Accident Investigation

Health and Safety
Executive
Investigating accidents and

incidents
A workbook for employers, unions, safety representatives
and safety professionals
This is a free-to-download, web-friendly version of HSG245
Investigating accidents and incidents
(Second edition, published 2004). This version has been adapted for online
use from HSE’s current printed version.
You can buy the book at www.hsebooks.co.uk and most good bookshops.
ISBN 978 0 7176 2827 8

Price £9.50
A workbook for employers, unions, safety representatives

and safety professionals
Every year people are killed or injured at work. Over 40 million working days are
lost annually through work-related accidents and illnesses.
This workbook gives organisations an opportunity to find out what went wrong.
Learning the lessons and taking action may reduce, or even prevent, accidents
in the future.
As a new step by step guide, it will help all organisations, particularly smaller
businesses, to carry out their own health and safety investigations. Investigating
accidents and incidents explains why you need to carry out investigations and
takes you through each step of the process:
Step one: Gathering the information

Step two: Analysing the information
Step three: Identifying risk control measures
Step four: The action plan and its implementation
HSE Books
Page 1 of 89
Health and Safety
Executive
© Crown copyright 2004
First published 2004

Reprinted 2005
ISBN 978 0 7176 2827 8
All rights reserved. No part of this publication may be reproduced, stored in

a retrieval system, or transmitted in any form or by any means (electronic,
mechanical, photocopying, recording or otherwise) without the prior written
permission of the copyright owner.
Applications for reproduction should be made in writing to:

The Office of Public Sector Information, Information Policy Team,
Kew, Richmond, Surrey TW9 4DU or e-mail: [email protected]
This guidance is issued by the Health and Safety Executive. Following the guidance
is not compulsory and you are free to take other action. But if you do follow the
guidance you will normally be doing enough to comply with the law. Health and
safety inspectors seek to secure compliance with the law and may refer to this
guidance as illustrating good practice.
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Contents
Reducing risks and protecting people 4
Understanding the language of investigation 5
The causes of adverse events 7
Why investigate? 8
A step by step guide to health and safety investigations 13
Gathering the information 14

Analysing the information 20
Identifying risk control measures 24
The action plan and its implementation 25
References and further reading 27
Adverse event report and investigation form: Worked examples 29

Adverse event report and investigation form: Blank form 57
Adverse event analysis: Rooting out risk 67
Adverse event analysis: Worked examples 74
Adverse event analysis: Blank form 84
Investigating accidents and incidents Page 3 of 89

Health and Safety
Executive
Reducing risk and protecting

people
Recent figures show that an average of 250 employees and self-employed people
are killed each year as a result of accidents in the workplace.1 A further 150 000
sustain major injuries or injuries that mean they are absent from work for more than
three days. Over 2.3 million cases of ill health are caused or made worse by work.2
According to the Labour Force Survey,3 over 40 million working days are lost
through work-related injuries and ill health, at a cost to business of £2.5 billion.4
“If you think safety is expensive, try an accident” Chairman of Easy Group
Clearly, there are good financial reasons for reducing accidents and ill health.
Costings show that for every £1 a business spends on insurance, it can be losing
between £8 and £36 in uninsured costs.4
The same accidents happen again and again, causing suffering and distress to an
ever-widening circle of workers and their families. The investigation and analysis of
work-related accidents and incidents forms an essential part of managing health
and safety. However, learning the lessons from what you uncover is at the heart of
preventing accidents and incidents. Identify what is wrong and take positive steps
to put it right. This guide will show you how.
Carrying out your own health and safety investigations will provide you with a
deeper understanding of the risks associated with your work activities. Blaming
individuals is ultimately fruitless and sustains the myth that accidents and cases
of ill health are unavoidable when the opposite is true. Well thought-out risk
control measures, combined with adequate supervision, monitoring and effective
management (ie your risk management system) will ensure that your work activities
are safe. Health and safety investigations are an important tool in developing and
refining your risk management system.
An effective investigation requires a methodical, structured approach to information

gathering, collation and analysis. The findings of the investigation will form the basis
of an action plan to prevent the accident or incident from happening again and for
improving your overall management of risk. Your findings will also point to areas of
your risk assessments that need to be reviewed. This link with risk assessment(s) is
a legal duty.5
This guide will help you to adopt a systematic approach to determining why an
accident or incident has occurred and the steps you need to take to make sure it
does not happen again.

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Understanding the language of

investigation
Certain key words and phrases will be used regularly throughout this guide.
‘Adverse event’ includes:
n accident: an event that results in injury or ill health;

n incident:

– near miss: an event that, while not causing harm, has the potential to cause
injury or ill health. (In this guidance, the term near miss will be taken to
include dangerous occurrences);
– undesired circumstance: a set of conditions or circumstances that
have the potential to cause injury or ill health, eg untrained nurses
Figure 1 Accident handling heavy patients.
Dangerous occurrence: one of a number of specific, reportable adverse events,

as defined in the Reporting of Injuries, Diseases and Dangerous Occurrences
Regulations 1995 (RIDDOR).
Hazard: the potential to cause harm, including ill health and injury; damage to
property, plant, products or the environment, production losses or increased
liabilities.
Immediate cause: the most obvious reason why an adverse event happens, eg
the guard is missing; the employee slips etc. There may be several immediate
causes identified in any one adverse event.
Consequence:
Figure 2 Near miss
fatal: work-related death;
major injury/ill health: (as defined in RIDDOR, Schedule 1), including fractures
(other than fingers or toes), amputations, loss of sight, a burn or penetrating
injury to the eye, any injury or acute illness resulting in unconsciousness, requiring
resuscitation or requiring admittance to hospital for more than 24 hours;
serious injury/ill health: where the person affected is unfit to carry out his or her
normal work for more than three consecutive days;
minor injury: all other injuries, where the injured person is unfit for his or her normal
work for less than three days;
damage only: damage to property, equipment, the environment or production

losses. (This guidance only deals with events that have the potential to cause harm
to people.)
Figure 3 Undesired Likelihood that an adverse event will happen again:

circumstance
certain: it will happen again and soon;
likely: it will reoccur, but not as an everyday event;
possible: it may occur from time to time;
unlikely: it is not expected to happen again in the foreseeable future;
rare: so unlikely that it is not expected to happen again.

