POLICY NOTE: OHSU P16 (2002)

CODE OF PRACTICE ON ACCIDENT AND INCIDENT INVESTIGATION

This Code of Practice sets out University Policy and provides guidance on accident and incident investigation at Bangor University. The Code of Practice advises on the nature and extent of accident and incident investigations that is required and identifies who or which Department should undertake the lead-role in the investigation.

The Code of Practice does in no way preclude or restrict recognised Trade Union Health and Safety Representatives from undertaking their own investigations and related activities, in accordance with the HSC Code of Practice L87 (the Brown Book).

Index

1 POLICY

2 BACKGROUND

3 DEFINITIONS

4 PURPOSE OF AN INVESTIGATION

5 RESPONSIBILITY

6 SPECIFIC GUIDANCE

6.1 When to Investigate

6.2 Who Should Do the Investigation?

6.2.1 Serious Incidents or Injuries

6.3 The Investigation Process

6.3.5 Witnesses Statements

6.3.6 Concluding the Interview

6.4 Reporting and Concluding

7 REVIEW

1 POLICY

It is the policy of the University that all accidents and incidents, which occur at the University or whilst on a University led activity, will be investigated with an aim of:

Establishing the cause; and
Preventing a re-occurrence.

2 BACKGROUND

The University has considered it necessary to introduce a requirement to investigate incidents and accidents at the University in order to seek to continually reduce their frequency and seriousness and to comply with the spirit of the Health and Safety at Work etc Act 1974 and the Management of Health and Safety at Work Regulations as well as its duty of care for all affected by it.

It is appreciated by the University that unless the cause of workplace accidents and incidents are properly understood, lessons will not be learned and suitable improvements will not be made to secure the future health and safety protection of those who may be affected by the University's activities.

If lessons are to be learned from accidents and incidents the underlying causes must be understood and the University must act to make sure that they are not repeated.

This Code of Practice supplements the reporting requirements stipulated within University Guidance on Reporting Accidents, Diseases and Dangerous Occurrences (OHSU G19).

3 DEFINITION OF AN ACCIDENT AND INCIDENT

Accidents and Incidents are defined as an unplanned or uncontrolled event that resulted in, or could have resulted in, physical harm, damage or loss to people, equipment, buildings, materials or the environment. For the purpose of this Code of Practice Accidents and incidents do not include theft.

4 PURPOSE

The main aim of an accident and incident investigation is to establish what went wrong (the cause) and establish how a recurrence could be prevented, or its effects lessened, by the introduction of additional safeguards, procedures, training and information or any combination of these.

5 RESPONSIBILITY

Heads of School/Department are responsible for ensuring that an investigation of all accidents and incidents, occurring within their area of responsibility, is carried out.

Accidents and Incidents which occur on those parts of the University estate not allocated to or under the control of any specific School, Department, Office or other such Unit shall be investigated by the Estates Department or in certain circumstances, the Occupational Health and Safety Unit.

The Occupational Health and Safety Unit shall investigate accidents where it is unclear as to where the responsibility lies or, due to the seriousness of an incident; a more detailed investigation is required. This is appropriate for all accidents that are reported to the Health and Safety Executive under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR).

6 GUIDANCE

6.1 When to Investigate

All accidents and incidents shall be investigated and the level and extent of the investigation should reflect the seriousness or potential seriousness of the accident or incident.

It is important that all accidents and incidents are investigated but it is equally important that extensive human resources are not employed on conducting minor investigations.

6.2 Who should do the investigation?

In all circumstances the Departmental Safety Co-ordinator, Line-Manager or Supervisor of the injured person (or the Supervisor or Manager for the area in question) and/or the Occupational Health and Safety Unit, should investigate accidents and incidents or be part of the accident investigation process.

The Supervisor or Manager under normal circumstances is the person with sufficient knowledge of the injured person or area, the job being undertaken, the history of the activity or area and of the safe working procedures in place.

Other persons may also be involved in the accident/incident investigation. Such people may include:

Staff Representatives (Trade Union or Non-Trade Union),
Student Representatives,
Managers or Head of Department,
Departmental Safety Monitors,
Estates Department Management (where site or building issues are involved); or the Occupational Health and Safety Unit.

The numbers of people involved should, where possible, be kept to a minimum and only involve those with sufficient knowledge of the processes or procedures and those with sufficient health and safety training or management responsibility.

Staff Safety Representatives must be given an opportunity to be part of all accident investigations. Staff representatives may also conduct their own separate investigation if they so wish and present a report to the University and appropriate Department/School.

6.2.1 Serious Incidents or Injuries

In all circumstances where the University is required to report accidents and incidents to Statutory Authorities, a member of the Occupational Health and Safety Unit shall lead the accident/incident investigation.

6.3 THE INVESTIGATION PROCESS

All accidents and incidents should, in normal circumstances be investigated as soon as possible after the occurrence as this is the period when witnesses will have a clear memory of the accident / incident and when the environmental conditions will have changed least. Where it is not possible to investigate immediately following an incident the investigation should commence as soon as practicable.

