Accident Investigation –

Key Concepts
Content
 Meanings & Paradigms
Dr Stephen Peckitt
 Accident causation
Head of H&S CEMEA
theories
Bovis Lend Lease
 What is an investigation
and why do it?
 Interviewing witnesses

 Analytical Methods

 Case study
 Incident Investigations – Key Concepts

Meanings & Paradigms

What does the word accident mean?
A worker drops his hammer whilst working on a roof. The
hammer falls off the roof (under gravity (E)) and hits (IB):
1) a person on the head (V) and cracks their skull
2) a car (P) denting the roof
3) the path next to the person
Accident as a simple equation –
E + IB + V = Injury (+/-P)
E + IB +/- P = Near Miss
 E = Energy - electricity, gravity, heat, mechanical, virus, wind, etc.
 IB = Inadequate Barrier – physical guard to protect against energy
emission or provide personal protection, distance, time,..
 V = Victim P = Property
Are these accidents?
 Incident Investigations – Key Concepts

Meanings & Paradigms

Definitions of Accidents:

 specific, unidentifiable, unexpected, unusual and

unintended external action which occurs in a particular
time and place, with no apparent and deliberate cause
but with marked effects (Wikipedia, 2010).

 unplanned loss events which result in physical harm to

people or property or the environment (Ridley, 1990)

 unplanned damage incidents.

 Incident Investigations – Key Concepts

Meanings & Paradigms

Causation

 What causes accidents?

 bad luck, carelessness, risk taking, failure of management
processes, natural products of the very complex world we live in,
etc.

 Four general accident causation paradigms:

 Fatalist – acts of god, destiny or bad luck,
 Individualistic – carelessness, risk taking and rule breaking
 Modernist – accidents are inevitable and unimportant by-
products of industrial age, and
 Postmodernist – accidents are failures to manage risk.
 Incident Investigations – Key Concepts

Meanings & Paradigms

Blame
 Accident victims often blame themselves; while managers are quick to
blame the victim or immediate supervisor, and are reluctant to place
any blame on themselves for accidents.
 It is a form of denial, a self-protective mechanism and a way of
simplifying a complex phenomena. It is a deep rooted human
psychological characteristic known as fundamental attribution error.

 We need to keep the blame bias out of investigations in order to get at

the facts and identify the root causes of incidents

 Only apportion blame where it is clearly proven to be due, eg for

sabotage and violations.
 Incident Investigations – Key Concepts

Meanings & Paradigms

Incident v Accident

 Risk management experts generally avoid use of the term 'accident' to

describe events that cause injury and loss to highlight the predictable
and preventable nature of most damage incidents.
 The term incident is preferred as it implies a generally negative
probabilistic outcome which may have been avoided or prevented had
circumstances leading up to the accident been recognized, and acted
upon, prior to its occurrence.
 Such incidents are viewed from the perspective of epidemiology, (i.e
they are predictable and preventable). Preferred words are more
descriptive of the event itself or severity of the damage, rather than of
its unintended nature (e.g. drowning, fall, first aid, lost time, major,
fatal, catastrophic, major and minor damage, etc.)
Source: Wikipedia
 Incident Investigations – Key Concepts

Causation Theories

 Domino – Heinrich, Bird & Loftus

 Human Error – HSE, Rassmussen

 Swiss Cheese Model – Reason

 Incident Investigations – Key Concepts

Heinrich’s Domino Theory

Unsafe Acts and Unsafe Conditions Paradigm

 Herbert Heinrich is credited with the first accident causation theory. He

analysed 12,000 accident insurance claims and over 50,000 injury reports
in the 1930s, and identified unsafe acts by workers as the primary cause
of 88% of accidents.
 Heinrich developed a domino theory of accident causation where a single
sequence of events results in an accident:
 the first domino is concerned with the accident victim’s personal
traits;
 the second – victims actions;

 the third - unsafe acts and conditions;

 the fourth - the accident;

 the fifth - the injury.

Incident Investigations – Key Concepts

Loss Control Domino Models

 Incident Investigations – Key Concepts

HUMAN ERROR – To Err is human

We all make mistekas

Slips & Lapses Skill based

Errors
Rule-based
Mistakes
Human Knowledge
failure based
Routine
Violations Exceptional
Situational
HSE 1999
 Incident Investigations – Key Concepts

Prof. James Reason

 Rather than being the main instigators of an
accident, operators tend to be the inheritors of
system defects created by poor design, incorrect
installation, faulty maintenance and bad
management decisions.
 Their part is usually that of adding the final
garnish to the lethal brew using ingredients that
have already been long in the cooking.
 Reason (1990) p173.
 Incident Investigations – Key Concepts

Reason’s Swiss Cheese Model

Errors made at
business planning Latent Pathogens Active INCIDENTS
stage failures
Errors made during
task planning
Active Errors at the
workface – lapse,
mistake, short cuts
 Incident Investigations – Key Concepts

Key concepts from causation

theories
 Incident causation is a complex dynamic process, not a
simple linear process.
 Everyone makes mistakes so activities and equipment
need to be designed to take account of human error.
 The negative impact of incidents and injuries is wider
than the victim – includes their family, worker morale,
production, profitability, and both personal and corporate
reputation (BP, Toyota!).
 Employers and those who control activities have a duty of
care towards workers and others who may be impacted
by their activities, so must ensure they effectively
manage the risks involved in their undertaking to prevent
incidents occurring.
 Incident Investigations – Key Concepts

Why Investigate Incidents?

