCIATED OCTEL
A contractor working for AO suffered severe burns
when a lamp broke setting fire to solvent vapours The contractor‟s company was prosecuted under Section 2 of HSAWA (duty to employees) AO was convicted under Section 3 of HSAWA (duties to others) AO appealed on the grounds that the work of the contractors was “not part of AO‟s undertaking” The appeal went all the way to the House of Lords before finally being dismissed: the work was part of AO‟s undertaking and they had a duty to ensure the H&S of the contractors
CORPORATE MANSLAUGHTER
A company cannot “have a criminal state of mind” At present, a company can only be convicted of
manslaughter if “the Controlling mind” is first proved guilty This is normally only possible with very small companies R v OLL Ltd (1994) following the death of 4 children on a canoe trip OLL fined £60K & the managing director jailed
Changes in the law are imminent
Legal Requirements
Health & Safety at Work etc Act 1974 Management of Health & Safety at Work
Regulations 1999
Failure to comply is a criminal act Employers CANNOT insure against failure
to comply
Section 2
Section 2(1) - employers‟ general duty
Duty to ensure „so far as is reasonably
practicable‟, the health, safety and welfare at work of employees and any others who may be affected by the undertaking….
Legal Standards
“Reasonably Practicable” or “SFARP”
Implies a weighing up of the risk against the cost
(in terms of time, money or trouble) of preventing or controlling the risk
Section 2 (cont.)
Provision of such information, instruction,
training and supervision as is necessary to ensure , SFARP, the health and safety at work of employees and any others who may be affected….
Section 2 (cont.)
Duty of Employers to Employees cont. 2.2a - safe plant and systems of work 2.2b - safe use, handling, storage and transportation of articles and substances 2.2c - information, instruction, training and adequate supervision 2.2d - safe place of work and a safe means of access and egress 2.2e - safe working environment and adequate welfare facilities
Section 7
Duty of Employees at Work It shall be the duty of every employee whilst at work: to take reasonable care of their own health and safety and of any other person who may be affected by their acts or omissions to co-operate with their employer so far as is necessary to enable that employer to meet their requirements with regards to any statutory provisions
Section 21
Improvement Notices If an inspector is of the opinion that a person: is contravening one or more of the relevant statutory provisions; or has contravened one or more of those statutory provisions, in circumstances that it is likely that the contravention will continue or be repeated, then he will issue an Improvement Notice.
Section 22
Prohibition Notices If any activity is being, or is about to be, carried out that could result in serious personal injury, then an inspector may issue a Prohibition Notice. This notice will cause the immediate cessation of the activity involved until all measures are rectified.
Enforcement
The HSE can take legal action against an employer/employee in a criminal court for H&S failures: Unlimited fine and/or Custodial sentence (Remember - you cannot insure against failure to comply with H&S legislation) If guilty = criminal record
British Justice
INNOCENT until proven GUILTY beyond ALL REASONABLE DOUBT
Civil Litigation
Provides for compensation to be paid to persons who suffer harm as a result of a work activity. Can insure - Employers Liability Insurance Burden of proof is NEGLIGENCE Proof is “on the balance of probabilities” Effectively “guilty until you prove your innocence”
Reportable
Reporting of:
Injuries (accidents & incidents)
Disease
Dangerous Occurrences
(Regulations)
Why investigate?
It is a reactive element in monitoring
phase of your safety management system:
– Eliminate the causes and underlying causes to prevent a recurrence; – Identifying safety management lapses by examining shortfall between what you plan to happen and what did happen; – Identify trends and patterns for future prevention; – Evaluates organisation‟s position in relation to potential breaches of law.
Why investigate?