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Risk: The level of risk is determined from a combination of the likelihood of a

specific undesirable event occurring and the severity of the consequences
(ie how often is it likely to happen, how many people could be affected and how
bad would the likely injuries or ill health effects be?)
Risk control measures: are the workplace precautions put in place to reduce the
risk to a tolerable level?
Root cause: an initiating event or failing from which all other causes or failings
spring. Root causes are generally management, planning or organisational failings.
Underlying cause: the less obvious ‘system’ or ’organisational’ reason for an

adverse event happening, eg pre-start-up machinery checks are not carried out
by supervisors; the hazard has not been adequately considered via a suitable and
sufficient risk assessment; production pressures are too great etc.

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The causes of adverse events

Adverse events have many causes. What may appear to be bad luck (being in the
wrong place at the wrong time) can, on analysis, be seen as a chain of failures and
errors that lead almost inevitably to the adverse event. (This is often known as the
Domino effect.)
These causes can be classified as:
n immediate causes: the agent of injury or ill health (the blade, the substance, the
dust etc);
n underlying causes: unsafe acts and unsafe conditions (the guard removed, the
ventilation switched off etc);
n root causes: the failure from which all other failings grow, often remote in time
and space from the adverse event (eg failure to identify training needs and
assess competence, low priority given to risk assessment etc).
To prevent adverse events, you need to provide effective risk control measures
which address the immediate, underlying and root causes.
A
B
Figure 4 Sequence of dominoes
Note: Each domino represents a failing or error which can combine with other failings and
errors to cause an adverse event. Dealing with the immediate cause (B) will only prevent his
sequence. Dealing with all causes, especially root causes (A) can prevent a whole series of
adverse events.

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Why investigate?
There are hazards in all workplaces; risk control measures are put in place to
reduce the risks to an acceptable level to prevent accidents and cases of ill health.
The fact that an adverse event has occurred suggests that the existing risk control
measures were inadequate.
Learning lessons from near misses can prevent costly accidents. (The Clapham
Junction rail crash and the Herald of Free Enterprise ferry capsize were both
examples of situations where management had failed to recognise, and act on,
previous failings in the system.) You need to investigate adverse events for a
number of reasons.
Legal reasons for investigating
n T o ensure you are operating your organisation within the law.

n The Management of Health and Safety at Work Regulations 1999, regulation 5,
requires employers to plan, organise, control, monitor and review their health
and safety arrangements. Health and safety investigations form an essential
part of this process.
n Following the Woolf Report6 on civil action, you are expected to make
full disclosure of the circumstances of an accident to the injured parties
considering legal action. The fear of litigation may make you think it is better not
to investigate, but you can’t make things better if you don’t know what went
wrong! The fact that you thoroughly investigated an accident and took remedial
action to prevent further accidents would demonstrate to a court that your
company has a positive attitude to health and safety. Your investigation findings
will also provide essential information for your insurers in the event of a claim.
Information and insights gained from an investigation
n A n understanding of how and why things went wrong.

n An understanding of the ways people can be exposed to substances or
conditions that may affect their health.
n A true snapshot of what really happens and how work is really done. (Workers
may find short cuts to make their work easier or quicker and may ignore rules.
You need to be aware of this.)
n Identifying deficiencies in your risk control management, which will enable you
to improve your management of risk in the future and to learn lessons which
will be applicable to other parts of your organisation.
Benefits arising from an investigation
n The prevention of further similar adverse events. If there is a serious accident,

the regulatory authorities will take a firm line if you have ignored previous
warnings.
n The prevention of business losses due to disruption, stoppage, lost orders and
the costs of criminal and civil legal actions.
n An improvement in employee morale and attitude towards health and safety.
Employees will be more cooperative in implementing new safety precautions
if they were involved in the decision and they can see that problems are dealt
with.

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n The development of managerial skills which can be readily applied to other

areas of the organisation.
While the argument for investigating accidents is fairly clear, the need to investigate
near misses and undesired circumstances may not be so obvious. However,
investigating near misses and undesired circumstances is as useful, and very much
easier than investigating accidents.
Adverse events where no one has been harmed can be investigated without
having to deal with injured people, their families and a demoralised workforce, and
without the threat of criminal and civil action hanging over the whole proceedings.
Witnesses will be more likely to be helpful and tell the truth. (Consider the following:
‘I mistakenly turned the wrong valve which released the boiling water because the
valves all look the same’ or ‘I don’t know how John was scalded.’ Which is the
likely response to a near miss and which to an accident? More importantly, which
is the most useful?)
It is often pure luck that determines whether an undesired circumstance translates

into a near miss or accident. The value of investigating each adverse event is the
same.
An investigation is not an end in itself, but the first step in preventing future adverse
events. A good investigation will enable you to learn general lessons, which can be
applied across your organisation.
The investigation should identify why the existing risk control measures failed and
what improvements or additional measures are needed. More general lessons on
why the risk control measures were inadequate must also be learned.
Which events should be investigated?
Having been notified of an adverse event and been given basic information on what
happened, you must decide whether it should be investigated and if so, in what
depth.
It is the potential consequences and the likelihood of the adverse event recurring
that should determine the level of investigation, not simply the injury or ill health
suffered on this occasion. For example: Is the harm likely to be serious? Is this
likely to happen often? Similarly, the causes of a near miss can have great potential
for causing injury and ill health. When making your decision, you must also consider
the potential for learning lessons. For example if you have had a number of similar
adverse events, it may be worth investigating, even if each single event is not worth
investigating in isolation. It is best practice to investigate all adverse events which
may affect the public.
Who should carry out the investigation?
For an investigation to be worthwhile, it is essential that the management and the

workforce are fully involved. Depending on the level of the investigation (and the
size of the business), supervisors, line managers, health and safety professionals,
union safety representatives, employee representatives and senior management/
directors may all be involved.
As well as being a legal duty, it has been found that where there is full cooperation
and consultation with union representatives and employees, the number of
accidents is half that of workplaces where there is no such employee involvement.7