An investigation is a systematic and thorough attempt to learn the facts

about something complex or hidden; an inquiry to ascertain facts based
on the detailed and careful examination of evidence.

There are four main reasons for investigating accidents:

 Identify causes – immediate and underlying;

 Assess weaknesses - legal compliance and risk management;

 Define remedial actions - corrective & preventative;

 Share lessons learnt – prevent similar incidents occurring by

encouraging learning, change and improved risk management.

The focus and depth of the investigation will vary depending on the role
and expertise of those undertaking the investigation.

The ultimate goal is to prevent similar events occurring again!

Incident Investigations – Key Concepts

What Incidents should be

Investigated?

 Fatal Incidents
 Major Injury Incidents
 Legally Reportable Incidents - > 3 day
 Lost Time Injury Incidents
 First Aid Injury Incidents
 Near Misses – no injury
 Incident Investigations – Key Concepts
The Injury Pyramid – where to
focus our efforts?
Injury statistics Become reality here in
are commonly the form of damage to
the sole focus
Fatal people, property and
of safety the environment…
initiatives Major injury

Lost time injury

First aid injury

To prevent What you
incidents we Near miss / near hit permit to
need to focus happen here…
on making the bad practice,
right decisions At risk behaviour & unsafe conditions poor decisions,
unsafe acts &
conditions
Unsafe decisions & choices
 Incident Investigations – Key Concepts

Who should be involved?

Dictated by severity of incident, speed of investigation,
technical complexity, processes, etc.

 Investigation Team – number of people, skills, experience,

availability, consultants, police, lawyers;
 Timing - ASAP to examine and record scene, collect witness
details and statements, consider wider implications,
reporting timescales;
 Reporting – to who, by when, what format, regular
updates, legal privilege;
 Management – who, roles and responsibilities
 Review – factually correct, technical issues, lessons learnt;
 Implementation of remedial measures – by who and when,
tracking and verification;
 Incident Investigations – Key Concepts

Investigations - Common Errors

 Stating the apparent, immediate cause rather than the root cause.
 Slip on oil spot on floor.

 Cause is related to outcome rather than the incident itself.

 Chemical leak spray in face - “employee not using face shield”

 Stopping investigation too soon not going far enough.

 Facility equipment failure

 “Be more careful”

 Blaming the victim

 Operator was attempting to pick up parts that were on floor
while not leaving their stool

It is easy and quick to identify the immediate causes but to get to

underlying causes to really understand how an incident occurs and
how to prevent a repeat – we need to get deeper into the chain of
events which ended in the injury.
Incident Investigations – Key Concepts

Importance of Analytical Approach to

Investigations

 Avoid investigators’ personal assumptions

 Logical approach to gathering evidence
 Co-ordinate investigation activities
 Identify Root Causes
 Verify findings
 Clearly communicate findings
 Implement actions taken to prevent future incidents
 Incident Investigations – Key Concepts

Evidence Gathering
• Gather the known facts about the incident to understand
the nature, scale, technical complexity, etc.
• Allocate appropriate resources to conduct investigation.
• Collect physical evidence at the scene.
• Identify witnesses and the organisations involved.
• Conduct interviews to establish:
• Who, What, Where, When, Why & How
• Keep probing for more information with open questions.
• Clarify understanding of the key issues with interviewees
• Don’t jump to conclusions and recommendations too quickly
• Go back and collect more evidence and statements if
needed
Incident Investigations – Key Concepts

Evidence Gathering
 Physical Evidence
 take pictures, copies of documents, measurements,
drawings, etc.
 take possession of items for detailed examination or
evidence for legal case
 obtain expert analysis of equipment
 Interviewing People
 Informal - information gathering
 Formal - statement taking

 Chain of evidence
 Give receipts for all physical evidence obtained
 All statements should be signed
 Keep secure where they cannot be tampered with
 Incident Investigations – Key Concepts

Evidence Gathering –
Investigator's Tools

 Personal Protective Equipment

 Digital Camera
 Logbook
 Statement forms
 Evidence bags & tags
 Tape measure
 Spare batteries, pens, SD card, etc
 Video recorder
Incident Investigations – Key Concepts

Who to Interview?
 Injured Person
 Witnesses of the incident
 Witnesses Pre-Accident
 Witnesses Post-Accident
 Supervisors
 Managers
 Maintenance, Housekeeping,
Engineering, Purchasing……...
 Incident Investigations – Key Concepts

Interviewing Techniques
An interview is a structured conversation with a
purpose – to establish facts.
 Respect

Developing a rapport  Empathy

with the witness  Supportive

is crucial to  Positive
effective interviewing  Open

 Non-Judgemental

 Straight forward

 Equal
Incident Investigations – Key Concepts

Interviewing Techniques
 Put person at ease - Assure “no blame”
 Listen carefully
 Repeat the story back and check understanding
 Be polite and thank the witness

Questions should be:

 Clear - short and simple using easily
understood language, one point at a time
 Logical - follow lines of enquiry, ask only
relevant questions
 Polite but firm tone – establish status
 Interview Techniques –
Key Information
 Personal details;
 Confirm employer, profession and role;
 What they were doing at the time of the
incident;
 What relevant information they remember:
 Use open questions about what they saw
happen?, where they were?, who was
involved?, what they did, etc.
 Probe issues of concern for clarity or to
check validity and compare with other
evidence;
 Use closed questions to confirm specific
details
 Witness signature and date
 Avoid using
 Leading & Hypothetical questions
 Statements
 Incident Investigations – Key Concepts