Accident Reporting & Investigation
Objectives for this section:
– to understand:
accident definition accident causation accident costs accident prevention accident reporting/notification accident investigation
Accident Reporting & Investigation
Common Uninformed Comments
– accidents just happen – we don‟t have many accidents – safety is expensive – the insurance will pay – safety is just common sense
Accident Definition
Accident Reporting & Investigation
what is an accident?
unplanned & uncontrolled event that led to, or could have led to:
– injury to persons, damage to property/plant/equipment, impairment to the environment or some other loss to the company
Accident Reporting & Investigation
Accident Definition
accident types
– – – – – – minor dangerous occurrence near miss plant/equipment damage minor injury lost time injury disablement/fatality
Accident Reporting & Investigation
– Accident Definition
Frank Bird (Accident Triangle)
– – – – 600 near misses 30 property damage 10 minor injuries 1 serious injury (lost time or fatal)
THE ACCIDENT
BASIC TYPES OF ACCIDENTS
THE ACCIDENT
MINOR ACCIDENTS:
Such as paper cuts to fingers or dropping
a box of materials.
THE ACCIDENT
More serious accidents that cause injury
or damage to equipment or property:
Such as a forklift dropping a load or
someone falling off a ladder
THE ACCIDENT
Accidents that occur over an extended
time frame:
– Such as hearing loss or an illness resulting from exposure to chemicals
THE ACCIDENT NEAR-MISS
Also know as a “Near Hit” An accident that does not quite result in
injury or damage (but could have).
Remember, a near-miss is just as serious
as an accident !
THE ACCIDENT
ACCIDENTS HAVE TWO THINGS IN COMMON
THE ACCIDENT
They all have outcomes from the accident
THE ACCIDENT
They all have contributory factors that cause the accident
ACCIDENT CAUSATION MODELS - 1
ACCIDENT
INVESTIGATE – PROCESS AND OUTCOME STEERED BY INVESTIGATORS’ PRE-CONCEPTIONS OF CAUSATION
CONCLUDE PRIMARY CAUSE IS EITHER:
UNSAFE ACT, or;
UNSAFE CONDITION
DEVISE A RULE FORBIDDING BEHAVIOUR
DEVISE A TECHNICAL SOLUTION
Accident Reporting & Investigation
– Accident Causation
Kings Cross Fire (1987) - 31died
– – – – – – – discarded cigarette accumulation of rubbish poor cleaning regime wooden escalator failure of fire fighting equipment lack of emergency training poor safety culture
Accident Reporting & Investigation
– Accident Causation
Herald of Free Enterprise (1987) - 189 died
– – – – – failure to close bow doors no checking/reporting system commercial pressures internal friction disease of sloppiness
Accident Reporting & Investigation
– Accident Causation
Clapham Junction (1988) - 35 died & 500 injured
– – – – – – – – signal failure incorrect maintenance degradation of working practices training problems communication problems poor supervision excessive working hours failure to learn lessons
Accident Reporting & Investigation
– Accident Causation
Piper Alpha (1988) - 167 died
– – – – – – maintenance error inexperience poor maintenance procedures communications breakdown permit to work system fault safety procedures not practised
Accident Reporting & Investigation
– Accident Causation
Automotive Supplier (1999) - 1 died
– – – – – – – – poor safety culture lack of guarding lack of training poor perception of risk no safe systems of work no risk assessment programme no effective accident system no communication
OUTCOMES OF ACCIDENTS
NEGATIVE ASPECTS
– Injury & possible death – Disease – Damage to equipment & property – Litigation costs, possible citations – Lost productivity – Morale
OUTCOMES OF ACCIDENTS
POSITIVE ASPECTS
– Accident investigation – Prevent recurrence – Change to safety programs – Change to procedures – Change to equipment design
The Aim of the Investigation
The key result should be to prevent a
recurrence of the same accident.
Fact finding: – What happened? – What was the root cause? – What should be done to prevent recurrence?
The Aim of the Investigation IS NOT TO:
Exonerate individuals or management.
Satisfy insurance requirements.
Defend a position for legal argument. Or, to assign blame.