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This joint approach will ensure that a wide range of practical knowledge and
experience will be brought to bear and employees and their representatives will feel
empowered and supportive of any remedial measures that are necessary. A joint
approach also reinforces the message that the investigation is for the benefit of
everyone.
In addition to detailed knowledge of the work activities involved, members of the

team should be familiar with health and safety good practice, standards and legal
requirements. The investigation team must include people who have the necessary
investigative skills (eg information gathering, interviewing, evaluating and analysing).
Provide the team with sufficient time and resources to enable them to carry out the
investigation efficiently.
It is essential that the investigation team is either led by, or reports directly to
someone with the authority to make decisions and act on their recommendations.
When should it start?
The urgency of an investigation will depend on the magnitude and immediacy of

the risk involved (eg a major accident involving an everyday job will need to be
investigated quickly).
In general, adverse events should be investigated and analysed as soon as

possible. This is not simply good practice; it is common sense – memory is best
and motivation greatest immediately after an adverse event.
What does it involve?
An investigation will involve an analysis of all the information available, physical

(the scene of the incident), verbal (the accounts of witnesses) and written (risk
assessments, procedures, instructions, job guides etc), to identify what went
wrong and determine what steps must be taken to prevent the adverse event from
happening again.
It is important to be open, honest and objective throughout the investigation

process. Pre-conceived ideas about the process, the equipment or the people
involved in an adverse event may blind you to the real causes. Question everything.
Be wary of blaming individuals.
What makes a good investigation?
To get rid of weeds you must dig up the root. If you only cut off the foliage, the
weed will grow again.
Similarly it is only by carrying out investigations which identify root causes that
organisations can learn from their past failures and prevent future failures.
Simply dealing with the immediate causes of an adverse event may provide a
short-term fix. But, in time, the underlying/root causes that were not addressed will
allow conditions to develop where further adverse events are likely, possibly with
more serious consequences. It is essential that the immediate, underlying causes
and root causes are all identified and remedied.
Investigations should be conducted with accident prevention in mind, not placing

blame. Attempting to apportion blame before the investigation has started is

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counterproductive, because people become defensive and uncooperative. Only

after the investigation has been completed is it appropriate to consider whether any
individuals acted inappropriately.
Investigations that conclude that operator error was the sole cause are rarely
acceptable. Underpinning the ‘human error’ there will be a number of underlying
causes that created the environment in which human errors were inevitable. For
example inadequate training and supervision, poor equipment design, lack of
management commitment, poor attitude to health and safety.
The objective is to establish not only how the adverse event happened, but more
importantly, what allowed it to happen.
The root causes of adverse events are almost inevitably management,

organisational or planning failures.
Man slipping
Inadequate Inadequate
on a patch
maintenance housekeeping
of oil
Management
Inadequate
not being Lack of
health
committed supervision
and safety
to health and monitoring
management
and safety
Look carefully at your health and safety policy and how it is reflected in the
workplace. Do staff understand the health and safety message in general and
in particular those parts that relate to their work? Is something missing from the
policy? Is it implemented, or is management failing to ensure that health and safety
measures remain in place and are effective at all times? If not, your health and
safety policy needs to be changed.
The investigation should be thorough and structured to avoid bias and leaping to
conclusions. Don’t assume you know the answer and start finding solutions before
you complete the investigation. A good investigation involves a systematic and
structured approach.
Information gathering:
n e xplores all reasonable lines of enquiry;

n is timely;
n is structured, setting out clearly what is known, what is not known and records
the investigative process.
Analysis:
n is objective and unbiased;

n identifies the sequence of events and conditions that led up to the adverse
event;
n identifies the immediate causes;
n identifies underlying causes, ie actions in the past that have allowed or caused
undetected unsafe conditions/practices;
n identifies root causes, (ie organisational and management health and safety
arrangements – supervision, monitoring, training, resources allocated to health
and safety etc).

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Risk control measures:
n i dentify the risk control measures which were missing, inadequate or unused;
n compare conditions/practices as they were with that required by current legal
requirements, codes of practice and guidance;
n identify additional measures needed to address the immediate, underlying and
root causes;
n provide meaningful recommendations which can be implemented. But woolly
recommendations such as ‘operators must take care not to touch the cutters
during run-down’ show that the investigation has not delved deep enough in
search of the root causes.
Action plan and implementation:
n provide an action plan with SMART objectives (Specific, Measurable, Agreed,

Realistic and Timescaled);
n ensure that the action plan deals effectively not only with the immediate and
underlying causes but also the root causes;
n include lessons that may be applied to prevent other adverse events, eg
assessments of skill and training in competencies may be needed for other
areas of the organisation;
n provide feedback to all parties involved to ensure the findings and
recommendations are correct, address the issues and are realistic;
n should be fed back into a review of the risk assessment. The Approved
Code of Practice5 attached to the Management of Health and Safety at Work
Regulations 1999 regulation 3 (paragraph 26), states that adverse events
should be a trigger for reviewing risk assessments);
n communicate the results of the investigation and the action plan to everyone
who needs to know;
n include arrangements to ensure the action plan is implemented and progress
monitored.
The last three steps, though essential, are often overlooked. But, without them, the
full benefits of the investigation will not be realised and in the long term nothing will
change.
Techniques for analysing adverse events
There are many tools and techniques for structuring the investigation, analysing
adverse events, and identifying root causes.8 HSE does not endorse any one
method – it is for you to choose which techniques suit your company. These
techniques are simply tools, not an end in themselves.
For large, complex or technically demanding investigations, these techniques may

be essential in determining not only how the adverse event happened, but also
what were the root causes.
However, provided a methodical approach with full employee participation is

adopted, a less complicated approach, such as that set out in this publication, will
be appropriate.