Interview Techniques
FUNNELLING
General Open Question
At home Journey to Day at Journey
leads to an account of work work home
several smaller sections

Specific Open Questions Open Open

Questions
to focus on specific Questions
areas of the account

Use 5 Whys
probe every
key issue
Closed
Closed Questions
LINK
Questions
clear-up Process is
repeated LINK
issues or Closed for every section
LINK
close out Questions Process is
repeated
line of Process is for every
enquiry repeated section
for every
section
Incident Investigations – Key Concepts

Interviewing Techniques
Questions & Perceptions
 Incident Investigations – Key Concepts

Interviewing Techniques
Cognitive Interviewing
Memory is selective and stored in isolated fragments
which fade and become influenced by attitudes and
beliefs. Cognitive interview techniques can help
increase memory recall by 10%.

 Free recall – ask the witness to recall everything

they can remember – don’t question
 Mental reconstruction – describe the scene by
describing everything they felt and saw
 Reorder recall – question issues in different order
 Different perspective – ask how other witnesses may
have perceived the incident
 Focus on specifics - conversations, reactions, noises,
numbers, smells, etc.
 Incident Investigations – Key Concepts

Interview Tips
 Actively listen - concentrate, comprehend and sustain

 Encouraging cues – open posture, eye contact, nod head, open hand
gestures, “uh huh”

 Pauses and silence - encourage responses

 Echoing – repeating witness phrases to prompt further elaboration;

 Summarise regularly - to keep focus, revisit issues if necessary and agree

statements

 Avoid misleading the witness – do not use leading questions, and opinion

 Observe Body Language – deception indicated by, shuffling feet and

crossing legs, touching face and licking lips, drumming and gripping,
blushing and perspiring.
 Incident Investigations – Key Concepts

Interviewing Techniques
Formal Statement Taking

P Plan & Prepare

E Engage & Explain
A Account
C Closure
E Evaluate
 Incident Investigations – Key Concepts

INTERVIEWING Techniques
Venue – Your place or theirs?
Timing – Too soon, too late?
P - Plan & Prepare Witness Support – accompanied?
Agenda – what do you need?
Prepare key questions
Physical evidence verification

Introductions - reason for interview,

E - Engage & their role, subsequent actions
Explain Explain format of interview
Any questions before starting?

Their account of what they witnessed

Introduce evidence
A - Account Ensure key questions answered
Go back to issues which need clarifying
 Incident Investigations – Key Concepts

INTERVIEWING WITNESSES
Check understanding of key issues
Go through statement to agree content
C - Closure Witness to sign any changes and at end of
statement
Give them a copy
Ask if they have any questions?
Clarify what happens next
Thank them for their cooperation

What have you learned?

E - Evaluation How does this fit with other evidence?
Anything missing – to follow up?
How did you perform?
Next actions
 Incident Investigations – Key Concepts

Interview Techniques -
Summary
 Conduct the interview as soon after the incident as possible.
 Create a relaxed atmosphere, avoid blame, get all sides and
request ideas for prevention.
 Keep the interview private to avoid group biases.
 Focus on establishing facts, avoid irrelevancies, assumptions,
and smoke screens.
 Ask open-ended non-leading questions to explore lines of
enquiry.
 Listen, test understanding and validate key evidence with
closed questions.
 Repeat the story back, probe into all aspects of the non-
conformance or accident, get all sides of the story.
 Incident Investigations – Key Concepts

Examples of Analytical Methods

Root Causes Analysis

 Fishbone
 5 Whys
 Decision / Event Trees
 Management Oversight Risk Tree
 Incident Investigations – Key Concepts

Fishbone Diagram
People Methods

Roots
Problem

Environment Equipment

 Tool for systematic review of cause and effects.

 Assists in categorizing many potential causes of problems in
orderly way.
 Start with categories – people, methods, environment,
equipment, etc.
 Review causes within each category.
 Incident Investigations – Key Concepts

