Incident Management: A Health And Safety Whodunit
In this blog post we will talk you through the process of investigating a workplace accident or incident. We will use an example accident and take you step by step through the incident management process so that you can identify gaps in compliance and prevent future accidents in your workplace.
So get your deerstalker hats at the ready for a health and safety whodunit. Except, instead of placing the blame on an individual culprit, in this case, our criminals are the causes, which we will identify and deal with.
Did you know?
Last year there were:
- Approximately 609,000 injuries at work, over 70,000 of which were reportable under RIDDOR;
- 137 deaths at work;
- 31.2 million working days lost;
- £69.9 Million in prosecution fines.
A suitably sensory story, because accidents stick with us
“When I was young, I witnessed the aftermath of an accident in which a man was crushed between the grill of a land rover and a building. The accident was curtained off so all I could see was the boot of the car and bustling paramedics, but my imagination and the buzzing spread of rumour took care of the details. The event, which resulted in fatality, stuck with me.
“As a writer and marketer I’m always looking at what moves people. And you can’t get more visceral than the shock of a real and very nasty accident,” says Becky Stout, our Marketing Executive. “With emotions running high, we can’t help but put ourselves into the shoes of the injured party and imagine what they went through.
“That can cause damage to morale, which in turn can cause losses in productivity, and lowered loyalty and brand trust from customers who’ve read news headlines; as well as the obvious cost implications of potential prosecution, disruption following an accident, compensation, ill-health absence, etc.”
You can minimise plummeting morale by showing that you are doing everything you can to prevent recurrence. In doing so, you are also improving attitudes to safety, particularly if you are discussing causes of the accident/incident with staff at all levels and improving your business’s safety management.
Why is incident management necessary?
Hunting for clues that tell us the causes of workplace accidents and incidents may sound onerous. By identifying these underlying causes will help us to find gaps in compliance, reduce risks, and prevent accidents and incidents from re-occurring in the future.
This is the cornerstone of incident management.
Put very simply: we identify the cause, eliminate it and prevent future accidents.
Incident management can help us understand:
- How and why problems arise;
- The different ways in which people are exposed to harm;
- Why people bypass safety rules and take shortcuts;
- Why your controls are ineffective.
There are legal reasons for investigating accidents, apart from general compliance:
- Meeting requirements of Management of Health and Safety at Work Regulation 5 – plan, organise, control, monitor and review safety arrangements.
- If an injured employee wants to consider legal action, you as the employer have to provide full disclosure of the accident/incident to them.
Incident management definitions
Before we head off into the world of incident management processes, let’s lay down some definitions.
Here are some different categories of ‘adverse event’ (i.e. the event that we are investigating).
Accident: An adverse event that results in injury, ill health, property or environmental damage, or production loss.
Incident: undesired circumstance with the potential to cause harm. I.e. near miss.
Dangerous occurrence: a specific, reportable event that is covered under RIDDOR. (More to come in the next few weeks about recording and reporting accidents. Subscribe to our blog at the bottom of the page if you’re interested in having safety explained.)
The following definitions are used, though be aware, there are different versions out there:
Fatal: Work related death.
Major: Anything defined under RIDDOR (broken bones, fractures, amputation, burn etc).
Serious: Injured party is unfit to carry out their work for more than 3 days.
Minor: Injured party is unfit to carry out their work for less than 3 days.
Damage: to property, equipment, production loss or environment.
Immediate: the most obvious reason for an ‘adverse event’ to occur, such as a wet floor causing a fall. There could be more than one immediate cause.
Root: The reason behind all immediate causes. These are usually planning or management failings, such as not enough supervisors on duty for that day due to absence.
Underlying: Hidden causes from which root causes originate. These are usually less obvious strategic level failings stemming from a problem in your management system. Examples could be internal audits not carried out or insufficient supervision for a dangerous activity.
What do we investigate?
What types of ‘adverse event’ do you investigate? Do you need to investigate a near miss? What about ‘damage only’?
If there is a potential to cause harm again in the future, even if in this instance no one was hurt, then finding and eliminating the causes is absolutely worth your time, so that a similar event doesn’t happen again.
There are different levels of investigation for incident management depending on the level of potential harm. More about that later.
Who should perform an investigation?
The investigation should be carried out by someone within a position of respect, an area manager or supervisor, for example. They have a vested interest in preventing future accidents/incidents within ‘their’ department, they know the people involved, and they have the ability to immediately oversee the implementation of any controls.
How do we investigate accidents / incidents?
If possible, the investigation should be carried out as soon after the event as possible whilst the details are fresh in everyone’s mind and witness accounts will be the most reliable.
Take a look at this infographic, which details the general incident management process.
Incident management is NOT about blaming people. During interviews we need to be objective and clear that we are not looking for a ‘culprit’ to place the blame on. We are simply finding evidence that can help improve safety management and prevent recurrence.
The interviewee should be asked open and not ‘leading’ questions. You should take notes, and have them confirmed and changed if necessary after you’ve finished the interview. Here are some ideas of who you could consider interviewing:
- Witnesses: such as supervisors, team members, bypassers, etc;
- ‘Experts’: which, in this case, refers to others who have experience doing the same job or activity in question;
- Injured party: to get their account of what happened. If possible, it’s best to get this soon after the accident. Although this is not always possible or ethical. It may, therefore, be necessary to visit them in their home or at hospital, subject to permission. This should be approached tactfully.
Earlier we mentioned different levels of investigation.
A basic investigation for a low level incident / accident might only look for root causes. You can just keep asking ‘why’ until you work your way down to a root cause.
An employee slipped and broke their arm. Why?
There was a wet floor after cleaning, with no signage displayed. Why?
Cleaning staff forgot to display signage. Why?
Health and safety training not up to date. This is your root cause. You now know you have an issue with your training arrangements, which can be put right to avoid this situation from happening again.
A more in depth investigation might include the following information:
- Details of injured party: employee name; age; gender; job title; hours worked; training; etc.
- Description of the accident/incident: date; time; exact location; weather conditions, immediate actions that led to the event; relevant details of PPE usage, risk assessments and safe systems of work in place; could the injured party returned to work that day.
- Details of consequences: details of injury or ill-health; who was affected; severity of harm; damage or disruption.
- Details of causes: immediate, root, and underlying.
- Details of immediate response: first aid response; management response; emergency procedures; etc.
- Written statements: management; witness; both of which should be signed and dated.
- Recommendations for corrective action; with task/deadline dates.
- Photographs with time stamps: where necessary.
The HSE have produced a workbook you may find useful (HSG245). You can download it here.
Hopefully this information will give you enough to go on when investigating accidents or incidents that may happen in your workplace. However if in any doubt, or if you have any complex queries, please feel free to contact us on 01926 623 133 or by email.
If you would like more information on RIDDOR reportable accidents, please subscribe to the ADL Associates Safety Blog below as we will be covering this in the next few weeks.