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A step by step guide to health

and safety investigations

Steps to take following an adverse event
Emergency response:
n t ake prompt emergency action (eg first aid);

n make the area safe (in some cases this may need to be done first).
Initial report:
n p reserve the scene;

n note the names of the people, equipment involved and the names of the
witnesses;
n report the adverse event to the person responsible for health and safety who
will decide what further action (if any) is needed.
Initial assessment and investigation response:
n report the adverse event to the regulatory authority if appropriate.
RIDDOR
For those accidents and dangerous occurrences that are reportable under
the provisions of RIDDOR (the Reporting of Injuries, Diseases and Dangerous
Occurrences Regulations 1995), this information must be notified to the Incident
Contact Centre (ICC) by phoning 0845 300 9923.
Although phoning is the quickest and most convenient way of informing the
enforcing authorities, whether you are HSE or LA-enforced, you can also make
reports to the ICC in the following ways:
Internet: www.riddor.gov.uk
or link in via the HSE website: www.hse.gov.uk
Email: [email protected]
Fax (local rate): 0845 300 9924
Post: Incident Contact Centre
Caerphilly Business Park
Caerphilly
CF83 3GG
A copy of your report will be provided for your records, free of charge.
You also need to enter details of the accident in an accident book. And, you need
to decide on the scale of the investigation. Where appropriate, decide who will
carry out the investigation, the resources required and brief the investigation team.
Note: The prompt notification of RIDDOR reportable events is a legal requirement. Do not
wait until you have carried out a thorough investigation before you report it to the ICC.
Fatalities and major injuries (as defined in RIDDOR) must be reported immediately. Those
accidents where employees have been absent from work (or moved to other duties as a
result of the accident) for greater than three days must be reported within ten days of the
accident date. Where a death has occurred the police may take charge and they should be
notified immediately.

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The decision to investigate
The table below will assist you in determining the level of investigation which
is appropriate for the adverse event. Remember you must consider the worst
potential consequences of the adverse event (eg a scaffold collapse may not have
caused any injuries, but had the potential to cause major or fatal injuries).
Likelihood of Potential worst consequence of adverse event

recurrence
Minor Serious Major Fatal
Certain
Likely
Possible
Unlikely
Rare
(The definitions of ‘consequence’ and ‘likelihood’ are set out in the section on
‘Understanding the language of investigation’)
Risk Minimal Low Medium High

Investigation level Minimal Low Medium High
level level level level
n In a minimal level investigation, the relevant supervisor will look into the
circumstances of the event and try to learn any lessons which will prevent
future occurrences.
n A low level investigation will involve a short investigation by the relevant
supervisor or line manager into the circumstances and immediate, underlying
and root causes of the adverse event, to try to prevent a recurrence and to
learn any general lessons.
n A medium level investigation will involve a more detailed investigation by the
relevant supervisor or line manager, the health and safety adviser and employee
representatives and will look for the immediate, underlying and root causes.
n A high level investigation will involve a team-based investigation, involving
supervisors or line managers, health and safety advisers and employee
representatives. It will be carried out under the supervision of senior
management or directors and will look for the immediate, underlying, and root
causes.
The investigation
The four steps include a series of numbered questions. These set out in detail the
information that should be entered onto the adverse event investigation form. The
question numbers correspond to those on the form.
Step one Gathering the information
Find out what happened and what conditions and actions influenced the adverse
event. Begin straight away, or as soon as practicable.
It is important to capture information as soon as possible. This stops it being

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corrupted, eg items moved, guards replaced etc. If necessary, work must stop and
unauthorised access be prevented.
Talk to everyone who was close by when the adverse event happened,
especially those who saw what happened or know anything about the conditions
that led to it.
The amount of time and effort spent on information gathering should be

proportionate to the level of investigation. Collect all available and relevant
information. That includes opinions, experiences, observations, sketches,
measurements, photographs, check sheets, permits-to-work and details of the
environmental conditions at the time etc. This information can be recorded initially
in note form, with a formal report being completed later. These notes should be
kept at least until the investigation is complete.
Where, when and who?
1 Where and when did the adverse event happen?
2 Who was injured/suffered ill health or was otherwise involved with the
adverse event?
Gathering detailed information: How and what?
Discovering what happened can involve quite a bit of detective work. Be precise
and establish the facts as best you can. There may be a lack of information and
many uncertainties, but you must keep an open mind and consider everything that
might have contributed to the adverse event. Hard work now will pay off later in the
investigation.
Many important things may emerge at this stage of the process, but not all of them
will be directly related to the adverse event. Some of the information gathered may
appear to have no direct bearing on the event under investigation. However, this
information may provide you with a greater insight into the hazards and risks in
your workplace. This may enable you to make your workplace safer in ways you
may not have previously considered.
3 How did the adverse event happen? Note any equipment involved.
Describe the chain of events leading up to, and immediately after, the adverse
event. Very often, a number of chance occurrences and coincidences combine to
create the circumstances in which an adverse event can happen. All these factors
should be recorded here in chronological order, if possible. Work out the chain of
events by talking to the injured person, eye witnesses, line managers, health and
safety representatives and fellow workers to find out what happened and who did
what. In particular, note the position of those injured, both immediately before and
after the adverse event. Be objective and, as far as possible, avoid apportioning
guilt, assigning responsibility or making snap judgements on the probable causes.

Plant and equipment that had a direct bearing on the adverse event must be
identified clearly. This information can usually be obtained from a nameplate
attached to the equipment. Note all the details available, the manufacturer,
model type, model number, machine number and year of manufacture and any
modifications made to the equipment. Note the position of the machinery controls
immediately after the adverse event. This information may help you to spot trends
and identify risk control measures. You should consider approaching the supplier
if the same machine has been implicated in a number of adverse events. Be