Example Flow/Decision Tree

WAS THE HAZARDOUS
YES CONDITION(S) OF EQUIPM ENT NO
A CONTRIBUTION FACTOR?
POSSIBLE CORRECTIVE ACTIONS
REVIEW PROCEDURES FOR DID ANY DEFECTS IN EQUIPM ENT, WAS THE LOCATION/POSITION OF
INSPECTING, REPORTING, M AIN- YES TOOLS, OR M ATERIAL CONTRIBUTE EQUIPM ENT, M ATERIAL, EM PLOYEE NO
POSSIBLE CORRECTIVE ACTIONS TAINING, REPAIRING, REPLACING, TO HAZARDOUS CONDITIONS? A CONTRIBUTING FACTOR?
REVIEW JOB PROCEDURE FOR OR RECALLING DEFECTIVE EQUIP-
HAZARD AVOIDANCE. REVIEW M ENT, TOOLS, OR M ATERIALS. NO YES
SUPERVISORY RESPONSIBILITY &
SUPERVISOR-EM PLOYEE POSSIBLE CORRECTIVE ACTIONS
COM M UNICATIONS YES WAS THE HAZARDOUS WAS THE HAZARDOUS CONDITION DID THE LOCATION/POSITION OF PERFORM JOB SAFETY ANALYSIS. WAS THE JOB PROCEDURE USED (CONTINUED PAGE 2) (CONTINUED FROM PAGE 1)
CONDITION REPORTED? YES RECOGNIZED? EQUIPM ENT, M ATERIAL, EM PLOYEE YES REVIEW JOB PROCEDURE. CHANGE A CONTRIBUTING FACTOR? NO
POSSIBLE CORRECTIVE ACTIONS NO CAUSE HAZARDOUS CONDITION? LOCATION/POSITION OF EQUIPM ENT POSSIBLE CORRECTIVE ACTIONS
TRAIN EM PLOYEE IN REPORTING OR EM PLOYEE. PROVIDE GUARD REVIEW JOB PROCEDURE FOR
PROCEDURES. STRESS INDIVIDUAL POSSIBLE CORRECTIVE ACTIONS NO NO RAILS, BARRIERS, SIGNS, ETC. HAZARD AVOIDANCE. REVIEW YES
ACCEPTANCE OF RESPONSIBILITY. PERFORM JOB SAFETY ANALYSIS. SUPERVISORY RESPONSIBILITY &
IM PROVE EM PLOYEE ABILITY TO SUPERVISOR-EM PLOYEE POSSIBLE CORRECTIVE ACTIONS
RECOGNIZE EXISTING OR WAS THE HAZARDOUS WAS THE HAZARDOUS YES COM M UNICATIONS WAS THERE A WRITTEN OR DID JOB PROCEDURES ANTICIPATE PERFORM JOB SAFETY WAS LACK OF PPE OR EM ERGENCY
POTENTIAL HAZARDS. CONDITION RECOGNIZED? YES CONDITION REPORTED? KNOWN PROCEDURE (RULE) YES THE FACTORS THAT CONTRIBUTED NO ANALYSIS AND CHANGE EQUIPM ENT A CONTRIBUTING NO
M ENT, TOOLS, OR M ATERIALS. NO POSSIBLE CORRECTIVE ACTIONS FOR THIS JOB? TO THE ACCIDENT? JOB PROCEDURE. FACTOR IN THE INJURY?
TRAIN EM PLOYEE IN REPORTING
POSSIBLE CORRECTIVE ACTIONS NO PROCEDURES. STRESS INDIVIDUAL NO YES YES
DEVELOP & ADOPT PROCEDURES WAS THERE EQUIPM ENT INSPEC- ACCEPTANCE OF RESPONSIBILITY.
TO DETECT HAZARDOUS NO TION PROCEDURES TO DETECT POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS
CONDITIONS. CONDUCT TEST. THE HAZARDOUS CONDITION? WAS EM PLOYEE SUPPOSED TO BE REVIEW JOB PROCEDURES & DID EM PLOYEE KNOW IM PROVE JOB INSTRUCTION. WAS APPROPRIATE PPE SPECIFIED WAS APPROPRIATE PPE PROVIDE APPROPRIATE PPE. WAS M ANAGEM ENT SYSTEM
IN THE VICINITY OF THE NO INSTRUCTIONS. PROVIDE GUARD THE JOB PROCEDURE? NO TRAIN EM PLOYEES IN CORRECT FOR THE TASK OR JOB? YES AVAILABLE? NO REVIEW PURCHASING AND A CONTRIBUTING FACTOR?
YES EQUIPM ENT/M ATERIAL? RAILS, BARRIERS, SIGNS, ETC. JOB PROCEDURE. DISTRIBUTION PROCEDURES.

