ACCIDENT & INCIDENT INVESTIGATION · 2014-10-07 · HSG245 Accident & Incident Investigation Form...
Transcript of ACCIDENT & INCIDENT INVESTIGATION · 2014-10-07 · HSG245 Accident & Incident Investigation Form...
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ACCIDENT & INCIDENT
INVESTIGATION
Course Directors
Lyn Harris & Graham Richens
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Welcome
Fire Alarm
Meals, Breaks, Toilets
Smoking area
Mobile Phones
Dress Code, Behaviour.
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Aim
To familiarise safety leaders with the
principles of
‘Accident & Incident Investigation’.
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Objectives
Discuss causes of accidents & incidents
Be aware of investigation policies
Consider different approaches to investigations
Help to prevent reoccurrences
Understand reasons & benefits of investigations
Gain Experience by Case Studies & Practicals.
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Brief Introductions
Name
Branch Board
1 thing you would change in your Force?
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List 10 causes of accidents in the
Police?
1. Lack of Information
2. Lack of Instruction
3. “ “ “ Training
4. “ “ Supervision
5. Human Error / Failings
6. Criminality
7. Poor Policies, Procedures, Practices
8. Inadequate Equipment or Resources
9. Tiredness
10. ‘F’ Factor.
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Reasons for Investigations?
Legal?
Criminal
Civil
Moral
Ethical
Financial
Efficiencies.
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Legal Reasons For Preventing Accidents
Compensation claims in civil courts
Out of court settlements
Enforcement notices
Corporate fines
Personal fines
Imprisonment.
}civil
} Criminal
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Benefits of Good Health & Safety Standards
accidents
injuries
sick leave
claims
costs
staff turnover
↑ performance
↑ productivity
↑ morale
↑ legal compliance
↑ reputation.
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HSE Statistics
2013
Fatalities = 148
Major/Specified = 19,707
Over 7 day “ = 175,000 (formerly 3 day)
Other Injuries = 78,222
Work illness = 1.1 Million
Work costs = £13.8 Billion.
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Police Service Injury & ill-
health statistics 2010
Fatal Injuries
2
Major/Specified
777
Over 3 day
2 340
Total
3 119
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£ Cost to
Greater Manchester Police
Police Officer strength 2008
7992x £250 x 8.5 days = £16,983,000
Support Staff strength 2008
4353x £150 x 9.5 days= £6,203,025
235 Officers per 100,000 populous
Home Office Statistical Bulletin 30th September 2008
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Worst Industries?
Agriculture
Construction
Manufacturing
Waste Recycling
Services
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RIDDOR – Reportable Outcomes
Enforcing Authority to be notified of:
Fatalities result of work accident
Specified injury
Hospitalisation of person
Off work over 7 Days
Industrial Diseases
Dangerous occurrence
Form of Report
Online
Phone 08453009923
Accident Book BL510.
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Accident & Near Miss
Accident = Event that results in injury, ill health or loss
Near Miss (HSE) = An event that, while not causing harm, has the potential to cause injury or ill health.
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Dangerous Occurrence (RIDDOR): If something happens which does not result in a reportable injury, but which could have done, it may be a listed dangerous occurrence
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What are your Forces
investigation policies,
procedures, or practices?
Does your force investigate Acc’s & Near misses?
Do they Review ‘Risk Assessments’ after?
Is ‘Reporting’ Encouraged or Discouraged?
Do they seek to ‘Blame’, or ‘Learn & Develop’?
Do they work ‘Together’ with all ‘Parties’?
Is there a Positive Health & Safety Culture?.
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Which events should be
investigated?
Consider:
Potential consequences
Likelihood of adverse event recurring
Not simply the injury / ill health suffered on this occasion
Include ‘Near Misses’.
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Consider different approaches
to investigations
HSG245
Accident & Incident Investigation Form
Protocol for Liaison (Work-related deaths)
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Help to prevent re-occurrences
Immediate Response
Inform All Stakeholders
Gather & Analyse Information
Identify Possible Causes
Suitable Risk Control Measures
Agree Action Plan & Implementation
Monitor & Review.
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Benefits arising from an
investigation?