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precise. Shop floor process and layout changes are a regular occurrence. Unless
you precisely identify plant and equipment, you will not detect, eg that a machine
or particular piece of equipment has been moved around and caused injuries on
separate occasions, in different locations.
4 What activities were being carried out at the time?
The work that was being done just before the adverse event happened can
often cast light on the conditions and circumstances that caused something to
go wrong. Provide a good description, including all the relevant details, eg the
surroundings, the equipment/materials being used, the number of employees
engaged in the various activities, the way they were positioned and any details
about the way they were behaving etc.
5 Was there anything unusual or different about the working conditions?
Adverse events often happen when something is different. When faced with a
new situation, employees may find it difficult to adapt, particularly if the sources
of danger are unknown to them, or if they have not been adequately prepared to
deal with the new situation. If working conditions or processes were significantly
different to normal, why was this?
Describe what was new or different in the situation. Was there a safe working
method in place for this situation, were operatives aware of it, and was it being
followed? If not, why not? Learning how people deal with unfamiliar situations will
enable similar situations to be better handled in the future.
Was the way the changes, temporary or otherwise, were introduced a factor?
Were the workers and supervisors aware that things were different? Were workers
and supervisors sufficiently trained/experienced to recognise and adapt to changing
circumstances?
6 Were there adequate safe working procedures and were they followed?
Adverse events often happen when there are no safe working procedures or where
procedures are inadequate or are not followed. Comments such as ‘…we’ve been
doing it that way for years and nothing has ever gone wrong before…’ or ‘…he
has been working on that machine for years and knows what to do…’ often lead to
the injured person getting the blame, irrespective of what part procedures, training
and supervision – or the lack of them – had to play in the adverse event. What was
it about normal practice that proved inadequate? Was a safe working method in
place and being followed? If not, why not? Was there adequate supervision and
were the supervisors themselves sufficiently trained and experienced? Again, it is
important to pose these questions without attempting to apportion blame, assign
responsibility or stipulate cause.
7 What injuries or ill health effects, if any, were caused?
It is important to note which parts of the body have been injured and the nature of
the injury - ie bruising, crushing, a burn, a cut, a broken bone etc. Be as precise
as you are able. If the site of the injury is the right upper arm, midway between the
elbow and the shoulder joint, say so. Precise descriptions will enable you to spot
trends and take prompt remedial action. For example it could be that what appears
to be a safe piece of equipment, due to the standard of its guarding, is actually
causing a number of inadvertent cut injuries due to the sharp edges on the guards
themselves.
Facts such as whether the injured person was given first aid or taken to hospital (by

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ambulance, a colleague etc) should also be recorded here.
8 If there was an injury, how did it occur and what caused it?
Where an accident is relatively straightforward, it may seem artificial to differentiate

between the accident itself (question 3) and the mode of injury, but when the
accident is more complicated the differences between the two aspects become
clearer and therefore precise descriptions are vital.
The mode of injury concerns two different aspects:
n t he harmful object (known as the ‘agent’) that inflicted the injury; and
n the way in which the injury was actually sustained.
The object that inflicted the injury may be a hand-held tool like a knife, or a
chemical, a machine, or a vehicle etc. The way in which it happened might, eg, be
that the employee cut themselves or spilt chemicals on their skin.
9 Was the risk known? If so, why wasn’t it controlled? If not, why not?
You need to find out whether the source of the danger and its potential
consequences were known, and whether this information was communicated to
those who needed to know. You should note what is said and who said it, so
that potential gaps in the communication flow may be identified and remedied.
The aim is to find out why the sources of danger may have been ignored, not fully
appreciated or not understood. Remember you are investigating the processes and
systems, not the person.
The existence of a written risk assessment for the process or task that led to
the adverse event will help to reveal what was known of the associated risks. A
judgement can be made as to whether the risk assessment was ’suitable and
sufficient’, as required by law5 and whether the risk control measures identified as
being necessary were ever adequately put in place.
10 Did the organisation and arrangement of the work influence the adverse
event?
The organisational arrangement sets the framework within which the work is done.
Here are some examples; there are many more:
n standards of supervision and on-site monitoring of working practices may be

less than adequate;
n lack of skills or knowledge may mean that nobody intervenes in the event of
procedural errors;
n inappropriate working procedures may mean certain steps in the procedures
are omitted, because they are too difficult and time-consuming;
n lack of planning may mean that some tasks are not done, are done too late or
are done in the wrong order;
n employees’ actions and priorities may be a consequence of the way in which
they are paid or otherwise rewarded;
n high production targets and piecework may result in safety measures being
degraded and employees working at too fast a pace.
11 Was maintenance and cleaning sufficient? If not, explain why not.
Lack of maintenance and poor housekeeping are common causes of adverse

events. Was the state of repair and condition of the workplace, plant and
equipment such that they contributed to or caused the adverse event? Were

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the brakes on the forklift truck in good working order? Were spills dealt with
immediately? Was the site so cluttered and untidy that it created a slipping or
tripping hazard? Was there a programme of preventative maintenance? What are
the instructions concerning good housekeeping in the workplace? You should
observe the location of the adverse event as soon as possible and judge whether
the general condition or state of repair of the premises, plant or equipment was
adequate. Those working in the area, together with witnesses, and any injured
parties, should also be asked for their opinion. Working in the area, they will have
a good idea of what is acceptable and whether conditions had deteriorated over
time. Consider the role the following factors may play:
n a badly maintained machine or tool may mean an employee is exposed to

excessive vibration or noise and has to use increased force, or tamper with the
machine to get the work done;
n a noisy environment may prevent employees hearing instructions correctly as
well as being a possible cause of noise-induced hearing loss;
n uneven floors may make movement around the workplace, especially vehicle
movements, hazardous;
n badly maintained lighting may make carrying out the task more difficult;
n poorly stored materials on the floor in and around the work area will increase
the risk of tripping;
n ice, dirt and other contaminants on stairs or walkways make it easier to slip
and fall;
n tools not in immediate use should be stored appropriately and not left lying
around the work area.
12 Were the people involved competent and suitable?
Training should provide workers with the necessary knowledge, skills and hands-
on work experience to carry out their work efficiently and safely. The fact that
someone has been doing the same job for a long time does not necessarily mean
that they have the necessary skills or experience to do it safely. This is particularly
the case when the normal routine is changed, when any lack of understanding can
become apparent.There is no substitute for adequate health and safety training.
Some of the problems that might arise follow:
n a lack of instruction and training may mean that tasks are not done properly;
n misunderstandings, which arise more easily when employees lack
understanding of the usual routines and procedures in the organisation;
n a lack of respect for the risks involved, due to ignorance of the potential
consequences;
n problems due to the immaturity, inexperience and lack of awareness of existing
or potential risks among young people (under18).You must assess the risks to
young people before they start work;
n poor handling of dangerous materials or tools, due to employees not being
properly informed about how things should be done correctly.
People should also be matched to their work in terms of health, strength, mental
ability and physical stature.
13 Did the workplace layout influence the adverse event?
The physical layout and surroundings of the workplace can affect health and safety.
Injuries may be caused by sharp table edges. Hazardous or highly inflammable
fumes may be produced in areas where operatives work or where there are naked
lights. Or, the workplace may be organised in such a way that there is not enough
circulation space. Or, it may be impossible to see or hear warning signals, eg
during fork lift truck movements.