POSSIBLE CORRECTIVE ACTIONS YES YES NO YES YES

REVIEW PROCEDURES. CHANGE DID THE EXISTING EQUIPM ENT
FREQUENCY OR COM PREHENSIVE- NO INSPECTION PROCEDURES DETECT POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS
NESS. IM PROVE EM PLOYEE ABILITY THE HAZARDOUS CONDITION? WAS THE HAZARDOUS CONDITION CHANGE LIGHTING OR LAYOUT TO DID EM PLOYEE DEVIATE DETERM INE WHY. ENCOURAGE ALL DID EM PLOYEE KNOW THAT REVIEW JOB PROCEDURES. WAS THERE A FAILURE BY SUPER- IM PROVE SUPERVISOR CAPABILITY
TO DETECT DEFECT & HAZARDOUS CREATED BY LOCATION/POSITION NO INCREASE VISIBILITY OF EQUIPM ENT FROM THE KNOWN JOB YES EM PLOYEES TO REPORT PROBLEM S WEARING SPECIFIED PPE WAS NO IM PROVE JOB INSTRUCTION. VISION TO DETECT, ANTICIPATE, YES IN HAZARD RECOGNITION AND
CONDITIONS. YES OF EQUIPM ENT/M ATERIAL VISIBLE? PROVIDE GUARDRAILS BARRIERS, PROCEDURE? WITH ESTABLISHED PROCEDURE. REQUIRED? OR REPORT A HAZARD CONDITION? REPORTING PROCEDURES.
SIGNS, ETC. COUNSEL OR DISCIPLINE EM PLOYEE.
POSSIBLE CORRECTIVE ACTIONS YES PROVIDE CLOSER SUPERVISION. YES NO
SPECIFY CORRECT EQUIPM ENT, WAS THE CORRECT
TOOLS, & M ATERIALS IN JOB NO EQUIPM ENT, TOOLS, OR M ATERIALS POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS
PROCEDURES. USED? WAS THERE SUFFICIENT REVIEW WORK SPACE WAS THE EM PLOYEE M ENTALLY REVIEW EM PLOYEE REQUIREM ENTS DID EM PLOYEE KNOW HOW TO USE IM PROVE JOB INSTRUCTION. WAS THERE A FAILURE BY SUPER- REVIEW JOB SAFETY ANALYSIS &
WORK SPACE? NO REQUIREM ENTS AND M ODIFY AND PHYSICALLY CAPABLE OF NO FOR THE JOB. IM PROVE EM PLOYEE AND M AINTAIN THE PPE? YES VISION TO DETECT/CORRECT DEV- YES JOB PROCEDURES. INCREASE
YES AS REQUIRED. PERFORM ING THE JOB? SELECTION. REM OVE OR TRANSFER IATION FROM JOB PROCEDURE? SUPERVISOR M ONITORING.
EM PLOYEES WHO ARE M ENTALLY CORRECT DEVIATIONS.
POSSIBLE CORRECTIVE ACTIONS YES YES OR PHYSICALLY INCAPABLE OF JOB. NO
PROVIDE CORRECT EQUIPM ENT, WAS THE CORRECT
M ATERIALS, & TOOLS. REVIEW PUR- NO EQUIPM ENT, TOOLS, OR M ATERIALS POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS
CHASING SPECIFICATIONS & READILY AVAILABLE? WERE ENVIRONM ENTAL CONDI- M ONITOR OR PERIODICALLY CHECK WERE ANY TASK IN THE JOB CHANGE JOB DESIGN AND WAS THE PPE USED PROPERLY DETERM INE WHY AND TAKE WAS THERE A SUPERVISOR/EM PL- ESTABLISH A PROCEDURE THAT
PROCEDURES. ANTICIPATE TIONS A CONTRIBUTING FACTOR YES ENVIRONM ENTAL CONDITIONS AS PROCEDURE TO DIFFICULT TO YES PROCEDURES. WHEN THE INJURY OCCURRED? NO APPROPRIATE ACTION. IM PLEM ENT OYEE REVIEW OF HAZARDS & JOB YES REQUIRES A REVIEW OF HAZARDS
FUTURE REQUIREM ENTS. YES (LIGHTING, NOISE, TEM P, AIR, ETC)? REQUIRED. CHECK RESULTS PERFORM (M ENTAL OR PHYSICAL)? PROCEDURES TO M ONITOR AND PROCEDURE FOR TASK & JOB PROCEDURES FOR TASK
AGAINST ACCEPTABLE LEVELS. ENFORCE USE OF PPE. INFREQUENTLY? PERFORM ED INFREQUENTLY.
POSSIBLE CORRECTIVE ACTIONS INITIATE ACTION IF NEEDED. NO YES
REVIEW PROCEDURES FOR STOR- DID EM PLOYEE KNOW WHERE TO NO
AGE, ACCESS, DELIVERY, OR DIS- NO OBTAIN EQUIPM ENT, TOOLS, OR POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS
TRIBUTION. REVIEW JOB PROCED- M ATERIALS REQUIRED FOR JOB? IS THE JOB STRUCTURED TO EN- CHANGE JOB DESIGN AND WAS THE PPE ADEQUATE? REVIEW PPE REQUIREM ENTS. POSSIBLE CORRECTIVE ACTIONS
URES FOR OBTAINING EQUIPM ENT, COURAGE OR REQUIRE DEVIATION YES PROCEDURES. NO CHECK STANDARDS, SPECIFICA- WAS SUPERVISOR RESPONSIBILITY DEFINE AND COM M UNICATE
TOOLS, & M ATERIALS. YES FROM JOB PROCEDURES? TIONS, AND CERTIFICATION & ACCOUNTABILITY ADEQUATELY NO SUPERVISOR RESPONSIBILITY &
OF THE PPE. DEFINED AND UNDERSTOOD? ACCOUNTABILITY. TEST FOR
POSSIBLE CORRECTIVE ACTIONS YES UNDERSTANDABILITY AND
PROVIDE CORRECT EQUIPM ENT, WAS SUBSTITUTE EQUIPM ENT, CONTINUED YES ACCEPTANCE.
TOOLS, & M ATERIALS. WARN YES TOOLS, OR M ATERIALS USED IN POSSIBLE CORRECTIVE ACTIONS ON PAGE 1
AGAINST USE OF SUBSTITUTES PLACE OF THE CORRECT ONE? INSTALL EM ERGENCY WAS EM ERGENCY EQUIPM ENT WAS EM ERGENCY EQUIPM ENT POSSIBLE CORRECTIVE ACTIONS
IN JOB PROCEDURES AND IN EQUIPM ENT AT APPROPRIATE NO READILY AVAILABLE? (CONTINUED FROM PAGE 2) YES SPECIFIED FOR THIS JOB (eg EM ER- NO WAS SUPERVISOR ADEQUATELY TRAIN SUPERVISORS IN
JOB INSTRUCTION. NO LOCATIONS. GENCY SHOWER, EYEWASH)? TRAINED TO FULFILL RESPONSIBILITY NO ACCIDENT PREVENTION
IN ACCIDENT PREVENTION? FUNDAM ENTALS.
POSSIBLE CORRECTIVE ACTIONS YES NO
ALTER EQUIPM ENT/TOOL TO M AKE DID DESIGN OF THE EQUIPM ENT OR YES
M ORE COM PATIBLE WITH HUM AN YES TOOLS CREATE OPERATOR STRESS POSSIBLE CORRECTIVE ACTIONS
CAPABILITY & LIM ITATIONS. EN- OR ENCOURAGE ERROR? INCORPORATE USE OF WAS EM ERGENCY EQUIPM ENT POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS
COURAGE EM PLOYEES TO REPORT EM ERGENCY EQUIPM ENT IN NO PROPERLY USED? PROVIDE EM ERGENCY WAS THERE A FAILURE TO INITIATE REVIEW M ANAGEM ENT SAFETY
POTENTIAL HAZARD CONDITIONS. NO JOB PROCEDURES. EQUIPM ENT AS REQUIRED? CORRECTIVE ACTION FOR A KNOWN YES POLICY AND LEVEL OF RISK ACC-
HAZARDOUS CONDITION? EPTANCE. REVIEW PROCEDURE &
POSSIBLE CORRECTIVE ACTIONS YES RESPONSIBILITY TO CARRY OUT
REVIEW CRITERIA IN STANDARDS, DID THE GENERAL DESIGN OR CORRECTIVE ACTIONS.
SPECIFICATIONS, & REGULATIONS. YES QUALITY OF THE EQUIPM ENT OR POSSIBLE CORRECTIVE ACTIONS
ESTABLISH NEW CRITERIA AS TOOLS CAUSE HAZARD CONDITION. ESTABLISH INSPECTION/M ON- DID EM ERGENCY EQUIPM ENT
REQUIRED. ITORING SYSTEM FOR EM ERGENCY NO FUNCTION PROPERLY?
POTENTIAL HAZARD CONDITIONS. EQUIPM ENT. PROVIDE FOR
IM M EDIATE REPAIR OF DEFECTS.
 Incident Investigations – Key Concepts