The line manager, safety co-ordinators or safety representatives through receipt of a verbal report or completed accident-reporting form, should instigate accident investigations. Details of accident and incident (internal and external) reporting arrangements are stated within the University Health and Safety Guidance Note OHSU G19 (1997).

The investigation process should establish the six principles of:

Who? - who was involved or injured (if anyone)?
When? - when did the accident or incident occur?
Where? - where did the accident or incident occur?
How? - how did the accident or incident occur and what happened?
Why? - why did the accident or incident occur?
Conclusion - how can it be prevented in future?

Guidance on the Investigation Process

6.3.1 Planning

Accident/Incident investigations must be in sufficient detail to: -

establish the facts;
use the facts established to try and determine the cause;
make recommendations to prevent or minimise the affects of a re-occurrence.

6.3.2 Process

Accident and incident investigations must be approached with an OPEN MIND and without prejudice and pre-conceived theories. Accident investigations must be methodical and organised and must not apportion blame to individuals.

Throughout the process it is important to write everything down and not depend on memory.

6.3.3 The Scene

The scene of the accident or incident should be inspected as soon as possible after the occurrence. Where appropriate the area should be cordoned off to prevent disturbance and further accident until the inspection is completed and thereafter-remedial action may be taken.

When assessing the area all appropriate environmental conditions, equipment and fittings must be examined. If equipment or fittings are involved these should be isolated until safety can be assured.

Photographs or sketches should be taken where appropriate.

Gather all items, tools, chemicals or objects associated with the accident or incident and label or identify where they were removed from.

Gather all relevant documentation pertaining to the area or activity, including where appropriate Risk Assessments, Safe Systems of Work, Permit to Work, Policies and Job Description.

Gather details of ALL witnesses to the accident/ incident.

6.3.4 Witnesses

Where witnesses are available to the accident or incident their views and observations should be sought. If the accident or incident involved, or could have resulted in a serious injury, witness statements should be also obtained.

Witnesses should always be put at ease and reminded that the purpose of the investigation is not to apportion blame. Their observations should be obtained without any prompting or suggestions from the interviewer.

6.3.5 Witnesses Statements

When the accident or incident necessitates the taking of witness statements it is important that the following criteria is followed:-

Note:- if the injured person is seriously injured and the incident is actively being investigated by the Health and Safety Executive, Local Authority or Police the injured person must not be interviewed until they have recovered sufficiently and the interview does not conflict with the wishes of the Enforcing Authority. In these circumstances the Occupational Health and Safety Unit will lead the investigation process.

Interviews should be undertaken at the scene of the accident / incident or in informal surroundings and in a non-threatening manner.
The witness should be advised that they may be accompanied by a friend or staff representative if they wish.
The witness should be put at ease and informed of the purpose of the investigation and that it is not the role of the investigators to apportion blame to any individual.
The witness should be encouraged to speak freely and not to withhold anything that could help the investigation.
The witness should not be led or directed and notes should be continuously taken.
Only interview one person at a time.

At the end of the interview the witness should read what he/she said and if they are in agreement be requested to sign to this affect. The witness can refuse to sign if he/she prefers.

6.3.6 Concluding the Interview

Having carried out the investigation and interview(s) the investigators should consider collectively all the evidence in a logical way in order to determine the real cause. Remember that the real cause is NOT always the obvious.

6.4 Reporting and Concluding

The detail and complexity of the report into the investigation should reflect the nature of the accident / incident and should not be over complex or be too detailed where this may not be appropriate.

Reports should be simple to read and follow the six principles (as stated above) of accident and incident investigation, namely: -

Who ? - who was involved or injured
When ? - when did the accident or incident occur?
Where ? - where did the accident or incident occur?
How ? - how did the accident or incident occur and what happened?
Why ? - why did the accident or incident occur?
Conclusion - how can it be prevented in future?

Think about:-

The scene:

The equipment, material and activity
The people
The management controls in place
The history of previous accidents or incidents

The Scene

Think about the environmental conditions, the time of the occurrence, housekeeping standards, lighting and other relevant factors.

Equipment, Materials and the Activity

Consider the nature of the equipment, machinery, chemicals, and materials and how and in which way they are used. Are there maintenance records for the equipment?

The People

Think about the injured persons experience and capabilities and that of others involved.

Management Controls

Consider the safety procedures in place, including Risk Assessments, Policies, Safe Working Practices, Supervision Levels and the Working Procedures. Do people know of the safety arrangements?

Are safety procedures implemented?
Were all the necessary safety rules in place?
Is there adequate safety information in place, such as posters, signs and other appropriate information?

Think about ALL the issues raised, dont discount anything out of hand.

Decide

After discussing and considering all the facts, a conclusion can on most occasions be achieved and the factors that caused the accident or incident can be clearly identified.

Produce Report

Produce and publish report and distribute to all affected or involved.

7. REVIEW

Introduce review procedures within School / Departmental management regimes. This could be done through the Departmental Safety Committee or a special working group of that committee. Where possible always include student and staff representatives in the review process as appropriate.

The purpose of the review is to provide the Head of Department/School with an overview of accident and incident occurrences within the Department and to ensure that all incidents are investigated adequately and remedial measures introduced where these be required.

End.