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Employees should be able to see the whole of their work area and see what their
immediate colleagues are doing. The workplace should be organised in such a
way that safe practices are encouraged. In other words, workplace arrangements
should discourage employees from running risks, eg providing a clear walkway
around machinery will discourage people from crawling under or climbing over it.
14 Did the nature or shape of the materials influence the adverse event?
As well as being intrinsically hazardous, materials can pose a hazard simply by their
design, weight, quality or packaging, eg heavy and awkward materials, materials
with sharp edges, splinters, poisonous chemicals etc.
The choice of materials also influences work processes, eg a particularly hazardous

material may be required. Poor quality may also result in materials or equipment
failing during normal processing, causing malfunctions and accidents.
15 Did difficulties using the plant and equipment influence the adverse
event?
Plant and equipment includes all the machinery, plant and tools used to organise
and carry out the work. All of these items should be designed to suit the people
using them. This is referred to as ergonomic design, where the focus is on the
individual as well as the work task the item is specifically designed to carry out. If
the equipment meets the needs of the individual user, it is more likely to be used as
it is intended - ie safely. Consider user instructions here. A machine that requires its
operator to follow a complicated user manual is a source of risk in itself.
16 Was the safety equipment sufficient?
You should satisfy yourself that any safety equipment and safety procedures are
both sufficient and current for all conditions in which work takes place, including
the provision and use of any extra equipment needed for employees’ safety. For
example:
n xtra technical safety equipment at machines;

e
n power supply isolation equipment and procedures;
n personal protective equipment (PPE);
n building safety systems, eg an extract ventilation system.
Make a note of whether the safety equipment was used, whether it was used
correctly, whether or not it was in good condition and was working properly etc.
17 Did other conditions influence the adverse event?
‘Other conditions’ is intended to cover everything else that has not been reported
yet, but which might have influenced the adverse event. For example:
n isagreements or misunderstandings between people;

d
n the weather;
n unauthorised interference in a process or job task;
n defective supplies or equipment;
n deliberate acts, such as trespass or sabotage.

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Step two Analysing the information
An analysis involves examining all the facts, determining what happened and why.
All the detailed information gathered should be assembled and examined to identify
what information is relevant and what information is missing. The information
gathering and analysis are actually carried out side by side. As the analysis
progresses, further lines of enquiry requiring additional information will develop.
To be thorough and free from bias, the analysis must be carried out in a systematic
way, so all the possible causes and consequences of the adverse event are
fully considered. A number of formal methods have been developed to aid this
approach.8
One useful method for organising your information, identifying gaps and beginning
the analysis is Events and Causal Factor Analysis (ECFA),9 which is beyond the
scope of this guidance.
The analysis should be conducted with employee or trade union health and
safety representatives and other experts or specialists, as appropriate. This team
approach can often be highly productive in enabling all the relevant causal factors
to emerge.
18 What were the immediate, underlying and root causes?
It is only by identifying all causes, and the root causes in particular, that you can
learn from past failures and prevent future repetitions.
The causes of adverse events often relate to one another in a complex way,
sometimes only influencing events and at other times having an overwhelming
impact, due to their timing or the way they interact. The analysis must consider
all possible causes. Keep an open mind. Do not reject a possible cause until you
have given it serious consideration.The emphasis is on a thorough, systematic and
objective look at the evidence.
Analysis
There are many methods of analysing the information gathered in an investigation

to find the immediate, underlying and root causes and it is for you to choose
whichever method suits you best.

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John breaks his leg
John is on ladder Falling due to gravity John falls off
Access to the roof The ladder slips
The ladder is not tied
Figure 5
What happened and why?
The first step in understanding what happened and why is to organise the
information you have gathered. This guidance uses the simple technique of asking
‘Why’ over and over, until the answer is no longer meaningful (see Figure 5). The
starting point is the ‘event’, eg John has broken his leg. On the line below, set out
the reasons why this happened. This first line should identify:
n t he vulnerable person, eg John on a ladder;

n the hazard, eg falling due to gravity;
n the circumstances that brought them together, eg John fell off the ladder.
For each of the reasons identified ask ‘Why?’ and set down the answers. Continue
down the page asking ‘Why’ until the answers are no longer meaningful.
Do not be concerned at the number of times you ask the question, ‘Why?’
because by doing so you will arrive at the real causes of the adverse event.
Some lines of enquiry will quickly end, eg ‘Why was the hazard of falling present?’
Answer: ‘Gravity’.

Having collected the relevant information and determined what happened and why,
you can now determine the causes of the adverse event systematically.
Checklist/question analysis of the causes
Using the adverse event analysis work sheets and checklist (in the Adverse Event
and Investigation Form), work through the questions about the possible immediate
causes of the adverse event (the place, the plant, the people and the process) and
identify which are relevant.
Record all the immediate causes identified and the necessary risk control
measures.
For each immediate cause, the analysis suggests underlying causes which may
have allowed the immediate causes to exist.
Consider the underlying/root cause questions suggested by the immediate causes.

