Accident Investigation Presentation
Accident Investigation Presentation
Welcome
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
injury accidents
An understanding of the legal and
2003/04 Statistics
235 fatalities
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
serious accidents, diseases and dangerous occurrences at work so they can perform their statutory role.
They can analyse where and how risks
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:
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
RIDDOR
Reportable diseases: any disease listed in the regulations as reportable
the employee, or someone acting on behalf of the employee The accident book must be kept accessible. An employer must investigate all accidents reported
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
Sprained arm (put on light duty with 5 days off normal job)
1 day
30days
1 day
Nil
No
2 3 4 5
Broken arm
4 hrs
3 hrs 3 hrs
Nil Nil
Broken finger
Broken finger
4 days
1 day
Dermatitis
2 days
RIDDOR: Answers
Details of employee injury (normal working Monday to Friday 8.00 am to 5.00 pm)
Days off work Hrs in hospital
7 8
2 days
6 hrs
nil
nil
Twisted ankle
4 days
nil
10 11 12 13
Twisted ankle
1 days
3 hrs
No
No
Over 5 metres high Unconsciousness
2 days
nil
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
result?
Do you do it?
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 contd
29
investigation findings failure to systematically record findings so that lessons can be learnt throughout the organisation Most firms dont know why accidents occur !
30
implications
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
Humane
Prevent suffering and maintain quality of life No-one should be expected to risk life and
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 cureProfits 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
Uninsured Costs
Insurance Costs
Employers Liability Public Liability
Product Liability
Motor Vehicle
Uninsured Costs
Product and material damage
Investigation time/Administration
Supervisors time Fines
Loss of expertise/experience
Loss of morale Bad publicity
Piper Alpha
167 dead
Grangemouth
BP refinery fire in 1987
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
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
Footwear
Unsafe people
Unsafe conditions
Accidents
contd
organisation
Good defect reporting and maintenance
arrangements
Careful, safety-based work planning The correct tools and equipment for the job
in hand
contd
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
Oberon: This is thy negligence - thou mistakest or else commitst 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?
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
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
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 Robinsons Rentals (1967): employer liable for reasonably foreseeable frostbite injuries to B
loss occurred because of the defendants 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 servants 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,
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 claimants 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
(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
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)
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
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 &
Crown Courts it can amend or reverse decisions or remit cases to lower courts
The House of Lords is the ultimate court of appeal
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
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
review health surveillance competent H&S personnel emergency procedures information & training co-operation with other employers serious dangers/shortcomings
machine guarding
precautions against specified hazards controls, isolation, stability, lighting markings & warnings mobile work equipment & power presses
maintenance of equipment
environmental monitoring health surveillance emergency procedures information, instruction & training
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
dangerous machine)
An Improvement Notice requires improvements (usually
Tribunal
The HSE names and shames offenders Enforcing Authorities can prosecute offenders for breaches
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 contractors 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 AOs undertaking The appeal went all the way to the House of Lords before finally being dismissed: the work was part of AOs 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
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
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:
Dangerous Occurrences
(Regulations)
Why investigate?
It is a reactive element in monitoring
Why investigate?
Accident Definition
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
THE ACCIDENT
THE ACCIDENT
MINOR ACCIDENTS:
Such as paper cuts to fingers or dropping
a box of materials.
THE ACCIDENT
More serious accidents that cause injury
THE ACCIDENT
Accidents that occur over an extended
time frame:
Such as hearing loss or an illness resulting from exposure to chemicals
as an accident !
THE ACCIDENT
THE ACCIDENT
They all have outcomes from the accident
THE ACCIDENT
They all have contributory factors that cause the accident
UNSAFE CONDITION
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 INVESTIGATION
Objectives
Recognise the need for an investigation
Investigate the scene of the accident
Accident causation
First accident model was Heinrich (1931).
Domino theory
Social environment Fault of person Unsafe Act
Unsafe condition
Accident
Injury
No guarding
Trip hazards
Poor maintenance Poor design
for investigation;
need for adequate training for investigators;
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;
contd
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
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
overview first
Statements
Introduce yourself (if necessary)and explain
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
Premises
Physical layout
Condition of building
Environment (weather) Tripping & slipping hazards
PLANT/SUBSTANCES
Machinery guarding
chairs
PROCEDURE
Written system of work/operating
procedure to be followed Safety Policy Work instruction Quality standard Custom and Practice does not have to be a document
People
Human factors
(Supervision) 8) Co-operation
HSG65 APPENDIX 5
IMMEDIATE CAUSE 1. PREMISES 2. 6. 5. PLANNING UNDERLYING CAUSE 9.
ORGANISATION COMMUNICATION
ASSESSING RISKS
10.
ORGANISATION COMPETENCE
3. PROCEDURES 4. PEOPLE
7.
ORGANISATION CONTROL
11.
MONITORING
8.
ORGANISATION CO-OPERATION
12.
REVIEW
Hazards Ideal
Management Arrangements Underlying Causes
Reality
RCS
Workplace Precautions
Accident
Immediate Causes
contd
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
H&S management Be ready to change things and challenge previous management practices Nurture, support and sustain the partnership.
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?
procedures? When accidents are investigated are safety reps fully involved? Do H&S audits include safety reps as well as managers?
in health and safety Aimed at the chemical industry but should apply to everyone Does it apply to you?
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
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
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
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
Identify hazards, make a site specific health and safety plan and method statements before work starts
subcontractors and with workers to inform, communicate and coordinate and to provide training
Have the necessary information on site regarding
Building Partnerships
PLANNING ORGANISATION
H&S
MEASURING
PARTNERSHIP
POLICY
ARRANGEMENTS
leadership
openness transparency
trust honesty
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
it works !