Objectives
Recognise the need for an investigation
Investigate the scene of the accident
Interview victims & witnesses
Distinguish fact from fiction Determine root causes Compile data and prepare reports Make recommendations
ACCIDENTS & ILL HEALTH REASONS FOR INVESTIGATION
to record what happened – RIDDOR legal reporting requirement – compensation claims/insurance to find out what & why it happened – immediate causes (What) – underlying causes (Why) to prevent recurrence – the next incident could be more serious
Traditional approach to accident investigation
Safety management has concentrated on accident investigation as it is a good deal easier than proactive prevention Key features: Search for the primary cause, and Debate whether the primary cause was and unsafe act or unsafe condition
HEINRICH'S TRIANGLE (1950)
1 29 300
MAJOR INJURY MINOR INJURIES NON-INJURY INCIDENTS
Accident causation
First accident model was Heinrich (1931).
Domino theory
Social environment Fault of person Unsafe Act
Unsafe condition
Accident
Injury
Acts and Conditions
UNSAFE ACT UNSAFE CONDITIONS
Human errors Failure to follow
No guarding
Trip hazards
Poor maintenance Poor design
procedures Violations mistakes
HSE Guidance on accident investigations [HSG 65]
Need for line managers to take responsibility
for investigation;
need for adequate training for investigators;
importance of investigating both accidents
and other incidents and near-misses - esp. those with potential for serious injury;
need to deal with immediate consequences at
scene by treating, helping and rescuing persons and making site safe;
cont’d
HSE Guidance on accident investigations [HSG 65] cont’d
investigating to appropriate depth, depending on its
seriousness; guidance on investigation process to investigators, including: – structured approach – appropriate use of observation, documents and interview evidence; – use of model to guide collection of evidence and its assembly for evaluation – need to explore immediate and underlying causes – developing specific objectives for implementing findings – need to record essential data
Attending the accident scene
OBSERVE
– Look at the scene and the surrounding area – Take measurements and produce a diagram – Take photographs INTERVIEW – The injured person and/or witnesses (preferably separately) – At the scene if possible(within 48 hours) – Note down beforehand some key questions to be answered - CHECKLIST – Ask open-ended questions in a friendly manner KEEP AN OPEN MIND (be aware of your bias)
Interviews
Start with initial discussions with preferably
the injured person and peers/witnesses (Mainly what happened)
Then move on to interview supervisors
and senior managers (Mainly why)
Do not rush into statement taking, get an
your role – what needs to be done
Invite safety rep or another person they would
like to sit in, but not answer questions
If trainee under 18 years, interview with an
adult, preferably a parent
Run through your questions and what they
witnessed and make notes to help structure a statement – „Each persons summary‟
A modern approach
Immediate causes and underlying causes
– HSG65 Accidents are Multi-causal Understanding of the complexities of human factors Understanding of management systems Promotion of a safety culture
experience and training, etc;
Description of circumstances - place, date,
time and conditions;
Details of the event - actions leading directly
to event/ direct injury causes;
Underlying causes;
cont’d
Essential data in investigation reports
Details of outcomes: – nature of injuries, ill-health, losses; – severity of harm; – immediate management response and its adequacy; – First-aid response; Potential consequences: – what was the worst that could have happened? – What prevented it from happening? – How often could it recur and how many affected?
Accident investigation
Notified of accident Scene made safe Collect facts to answer 5 Qs: What, when, where, who, how?
By:
1. observation
2. documentation
3. interviews
Refer to relevant standards for comparison: [a] legal or good practice, and; [b] safety management plan.
Analyse differences between what happened and what should have happened to identify causes and underlying SMS lapses
Target report at decision-makers Feed into monitoring/review stages of SMS for validation/verification comparison
Follow-up to implement necessary changes to SMS plan AND site
Accident Reporting & Investigation - techniques
– Accident Investigation
investigation techniques
– – – – – – – – attend promptly ensure medical attention leave scene undisturbed take photographs/sketches take measurements take samples gather documentation interview witnesses
Accident Reporting & Investigation - techniques
– Accident Investigation
investigation techniques
– interviewing witnesses explain purpose their version of events do not listen to „hear say‟ ask open questions avoiding leading or implying do not apportion blame express appreciation
ACCIDENTS ……..... DON‟T JUST REPORT THEM & ………PREVENT THEM !
