Health and Safety
Executive
Introduction to
Accident Investigations
Mark Burton – CI2A
&
Gill Chambers – CI2B
H.S.E. Inspectors
Health
Healthand
andSafety
Safety
Executive
Executive
Introduction to
Accident Investigations
Mark Burton – CI2A
&
Gill Chambers – CI2B
H.S.E. Inspectors
Aims for Today
•
Provide an opportunity for the exchange of
information and advice on incident investigation
techniques in a positive environment.
•
Demonstrate how these techniques can be used
to learn from an incident and to assist in their
reoccurrence.
•
Facilitate informal discussion and provide
networking opportunities.
•
Build on and maintain positive relationships
between HSE and stakeholders.
Objectives for Today
•
•
•
•
•
•
Provide sources of HSE guidance on accident
investigation.
Provide techniques for investigating incidents and
accidents.
Provide an awareness of the relationship of human
factors in accident and incident investigations.
Identify the benefits of taking the lessons and learning
from an incident.
Provide a local industry perspective of developing an
accident and incident methodology and the benefits
gained.
Provide a syndicate exercise to enable knowledge
sharing and networking.
Health and Safety Investigations
• Background
• Why Investigate
• Difficulties with investigations
• Investigation Benefits
Background
• Previous Seminar feedback have asked for
accident investigations as a topic.
• Standard of some site investigations we see
indicated it was really needed.
Background
• Cost to society
– 192 people killed from accidents 4/09 – 12/09
– 180 killed 2008/09
– 18415 Major accidents; 86,110 3 day injuries
first 9 months
– 133,914 total RIDDOR’s 2008/09
– 8 231 D.O’s,
Background
• Working days lost
– 29.3 million days were lost overall (1.24
days per worker), with 24.6 million due to
work-related ill health and 4.7 million due to
workplace injury - 08/09
• Cost to economy/business
– Est. £3.3 to 6.5 Billion P.A.
– £910 to £3710 million – Accidental Damage
to property & equipment
Background
• Pressure for Duty to Investigate
• Consultation Document in 1999
• Led to Contract Research report
344/2001
– Less than 1 in 5 small companies have
procedures for investigations
– Less than 3 in 4 large companies have
procedures for investigations
Background
• Cont:
– Companies that carried out investigations:• Almost 40% are unstructured and informal
• 50% progressed no further than immediate causes
– Procedures did not ensure action plans /
recommendations were acted upon
– No linkage between investigation findings and
risk assessments
– Small companies accidents are rare developing and maintaining investigative skills is
difficult.
Background
•
Need for guidance for
SME’s
•
Led to HSG 245
Investigating
accidents and
incidents
•
Guidance issued in
2004
Why Investigate?
• Insurance
• Regulator may visit
• Legal requirements
• Cost
• HSE Perspective
– Identifying Immediate, root and underlying
causes (all causes)
– Prevent re-occurrences and reduce risks
Insurance
• Protection against
– Insurance Claims
– Insurance Companies/Solicitors need something
to work with
– Woolfe Report – companies expected to make full
disclosure for civil claims.
– Increased Insurance Costs – Excess, premiums,
possible refusals
Insurance Objectives
• Accident Investigations:
– Protection against pay outs
– Spread Blame
– Protect their share holders
• Are their objectives the same as
your companies?
Regulator May Visit
• Reported RIDDOR’s
• Complaints
– Members of Public
– Family
– Disgruntled employees
• Solicitors “personal accident claims”
Legal Duty
• “Duty to Investigate”
– Explicit, Implied or both
•
Management of Health and Safety at
Work Regulations 1999 – (MHSW)
•
Control of Major Accident Hazards
1999 (as amended) – COMAH
•
Control of Substances Hazardous to
Health Regulations 2006 - (COSHH)
MHSW Reg 3(3)
•
Review Risk Assessments:– (a) Reason to suspect that it
is no longer valid
– (b) Significant change in the
matters to which it relates
– ACoP Para 26(b)
“adverse events such as an
accident, ill health or
D.O.…. Such events should
be a trigger for reviewing
the original assessment”
MHSW Reg 5(1)
• Health and Safety Arrangements
– effective planning, organisation, control,
monitoring and review of the preventative
and protective measures”
– ACoP Para 36(b). monitoring includes –
“adequately investigating the immediate
and underlying causes of incidents and
accidents to ensure that remedial action is
taken, lessons learnt and longer term
objectives are introduced.”