Understanding of how / why things went wrong
True snapshot of what really happens, and how work
is Actually done
Identifies deficiencies in risk control management
Prevention of further similar adverse events
Prevention of losses
Improvement in morale and attitude towards H&S.
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Accident Investigation
In addition, investigation will enable services to:
Report certain accidents and dangerous occurrences to
the HSE, Reporting Injuries, Diseases & Dangerous
Occurrences Reg’s 2013 (RIDDOR);
Comply with Social Security (Claims and Payments)
Reg’s 1979. Preservation of data about injured persons,
Enables claims for industrial disability to be processed.
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Rights, Wrongs, & Entitlements?
1. What Must the Force do?
2. What should Safety Reps Do / Not do ?
3. Accidents Good/Bad Practice?
Reg 6-7 Safety Reps & Safety Committees
Reg 6 = Inspections after A.I.O.& D’s
Reg 7 = Provision of Information
JBB Circular 30 / 2010 Computer Data.
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Accident / Incident Investigation,
Issues to be covered
Circumstances of accident / incident
What preventive measures were in place
before the accident
Breaches of relevant legislation
What measures are necessary to prevent
recurrence of accident/incident
Person(s) who can implement changes.
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A.I.I. Form Reported by:
Date/time of event:
Incident
Ill Health Minor Injury Serious Injury
Major Injury
Brief details (What, where, when, who and emergency measures taken):
Ref no:
Accident and Incident Investigation Form
Overview
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Accident / Incident
Investigation
Step 1: Gather Information
Step 2: Analyse the information
Step 3: Identify risk control measures
Step 4: Action plan & implementation.
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Step 1 - Information
Gather information
Where & When did the event happen
Who was injured / involved
How did the event happen
What activities were being carried out
Anything unusual
Were safe working procedures foIIowed
Injuries / ill-health effects caused.
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Step 2 - Analysis
Should be objective and unbiased
Identifies consequence of events that led
up to accident / incident
Identifies the immediate causes
Identifies the underlying & root causes
Achieved by asking WHY?.
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Fall from a ladder: what happened and
why? John breaks his leg
John is on ladder Fall due to gravity John falls off
Access to the roof
To replace tiles
The ladder slips
Ladder not secured
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Immediate and Underlying Causes
Immediate causes: personal and job factors
Underlying causes: organisation and management
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Causes
Immediate causes
Premises, Equipment, Procedures, People
Underlying causes
Planning, Risk Assessment, Organisation,
Attitudes, Morale, monitoring, review.
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Human failings/factors
human
failings
skill-based
errors
slip
lapse
mistake
violation
no rule
wrong rule
rule breaking
rule/
knowledge
based
mistakes
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Attitudes & Behaviours to H&S
I have to
I should
I want to
It’s automatic
I’m told I must
The company says so
It’s best for me
I just do it
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Case Study: Assault
John is assaulted
John is at his desk Flying monitor John struck by monitor
To deal with the public Thrown by assailant He is unprotected
Angry man Unsecured monitor Screen removed His duty
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Step 3 – Risk Controls
Identify risk control measures missing,
inadequate or not used
Compare actual conditions/practices with
those required by legal requirements,
codes of practice and guidance
Provide meaningful recommendations that
can be implemented.
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Step 4 – Implementation
Action Plans with SMARTA objectives
Specific, Measurable, Achievable,
Relevant, Timescales, Agreed
‘Management, safety professionals,
employees & reps should discuss the
contents of the action plan
Prioritise the implementation of risk control
measures, according to risk assessment.
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Case Study
Assault
Step 3 - Risk Control Measures
Step 4 – Action Plan.
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Case Study: Assault
Steps 3 & 4
Fit rising screen to front desk
Secure computer monitor to counter
Secure chairs in the area
Install CCTV camera in front desk area
Train receptionists to defuse potentially
dangerous situations.
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HSE References
HSG48 - Reducing error and
influencing behaviour
HSG245 – Investigating A&I’s
HSG65 – Successful H&S Management
Stat’s – Police, Security, Law & Order
INDG453 Reporting Accidents &
Incidents at work.