Working together … … improving safety
What are you doing to involve your workforce?
What is workforce involvement?
Involve the workforce as equal partners
Actively seek their views
Value their positive contribution Enable effective involvement in all areas of
H&S management Be ready to change things and challenge previous management practices Nurture, support and sustain the partnership.
Do you shape up?
Have the workforce as well as
managers been involved in writing the company safety policy? Are all H&S Committee members equal partners? Have safety reps, supervisors and others been trained to enable them to play an equal role in the H&S Committee? Does your company provide cover for workers to enable attendance at safety meetings and training courses?
Do you shape up?
Are employees involved in long term H&S
Are workers involved in writing safe working
procedures? When accidents are investigated are safety reps fully involved? Do H&S audits include safety reps as well as managers?
Where is all this from?
HSE booklet HSG217 “Involving employees
in health and safety” Aimed at the chemical industry – but should apply to everyone Does it apply to you?
Health and Safety Management
Safety Representatives Safety Officers And Safety Committees
Members and Meetings
All work areas Meetings discuss
should be represented Members should be interested,concerne d and willing to learn more about h&s Willing to meet once a month and to communicate with workers
workers‟ concerns Possible solutions Approaches to management negotiations Ongoing concerns and progress reports to union
Functions of Committee
Conduct regular inspections and
surveys on safety and health Respond to workers concerns on OHS Make reports and recommendations to improve compliance with law and standards Propose policies, work plans, projects and activities to reduce accidents and illness Propose and organise training programmes for the workforce
Functions of Committee
Promote and support activities on OHS
Follow up progress of proposals
Report on results achieved, point out
obstacles and problems Investigate, record and report on all accidents, ill health and near misses Propose regulations on health and safety Organise occupational health services
What makes a committee work?
Have a plan and objectives and actively pursue
them with the broadest support possible
Communicate and educate to get that support Need facilities, time off, info and training Agendas in advance, proper minutes, decisions If union reps make coherent proposals in writing:
describe the problem, include the facts; suggest improvements; decide who will do what; timetable and budget.
Directors Responsibilities
“The board needs to recognise its role in engaging
the active participation of workers in improving H&S”
“You should encourage workers at all levels to
become actively involved in all aspects of your health and safety management system”
“The best form of participation is a partnership for
prevention, where workers and their representatives are involved in identifying and tackling potential or actual problems, rather than being consulted only after decisions have already been taken”
“Directors‟ responsibilities for health and safety” UK HSE IND(G)343
Employer‟s role- Planning and Coordination
Understand the legislative requirements and have a
written health and safety policy.
Identify hazards, make a site specific health and safety plan and method statements before work starts
Designate OSH responsibilities - safety officer to
implement safety management on site
Conduct inspections, and meetings with all
subcontractors and with workers to inform, communicate and coordinate and to provide training
Have the necessary information on site regarding
hazards and conduct regular tool box meetings
Use the safety committee as the motor for prevention
Building Partnerships
PLANNING ORGANISATION
H&S
MEASURING
management system HSG65
PARTNERSHIP
POLICY
ARRANGEMENTS
AUDIT & REVIEW
commitment agreed goals
leadership
respect for legitimate interests
shared vision positive culture change
openness transparency
trust honesty
Partnership building blocks
This is what you need to do
Involve the workforce as equal partners
Actively seek their views Value their positive contribution
Enable effective involvement in all areas of
H&S management Be ready to change things and challenge previous management practices Nurture, support and sustain the partnership.
If you do that …
We will genuinely be working together You will be improving H&S The workers will be healthier and safer You will be financially healthier and safer