Event analysis trees

 Management
Oversight
and Risk Tree -
logical, structured,
generic fault tree
based on equation
E+V+IB = Incident

 Aims to identify and prevent - management

errors, control risks and optimise performance
 Incident Investigations – Key Concepts

“5 Whys” Cause & Effect Analysis

Why?
 A ‘5 Why’ analysis is a simple method which adds Why?
discipline to the incident investigation based on asking
“why” something occurred and answering with
“because” then repeating this up to five times
 It ensures that the key relevant contributory factors
are fully considered and analysed.
Why?
Why? It focuses on gaining a deep understanding of why an
incident occurred by analysing critical factors
 It facilitates the identification of the root causes of an
incident
 It facilitates the creation of remedial action plans
which focus on preventing the root causes occurring
again. Why?
 Incident Investigations – Key Concepts

Cause & Effect Analysis – “5 Whys”

• The 5 Why’s analysis leads to a comprehensive

picture of the potential contributing factors of an Root
incident and ultimately their root causes Causes
Immediate
Causes

Incident Why? Why? Why?

Why? Why?

Irrelevant
 Incident Investigations – Key Concepts

RCA findings from UK Govt Study of

construction fatal accidents (2009)

Equipment

Competence Planning Supervision

Leadership
Incident Investigations – Key Concepts

RCA Incident
INVESTIGATION
PROCESS Emergency Response:
Rescue, Treat, Make Safe, Preserve, Record

All injury incidents

Gather the key information and near misses
Phase 1 Who, What, Where, When, Why should be
investigated to
determine 5 Ws
Analyse and identify the immediate
Phase 2 critical factors

Conduct Root Cause

Analysis for fatal and
Analyse and Identify underlying causes
Phase 3 major accidents,
and root cause of each critical factor
major environmental
or property damage
and high potential
Validate findings, lessons learnt, and near miss incidents
Phase 4
corrective and preventative measures

Phase 5 Complete investigation report LESSONS LEARNT

CORPORATE MEMORY

Close out investigation report by

Phase 6 validating implementation of improved
risk control measures.
Incident Investigations – Key Concepts

Emergency Response:
 Rescue and Treat Injured Persons

 Make Safe

 Preserve Scene – secure evidence

 Record - witness details, etc.

 Incident Investigations – Key Concepts

Evidence gathering
4Ps
Who What

Where When
When gathering evidence Phase 1
Why
it is useful to remember the 4Ps.
• Ensure that all relevant people
have been identified and
interviewed People
Parts
• Review the equipment and parts
of machinery which may have been
involved
• Consider the positions of people
and equipment at the time of the
incident Positions Paper
• Examine and collect copies of
relevant documents
 Incident Investigations – Key Concepts

Evidence gathering - Phase 1

Who was injured, suffered ill health or was otherwise involved
What injury, ill health or damage was caused?
People
Who witnessed the incident?
Who was in charge of supervising the work?
What other people and organisations were involved?

Were any of the following involved - Plant / Equipment / Machinery

Parts / Tools / Equipment / Materials / PPE.
How was it being used and was it in good working order?
What activity was being carried out and was there anything
unusual in the work environment?
Were the shape / nature of the materials, etc., relevant to the
accident / incident?
Was difficulty / unfamiliarity in using the plant, etc. a contributory
factor?
Was safety equipment adequate?
 Incident Investigations – Key Concepts

Evidence gathering - Phase 1

Where and when did the incident occur?
Was the immediate environment safe?
The position of all parties (injured party(s) / witnesses), any
Positions machinery, materials, barriers, signs, protections, tools &
equipment are to be considered
Was there anything unusual about the working conditions?
Were maintenance, workplace layout or housekeeping relevant
factors?