COMAH Reg 4
•
All measures necessary to
prevent major accidents
and limit their
consequences to persons
and the environment
– An accident or incident
should trigger a review
that all measures
necessary have been
taken
COSHH Reg 11 (9)
•
Investigate cases of reportable occupational
disease:
– Informs the employee with information and
advice regarding further health surveillance;
– Review relevant risk assessments;
– Review control measures taken to comply with
COSHH Reg 7;
– Assigning employee to alternative work; and
– Review the health of other employees who may
have been exposed.
Accidents Cost
• Accidents and ill-health at work cost time and
money
• I have not had an accident
– Luck or good safety management
– What about near misses
– Could you afford to lose a key worker
• I’m Insured!!!
– Insurance cover (£1 spent on insurance)
– Uninsured costs (£8 - £36 spent on uninsured
costs
Accidents Cost
•
Insurance cover
– Injury, ill health, damage
•
Uninsured costs
– Lost time
– Extra pay
– Damage to products, plant,
buildings, tools, equipment
– Clearing up after an incident
– Legal costs, fines
– Insurance - Excess, premiums,
refusal
– Loss of contracts, business
reputation, share prices (BP)
Reduce Risks/Cut Costs
• Fractured Arm to a worker on an unguarded
drill in as a small engineering company; cost
in excess of £45,000
– Managing Director - prosecuted / criminal record
– Two further employees made redundant
• Half a finger amputated off work for around
10 weeks cost just over £4000.
• Fall from delivery ramp off work for two
weeks. total cost £14 800.
More Costly
• Piper Alpha - 167 dead - 2 billion in costs
• Buncefield ? - ongoing
• BP Gulf of Mexico?
Recent Changes
• Corporate Manslaughter
– Sentencing Guidelines Council (SGC)
– Corporate Manslaughter can be fined
millions of pounds with a £500,000
minimum
– other health and safety offences that cause
death, fines should begin at £100,000 and
go into the “hundreds of thousands”
• Health & Safety Offences Act 2008
– Act/Regs £20,000 in lower Courts
– Imprisonment an option in both courts
HSE Costs
• Instructed to claim all costs
• Recent cases
– £24,000 HSE and Solicitors – Fine £30k
– £14,780 HSE – Fine £15k
– £8,926.50 – Fine £13.5K
• Non-COMAH investigation £59 ph
• COMAH investigations £155 ph
Difficulties with Investigations
•
•
•
•
•
Inadequate policies & procedures - no clear
objectives
Lack of investigation skills
Change - Management, business, people,
technology
Corporate memory loss /short memories – we
forget & have to relearn
Failing to act on previous failings:
– Clapham Junction
– Herald of Free Enterprise
– BP Texas
Investigations Benefits
• Investigating Adverse Events Provides
– A ‘snapshot’ of reality.
– Opportunity to Identify their causes
– Learn lessons - specific & general
– Review your existing risk control measures
– Identify future prevention
– Prioritise actions
– Development of managerial skills – can be
applied to other areas of the organisational
Benefits
• Reduced Regulatory time for some
RIDDOR’s
• Demonstrate Improvement & ownership
of outcomes
• Provide Regulator with your action
plans
Health and Safety Investigations
• Background
• Why Investigate
• Difficulties with investigations
• Investigation Benefits
Health
Healthand
andSafety
Safety
Executive
Executive
Any Questions