Managers may be required to investigate all sorts of issues, ranging from an employee or customer complaint, a quality issue, through to an accident or near miss. In just about all cases, the chain of events leading up to the incident may not have been planned, but the investigation, with the benefit of hindsight, can invariably identify that it was an incident waiting to happen, i.e. it was foreseeable. Put another way, most incidents happen for a reason, which is usually down to human error, or management failings, but invariably a mixture of both. Indeed, it has been estimated that in the case of accidents, only 5% are events that could not have possibly been predicted.
Therefore, part of the process of any good investigation is to work out more than just what happened, but why, i.e. the root cause. What were the influencing factors? For example, what was people’s motivation for behaving the way they did? Were people taking accepted short cuts which management were well aware of, and permitted to happen by doing nothing to stop it? How well was management overseeing activities, and what part did they play in the acts and omissions that took place, prior to the incident happening?
The purpose of an investigation, therefore, goes beyond establishing the facts leading up to the incident, but involves identifying what were the real factors that led up to the event happening. Like it or not, management usually play a starring role in letting issues happen. The easy option for an investigator is to blame an individual, or series of individuals, but does that actually solve why the incident happened. The more important part of any investigation is to actually make (i) balanced conclusions as to the factors that influenced the incident happening, and (ii) recommendations regarding what steps need to now be put in place to prevent such an incident happening again. Whilst the rest of this article really is more about accident investigation, I would argue that the principles are the same, regardless of what incident is being investigated.
There is no specific legal requirement to investigate accidents and incidents. However, such investigations are a core, if not fundamental, part of a successful health and safety management system. The Health and Safety Executive’s (HSE) document, HSG65 Managing for Health and Safety, promotes a Plan, Do, Check, Act approach. Investigation of accidents and incidents is part of the “Check” step, and may highlight shortcomings in the organisation’s management system for health and safety. The purpose of accident and incident investigation, if done well, should lead to the prevention of such events in the future.
For an investigation to be meaningful there must be a methodology in place, which ensures such outcomes. Managers need to understand how to investigate accidents effectively, and that their remit goes far beyond merely establishing whose fault was it. Sadly, many investigations end up being merely a scapegoating exercise, which is why in the health and safety policies we do for clients, we make it clear that this is not the purpose of an accident investigation.
It is usually not practicable to investigate all minor or apparently trivial accidents, so it is important that organisations take a sensible and proportionate approach to the investigation of accidents. Therefore, decisions need to be made as to what accidents need investigating. It is the potential consequences and the likelihood of the adverse event recurring that really should determine the level of investigation, not simply the injury or ill health suffered on a particular occasion.
Similarly, the causes of a near miss can have the potential to cause injury and ill health, and a decision must be made as to the investigation of such near misses. It will also be important to consider who was injured in the accidents, and it may be necessary to give higher priority to investigations where, for example, young people or members of the public are involved.
The organisation’s policy should also decide when the investigation should take place. The urgency of an investigation will depend on the magnitude and immediacy of the risk involved (e.g. a major accident involving an everyday job will need to be investigated quickly). In practice, where the decision has been made to investigate an accident, it should take place as soon as possible, otherwise evidence may be lost and, individual recollections of the accident may be less reliable. There may also be external demands for an investigation to take place within a defined timescale, e.g. the enforcing authorities or insurance companies may require an investigation.
Who should investigate accidents?
This will depend on the size of the management team, and whether there is someone that takes responsibility for health and safety matters. It is usually a good idea that it is not the Manager that investigates, as there may not be sufficient independence. What I mean by this is that the temptation to cover up acts and omissions may be too great, and it is unlikely that they may admit that poor supervision was a major contributory factor. If the organisation has proper health and safety representatives, it is a good idea to ask for their input, especially if they routinely perform the work or processes themselves.
The collection of information must be detailed. Photographs or videos of the scene should be taken and, where necessary, dimensions and other technical measurements can be helpful, e.g. machine speeds, or the precise measurement of how far someone fell.
Interviewing witnesses will form an important part of any accident investigation. To ensure a clear recollection of events, witnesses need to be interviewed as soon as possible after the accident. Where the injured have been seriously harmed, it may be necessary to delay interviews depending on required medical treatment. Where there are a number of witnesses, it is good practice to separate them immediately after the accident, and prior to interview, to avoid any deliberate or inadvertent collusion, or worse, witnesses are pressurised into not admitting the full extent of what people were doing at the time of the incident.
In all cases, it is important to manage interviews with witnesses carefully. Some may be nervous, and even in shock, if a very serious accident has occurred. It is essential to explain that the purpose of the investigation is to prevent a recurrence, and not to allocate blame.
When interviewing witnesses, and, in particular, when taking statements from witnesses, it is important not to use leading questions, or to put words in the witness’s mouth. The interviewer must also bear in mind that not all witnesses will be helpful and co-operative. Some may be deliberately misleading. Others may be trying to pursue a false claim, or be attempting to cover up actions of their own that were involved in the accident. Consequently, the organisation’s policy for accident investigation should stipulate that giving false evidence during an accident investigation could lead to disciplinary action.
The collection of information, as part of accident investigation, will also include the examination of records relevant to the accident. These may include:
- risk assessments relating to the activities or processes involved in the accident
- relevant working procedures and practices, including any applicable safe systems of work, written or verbal
- training records
- maintenance or cleaning and inspection records
- previous accident investigation reports
- sickness and absence records
- disciplinary records
The process of the collection of information during an investigation should be recorded, and should meet the following criteria:
- It must be objective and unbiased.
- It must identify the sequence of events, and conditions that led up to the accident or incident.
- It must identify the immediate causes.
- It must identify underlying causes, i.e. previous actions that have perhaps been allowed, or caused undetected, unsafe conditions or practices.
- It must identify root causes, such as poor supervision, inadequate monitoring, insufficient training or a lack of resources to name but a few, contributing factors that lead to an inadequate health and safety management system.
Following the investigation, suggested outcomes for improvement must be carefully analysed, and an action plan for the implementation of additional control measures should be developed, and implemented. It will be important at this stage to involve senior management, especially if more resources and expenditure will be required.
The action plan should have SMART objectives (be Specific, Measurable, Agreed, Realistic, with Timescales). For the proposed action plan to be SMART, management, employees and their representatives should all contribute to a constructive discussion, prior to agreeing the final action plan. The implementation of additional control measures must also be sensible (including timescales for implementation) and proportionate with the level of risk involved.
The investigation of accidents and incidents is a key activity, and plays an important part in the management of health and safety. It should be taken seriously, should not be a knee jerk reaction, apportioning blame and alike.
Organisations must carefully plan how they will investigate accidents, and to make sure that those involved have received adequate training, and are fully aware of the organisation’s policies and procedures.
A quality accident investigation, which identifies weaknesses in the management of health and safety that are then corrected or improved upon, will lead to the reduction of more accidents in the future.
Our Consultants would be pleased to advise you on any element of the issues arising from this newsletter.