Incident investigation management procedures

Introduction

Accident and/or incident investigation and analysis are an essential part of managing health and safety. Investigating will ensure that the organisation is operating within the law, will gain an understanding of how and why things went wrong and will assist in preventing future adverse events of a similar nature.

Good practice for investigation has been published by the Health and Safety Executive in the form of HSG245: Investigating Accidents and Incidents the primary focus of which is on the investigation process.

The British Standards Institution has published BS 45002-3: Occupational Health and Safety Management Systems — General guidelines for the application of ISO 45001. Part 3: Guidance on Incident Investigation. This publication provides a framework for managing the accident investigation process.

Pre-planning

HSG245 contains some basic information in respect of action to take as part of pre-planning with the focus on what to investigate and who should undertake the investigation.

The British Standard noted above contains a number of clauses and recommendations that enhance the basic guidance given in HSG245. It commences by noting that understanding the “organisational context” will “improve the effectiveness of accident/incident investigation by proportionate and focused consideration of their context”.

External factors to consider include legal requirements and stakeholder expectations, whileinternal factors include cultural factors (eg no blame approach) and workers expectations.

Both HSG245 and BS45002-3 highlight the need for a collaborative approach to investigations. The former notes that “it is essential that the management and the workforce are fully involved” while the latter notes that “a team approach to investigating incidents helps the organisation involve appropriate workers in the investigation, and ensures that the correct people in the organisation are aware so that other implications for the business can be considered and improvements can be identified and implemented”.

The British Standard provides a useful list of criteria that can be considered as part of pre-planning. This includes:

• types of incidents requiring investigation and associated methods of notifying and reporting

• to whom, when and how the occurrence of incidents is to be reported and investigated, taking account of the potential significance of the incident

• who internally and externally is to be contacted to take charge of the investigation, and how, dependent on the type of investigation

• defining and communicating the expected levels of investigation, in terms of resource allocation, depth and overall approach

• the tools and techniques to be used by those carrying out the investigation

• the competency levels needed by those involved in investigating and investigation report preparation

• the process for reviewing recommendations and implementing actions

• the process for drafting, approving and signing off the report prior to release.

Investigation good practice

Both publications noted above make recommendations for immediate action following an unwanted incident ranging from making the scene safe, preserving the scene and undertaking the necessary initial reporting.

HSG245 then details a four-step approach to the investigation, which can be summarised as follows:

• gathering information in relation to the unwanted event

• analysing the data to identify immediate, underlying, root and causes

• identifying appropriate risk control measures that were absent, inadequate or unused

• planning remedial action and implementing this.

BS45002-3 follows a similar approach. It suggests that the organisation must “determine and collate data”. Whereas HSG245 provides a list of questions to be answered as part of the gathering of information, the British Standard describes a number of actions to take in determining and collating the data.

Both publications cover the need to take into account environmental conditions, equipment and materials used and obtaining documented evidence but BS 45002-3 explains in more detail other aspects.

This includes inspecting the scene and the interviewing of witnesses. In respect of the latter the British Standard notes that “witnesses should be identified and interviewed as early in the investigation as possible whilst their recollection is fresh” and it should be borne in mind “that different witnesses could have a different recollection due to factors such as their location, and their frame of mind at the time”.

As such, it is recommended that the investigation team “should avoid prejudging and/or making assumptions about both worker(s) and situations, as this could result in the investigator leading witnesses and receiving answers which they desire rather than the actual facts”.

In respect of analysing the facts both publications reflect on the need for immediate, underlying and root causes to be identified. In summary, both note the need for the investigation to examine the following:

• management and organisational factors resulting in ineffective management of risk

• job factors such as unsuitable working environment and systems of work

• personal factors including lack of appropriate decision making, behaviour and aptitude to carry out duties safely.

Post-investigation action

Clearly reporting on the outcomes of any investigation is a key element of the whole process. BS45002-3 contains useful information on the content of such a report and highlights the need for the report to be distributed to appropriate persons.

When remedial action is required to prevent recurrence, staff should be fully consulted on any issues that will impact on the activities taking place. Information, instruction and training in any additional control measures, systems of work or protective equipment will have to be considered, along with the potential costs of the remedial action.

Whereas HSG245 refers to the implementation of an action plan to apply identified recommendations (additional risk control measures), the British Standard makes reference to implementing recommendations and also “trend analysis”.

In respect of the latter, it recommends that by “structuring the information on incidents and their causes, trends can be identified which bring to light repeated OH&S exposures, incorrectly evaluated risks and inadequate controls” and, as such, “incident reports over a pre-defined rolling period should be analysed to monitor for trends”.

This could be based around types/category of incidence, consequence of incidents, causes and completion of remedial actions.

It is essential that progress on the identified remedies is closely monitored to ensure that they do not get unnecessarily delayed or even forgotten. There should be a follow-up review to ensure that the actions taken are effective and do not create other unforeseen hazards.

Post-investigation managerial recommendations within the British Standard will assist with this element. These include the following:

• periodic reviews of past incidents by an appropriate management committee, including the status of any recommendations raised as a result of the investigations

• management reviews of incidents to include progress of overdue actions, ongoing investigations and trend analysis

• internal audits completed of the investigation and reporting procedures so as to identify improvements, training needs (of investigators) etc.

Summary

Accident or incident investigation and analysis form an essential part of managing health and safety.

Learning lessons from an investigation is at the heart of preventing further accidents and incidents. The prime objectives should be to:

• determine the facts and sequence of events leading to the accident/incident.

• determine the causes by establishing any unsafe acts or conditions.

• determine the human, organisational and/or job factors that gave rise to the unsafe acts and/or conditions

• take both long-term and short-term measures to prevent a recurrence

• ensure compliance with the law.

To help achieve these objectives, accident/incident investigations should be undertaken within a framework that addresses not only the actual investigation but the necessary pre-planning to ensure an investigation is successful in its objective.

It is also important that post-investigation procedures are adopted that enable not only the outcomes of investigations to be kept under review but also enable any trends to be identified.

Finally, like any system there is a need to have a process that enables it to be reviewed to ensure it remains fit for purpose.