Paper evidence includes all relevant documentation, e.g. risk

assessment and risk register / safety method statements / H&S
plans / drawings / instructions / permits / certification (test,
Paper examination, training) / licenses / induction & toolbox talk
registers.
Was the method for completing task detailed in a written plan?
Are there records of inspections, training, etc.
What are the organisation’s processes and systems?
 Incident Investigations – Key Concepts

Evidence gathering - Phase 1 Culture

Assess the impact of company culture:

- the way things are
done around here
- interplay of people,
systems, technology,
Culture
and power
- eg rule breaking, short cuts,
command and control
 Incident Investigations – Key Concepts

When is Root Causes Analysis

required?

 After fatal & major injury incidents

 Other incidents, including near misses where
circumstances could have resulted in a fatal or
majory injury – eg falls from height above 2 metres
 To be completed with 4 weeks (where possible).
 Incident Investigations – Key Concepts

Investigation and RCA summary

 Establish Investigation Teams – number, skills, etc.
 Collect Evidence - 4 Ps + statement taking
 Establish the time line and immediate causes of the
incident,
 Identify the critical factors (ie which if eliminated would
prevent the incident) in the time line
 Identify the underlying causes of each critical factor
using Why/Because analysis (5 Whys)
 Label the key cause of each factor using the underlying
factors terminology
 Identify key Corrective & Preventative actions
 Identify the Lessons Learnt which need to be
communicated and implemented
 Incident Investigations – Key Concepts

RCA Terminology
Immediate causes
• Actions – acts directly contributing to the incident
• Conditions – environmental/operational factors directly contributing to
the incident
• Critical Factor – an immediate cause which if taken away would have
prevented the incident
Underlying causes
• Job Factors – how the task was planned and executed
• Organisational Factors – effectiveness of policies and systems
• Personnel Factors – attitudes, competencies, personality, perceptions

ROOT CAUSES – the factors at the end of the causal chain for each
critical factor – the causes which need to be addressed
to prevent reoccurrence.
 Incident Investigations – Key Concepts

Phase 2 – Analyse the information

1) Sift through all the evidence gathered to establish the facts.
- John had tip of finger amputated by v belt on compressor in paint
shop which was not guarded
2) Identify the IMMEDIATE CAUSES:
Conditions: (operating / environmental conditions)
- the air compressor was running.
Actions: (what people did immediately prior to the incident occurring)
- John’s hand slipped off the side of the machine and onto the drive
belt
3) Establish a ‘timeline’ of single, irreducible facts that describe the
key actions and conditions working backwards from the incident.
 Incident Investigations – Key Concepts

Phase 2 – Analyse the information –

Timeline and Critical Factors
Establish a time line from
immediate causes backwards.
Then identify the ‘CRITICAL
FACTORS’, i.e. those factors in
the ‘timeline’ or sequence of
events leading up to the incident,
that had they not been present the
sequence of events would have
been broken and the accident /
incident would not have occurred
or at least its severity reduced.
As a guide the number of critical factors
identified for any incident should range from five
to ten
 Critical Factors

 The compressor was running

 John was maintaining the compressor

 The guard was missing to the “v”belt pulley

drive
 Incident Investigations – Key Concepts

Immediate Causes
Conditions
Actions
1 – Open / Exposed edge (ext., Int.,
1 - Work at height (inc Access) platform, etc.)
2 – Lifting (Manual or 2 – Guards, protective devices or
mechanical) equipment
3 – Use of safety devices and 3 – Housekeeping
equipment
4 – Tools, equipment, plant
4 – Use of tools, equipment,
plant and machines 5 – Vehicle movements
5 – Use of PPE 6 – Lifting and Slinging
6 – Method of work 7 – Live systems or equipment (electrical /
mechanical)
7 – Communications
8 – Exposure to chemicals, noise,
8 – Operator error vibration, etc.
9 – Violation 9 – Environment (heat, cold, ventilation,
10 – Horse play weather, etc.)
11- other (specify) 10 – Structural failure
11 – Communications - instructions, signs,
barriers and warnings
 Incident Investigations – Key Concepts

Phase 3 - Identify the Underlying

causes for each Critical Factor
For each Critical Factor – identify:
 Underlying Causes - the factors that resulted in or
allowed the immediate cause of each critical factor to exist
 Root Causes - the last factor identified in the causal
chain of each critical factor
By
 Examining each critical factor using the “why and
“because” question and answer technique.
 Asking “why” and “because” between 3 and 5 times to
identify the underlying causes.
 Choose the most relevant factor from the factors detailed
in the RCA topic headings which best describes the root
cause identified.
 Critical Factors –
5 Whys Analysis
 The compressor was running – why? …… because
- Being used for spraying operation
- Supervisor said do not switch off
- Part of finishing an urgent order
- Focus on production
 John was examining the compressor
- Supervisor asked him to look at it because it was not operating correctly
- Not maintained and inspected regularly
- Manager not aware of need for regular maintenance
- New to role and not experienced
- Inadequate training and instructions
 The guard was missing to the “v”belt pulley drive
- Removed and not replaced over a year ago when belt was replaced
- Person who did it was not trained in safe maintenance operations
- No formal machinery maintenance or safety systems in place
 Incident Investigations – Key Concepts

Underlying Causes of Incidents:

Job Factors
1) Risk assessment and safe method of work (done,
adequate, appropriate, checked, etc.).
2) Task planning (complies with RA and SMW, adequate
resources, buy in, communication, etc.).
3) Supervision (numbers, communication, competence,
control, etc.).
4) Communications (shift hand over, changes, toolbox talks
language, induction, etc.).
5) Provision & maintenance of plant, tools, equipment.
6) Management of hazardous materials and emergency
response.
7) Maintenance of safe work environment (noise, layout,
interfaces, atmosphere, etc.).
8) Compliance (Law, procedures, permits, etc.).
 Incident Investigations – Key Concepts

Underlying Causes of Incidents:

Organisation Factors
1 – Contractor management (selection,
standard setting, liaison, 9 – Responses to emergencies and
monitoring, supervision) previous incidents
2 – Programme (time, co-ordination, 10 – Allocation and fulfillment of
progress, realism, change) responsibilities (just culture
approach)
3 – Design & planning risk
management (elimination, 11 – Allocation of staff &
assessment, control HSE risks) resources (competence, time,
cost, equipment)
4 – Training (provided, adequate,
recent) 12 – Community issues (lack of
liaison – neighbours /
5 – Leadership (provided, adequate, regulators)
visible, followed, credible, trusted)
13 – Client demands (time, cost,
6 – Change Management schedule, design, novated
(communication, consultation contractors, etc.)
evaluation, implementation)
14 – External pressures (legal,
7 – HSE management system market, environment)
(document control, investigation,
lessons learnt) 15 – Corporate values and
perceptions
8 – Communication (Corporate,
project, business unit) 16 – Reward and recognition
 Incident Investigations – Key Concepts

Underlying Causes of Incidents:

Personnel Factors
1 – Competence (skill, knowledge, experience)
2 – Excessive demands (physical, mental, workload)
3 – Fatigue (Excessive work hours, personal issues)
4 – Error (lapse, slip, mistake)
5 – Violation (deliberate rule breaking)
6 – Rushing work (programme, catch up, bonus, etc.)
7 – Morale (bored, disheartened, personal issues)
8 – Perception of risk – (unaware, under estimate, macho)
9 – Perception of priorities (supervision, peers, site team)
10 – Distraction (by colleagues, others, personal issues)
11 – other (specify)
 Incident Investigations – Key Concepts

Areas for Corrective and

Preventative Actions
New guard
fitted
Physical
Changes
Behavioral
Environment
Changes
New manager
Personnel
Maintenance
Procedure and safety
systems
Changes implemented
Training on Training
maintenance and risk
assessment
Program
 Incident Investigations – Key Concepts

Writing up the Investigation

 Try to be as concise, factual and precise as possible
 summarise findings at start and conclusion at the end
 use neutral language “incident vs. catastrophe”
 use referenced diagrams and pictures
 put detailed evidence in appendices, eg statements
 Describe the 5Ws
 State RCA findings
 Identify corrective and preventative actions
 Do not draw legal conclusions, e.g., “the negligence of the two
electricians caused the accident”
 Avoid speculation on facts, motives, causes, and outcomes,
unless absolutely essential for the report. Personal opinion
should be kept out of the factual report – should put in a
separate section
 Consider carefully to who should be sent the report
 Incident Investigations – Key Concepts

Investigation Report

Business Unit:
Investigation Completed by:

Date of Incident:
Severity of Incident (from list below):
Fatal/ Major Injury/High Potential Incident (minor injury or near hit)/ Ill health

Nature of Incident (from list below):

fall,of person(s) lifting equip or plant failure vehicle,
fall of material release violence
collapse exposure, viral
electrical fire / explosion other

Description of Incident
Who:

What:

Where:
When:

Why:
 Incident Investigations – Key Concepts

Investigation Report pt2

Immediate Causes (see terminology – pick most relevant factors):

Actions:

Conditions:

Underlying Causes (see terminology - pick most relevant factors):

Job factors:

Organisational factors:

Personnel factors:

Corrective Action(s) (ie actions to correct deficiencies - inc responsibilities, resources and timescales)

Preventative Action(s) ( ie actions to prevent situation occurring again - inc responsibilities, resources and timescales)

Lessons Learnt (i.e. what are the key learning points for the business to prevent this type of incident happening again)
 Incident Investigations – Key Concepts

Corrective & Preventative Actions

 Identify the corrective/remedial actions necessary to
eliminate the root cause of each critical factor following the
hierarchy of control:
 Measures that eliminate the causal factor, e.g. a change of process,
equipment, sequence, materials, etc.
 Measures that control the causal factor, e.g. the provision of physical
barriers, guarding, protection, etc.
 Measure which protect people from the risk, e.g. PPE, etc.
 Action By Whom, By When
 Date to be completed by – verification/sign off by who?
 Capture lessons learnt for the organisation – communicate,
revise process and standards.
 Incident Investigations – Key Concepts

INVESTIGATION SUMMARY
 When undertaking an incident investigation, think
carefully about who to involve and when – then act
quickly
 Gather the evidence to answer – who, what, where,
when why and how
 Stick to the facts and follow chains of evidence.
 Analyse the evidence methodically using “5 Whys”
approach to identify root causes
 Take the time to write the report correctly excluding
personal opinion. Avoid derogatory remarks, legal
buzzwords and jargon that can be misinterpreted or
difficult to explain.
 Ensure corrective and preventative actions are identified
and implemented