Record those that are relevant and note the measures needed to remedy them.
The final step of your analysis is to consider the environment in which the

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organisation and planning of health and safety was carried out.
This ‘Management’ section of the analysis must be carried out by people within
the organisation who have both the overall responsibility for health and safety, and
the authority to make changes to the management system. Record the underlying
failings in the overall management system (ie the root causes of the adverse event)
and the remedial action required at management level. The root causes of almost
all adverse events are failings at managerial level.
Worked examples of the Adverse Event Report and Investigation Form are on
page 29.
What if ‘human failings (errors and violations)’10 are identified as a

contributory factor?
If your investigation concludes that errors or violations contributed to the adverse

event, consider carefully how to handle this information.
Not addressing the ‘human’ factors greatly reduces the value of the investigation.
The objective of an investigation is to learn the lessons and to act to prevent
recurrences, through suitable risk control measures. You will not be able to do that
unless your workforce trusts you enough to co-operate with you.
Laying all the blame on one or more individuals is counter-productive and runs
the risk of alienating the workforce and undermining the safety culture, crucial to
creating and maintaining a safer working environment.

Speak to those involved and explain how you believe their action(s) contributed
to the adverse event. Invite them to explain why they did what they did. This may
not only help you better understand the reasons behind the immediate causes of
the adverse event, but may offer more pointers to the underlying causes: perhaps
the production deadline was short, and removing the guards saved valuable time;
maybe the workload is too great for one person etc.
Unless you discover a deliberate and malicious violation or sabotage of workplace

safety precautions, it may be counter-productive to take disciplinary action against
those involved. Will anyone be open and honest with you the next time an adverse
event occurs? What you should aim for is a fair and just system where people are
held to account for their behaviour, without being unduly blamed. In any event, your
regime of supervision and monitoring of performance should have detected and
corrected these unsafe behaviours.
Human failings can be divided into three broad types and the action needed to
prevent further failings will depend on which type of human failing is involved. See
Figure 6.

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Slip
Skill-based
errors
Human Lapse
failings
Rule-based
Mistake
Knowledge-based
Violation
Figure 6
Skill-based errors: a slip or lapse of memory:
n slips happen when a person is carrying out familiar tasks automatically, without
thinking, and that person’s action is not as planned, eg operating the wrong
switch on a control panel;
n lapses happen when an action is performed out of sequence or a step in a
sequence is missed, eg a road tanker driver had completed filling his tanker
and was about to disconnect the hose when he was called away to answer
the phone. On his return he forgot that he hadn’t disconnected the hose and
drove off. These types of error can be foreseen and measures can be taken
to prevent or reduce their likelihood, eg colour coding, a checklist, an interlock
etc.
Mistakes: errors of judgement (rule-based or knowledge-based):
n rule-based mistakes happen when a person has a set of rules about what to
do in certain situations and applies the wrong rule;
n knowledge-based mistakes happen when a person is faced with an
unfamiliar situation for which he or she has no rules, uses his or her knowledge
and works from first principles, but comes to a wrong conclusion. For example
when the warning light comes on indicating that the cooling system pump is
overheating, is there a rule for what to do? If not, do you leave the pump on,
turn it off, or shut down the whole unit?
Training, comprehensive safe working procedures and equipment design are most
important in preventing mistakes.
Violation (rule breaking):
n deliberate failure to follow the rules, cutting corners to save time or effort,
based on the belief that the rules are too restrictive and are not enforced
anyway, eg operating a circular saw bench with the guard removed.
This type of behaviour can be foreseen. The provision of training, simple practical
rules, and routine supervision and monitoring of performance will reduce this type
of behaviour.
When considering how to avoid human failings, bear in mind the fact they do not
happen in isolation. If human failings are identified as a cause of an adverse event,
consider the following factors that can influence human behaviour.

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Job factors:
n how much attention is needed for the task (both too little and too much can
lead to higher error rates)?
n d ivided attention or distractions are present;
n inadequate procedures;
n time available.
Human factors:
n physical ability (size and strength);

n competence (knowledge, skill and experience);
n fatigue, stress, morale, alcohol or drugs.
Organisational factors:
n ork pressure, long hours;

w
n availability of sufficient resources;
n quality of supervision;
n management beliefs in health and safety (the safety culture).
Plant and equipment factors:
n h ow clear and simple to read and understand are the controls?

n is the equipment designed to detect or prevent errors? (For example different-
sized connectors are used for oxygen and acetylene bottles to prevent errors in
connecting the hoses);
n is the workplace layout user-friendly?
Step three Identifying suitable risk control measures
The methodical approach adopted in the analysis stage will enable failings and
possible solutions to be identified. These solutions need to be systematically
evaluated and only the optimum solution(s) should be considered for
implementation. If several risk control measures are identified, they should be
carefully prioritised as a risk control action plan, which sets out what needs to be
done, when and by whom. Assign responsibility for this to ensure the timetable for
implementation is monitored.
19 What risk control measures are needed/recommended?
Your analysis of the adverse event will have identified a number of risk control
measures that either failed or that could have interrupted the chain of events
leading to the adverse event, if they had been in place. You should now draw up a
list of all the alternative measures to prevent this, or similar, adverse events.
Some of these measures will be more difficult to implement than others, but this
must not influence their listing as possible risk control measures. The time to
consider these limitations is later when choosing and prioritising which measures to
implement.
Evaluate each of the possible risk control measures on the basis of their ability to
prevent recurrences and whether or not they can be successfully implemented.
In deciding which risk control measures to recommend and their priority, you
should choose measures in the following order, where possible:

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n measures which eliminate the risk, eg use ‘inherently safe’ products, such as a
water-based product rather than a hydrocarbon-based solvent;
n m easures which combat the risk at source, eg provision of guarding;
n measures which minimise the risk by relying on human behaviour, eg safe
working procedures, the use of personal protective equipment.
In general terms, measures that rely on engineering risk control measures are more
reliable than those that rely on people.
20 Do similar risks exist elsewhere? If so, what and where?
Having concluded your investigation of the adverse event, consider the wider
implications: could the same thing happen elsewhere in the organisation, on this
site or at another location? What steps can be taken to avoid this?
Adverse events might not have occurred at other locations yet, but make an
evaluation as to whether the risks are the same and the same or similar risk control
measures are appropriate.
21 Have similar adverse events happened before? Give details.
If there have been similar adverse events in the past why have they been allowed
to happen again? The fact that such adverse events are still occurring should be a
spur to ensure that action is taken quickly. You will be particularly open to criticism
if you as an organisation ignore a series of similar accidents.
Remember that there is value in investigating near-misses and undesired

circumstances: it is often only a matter of luck that such incidents do not result in
serious injuries or loss of life.
Step four The action plan and its implementation
22 Which risk control measures should be implemented in the short and long
term?
The risk control action plan
At this stage in the investigation, senior management, who have the authority to
make decisions and act on the recommendations of the investigation team, should
be involved.
An action plan for the implementation of additional risk control measures is the
desired outcome of a thorough investigation. The action plan should have SMART
objectives, ie Specific, Measurable, Agreed, and Realistic, with Timescales.
Deciding where to intervene requires a good knowledge of the organisation and the
way it carries out its work. For the risk control measures proposed to be SMART,
management, safety professionals, employees and their representatives should all
contribute to a constructive discussion on what should be in the action plan.

Not every risk control measure will be implemented, but the ones accorded the
highest priority should be implemented immediately. In deciding your priorities you
should be guided by the magnitude of the risk (‘risk’ is the likelihood and severity
of harm). Ask yourself ‘What is essential to securing the health and safety of the
workforce today?’ What cannot be left until another day? How high is the risk to
employees if this risk control measure is not implemented immediately? If the risk is

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high, you should act immediately.
You will, no doubt, be subject to financial constraints, but failing to put in place
measures to control serious and imminent risks is totally unacceptable. You must
either reduce the risks to an acceptable level, or stop the work.
For those risks that are not high and immediate, the risk control measures should
be put into your action plan in order of priority. Each risk control measure should
be assigned a timescale and a person made responsible for its implementation.
It is crucial that a specific person, preferably a director, partner or senior manager,

is made responsible for ensuring that the action plan as a whole is put into effect.
This person doesn’t necessarily have to do the work him or herself but he or she
should monitor the progress of the risk control action plan.
Progress on the action plan should be regularly reviewed. Any significant

departures from the plan should be explained and risk control measure
rescheduled, if appropriate. Employees and their representatives should be kept
fully informed of the contents of the risk control action plan and progress with its
implementation.
23 Which risk assessments and safe working procedures need to be

reviewed and updated?
All relevant risk assessments and safe working procedures should be reviewed
after an adverse event. The findings of your investigation should indicate areas
of your risk assessments that need improving. It is important that you take a
step back and ask what the findings of the investigation tell you about your risk
assessments in general. Are they really suitable and sufficient?
Failing to review relevant risk assessments after an adverse event could mean that
you are contravening the Management of Health and Safety at Work Regulations
1999 regulation 3(3).5
24 Have the details of adverse event and the investigation findings been
recorded and analysed? Are there any trends or common causes which
suggest the need for further investigation? What did the adverse event cost?
In addition to the prompt notification of RIDDOR reportable events to the regulatory

authorities you should ensure that you keep your own records of adverse events,
their causes and the remedial measures taken. This will enable you to monitor your
health and safety performance and detect trends, the common causes of adverse
events and so improve your overall understanding and management of risk.
It is also useful to estimate the cost of adverse events to fully appreciate the true
cost of accidents and ill health to your business. To find out more about the costs
of accidents and incidents visit HSE’s website cost calculator.11
The step by step approach that is set out in this guide is only one of a number of
possible approaches. It is for you to decide which approach suits your business
best.

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References and further reading

References
Health and safety statistics 2000/01 Report HSE Books 2001 ISBN 0 7176 2110 3
Health and Safety Statistics Highlights 2002/03 Report MISC623 HSE Books 2003
European Social Statistics: Labour Force Survey Results 2001 ISBN 9289436050
The cost to Britain of workplace accidents and work-related ill health in 1995/96
HSG101 (Second edition) HSE Books 1999 ISBN 0 7176 1709 2
Management of health and safety at work. Management of Health and Safety at

Work Regulations 1999. Approved Code of Practice and guidance L21 (Second
edition) HSE Books 2000 ISBN 0 7176 2488 9 (Regulations 3(3) and 5 refer)
Access to Justice: Final report by the Right Honourable Lord Woolf, Master of the
Rolls July 1996 available on the Lord Chancellor’s Department website www.lcd.
gov.uk/civil/finalfr.htm
Safety representatives and safety committees L87 (Third edition) HSE Books 1996
ISBN 0 7176 1220 1
Root causes analysis: Literature review CRR325

HSE Books 2001 ISBN 0 7176 1966 4
Events and Casual Factors Analysis is a technique developed for the United States
Department of Energy. A full description of the technique is available via their
Environmental Health and Safety internet information portal at http://tis.eh.doe.gov/
analysis/trac/14/trac14.htm
Reducing error and influencing behaviour HSG48 (Second edition) HSE Books
1999 ISBN 0 7176 2452 8
Advice and case studies relating to the costs of accident/incidents in the workplace
may be obtained from HSE’s Ready Reckoner website atwww.hse.gov.uk/costs
Further reading

Free publications
Five steps to risk assessment Leaflet INDG163(rev1) HSE Books 1998 (single copy
free or priced packs of 10 ISBN 0 7176 1565 0)
Directors’ responsibilities for health and safety Leaflet INDG343 HSE Books 2001
(single copy free or priced packs of 10 ISBN 0 7176 2080 8)
RIDDOR explained: Reporting of Injuries, Diseases and Dangerous Occurrences

Regulations Leaflet HSE31(rev1) HSE Books 1999 (single copy free or priced packs
of 10 ISBN 0 7176 2441 2)

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Priced publications
Management of health and safety at work. Management of Health and Safety at
Work Regulations 1999. Approved Code of Practice and guidance L21 (Second
edition) HSE Books 2000 ISBN 0 7176 2488 9
A guide to the Reporting of Injuries, Diseases and Dangerous Occurrences

Regulations 1995 L73 (Second edition) HSE Books 1999 ISBN 0 7176 2431 5
Successful health and safety management HSG65 (Second edition) HSE Books
1997 ISBN 0 7176 1276 7
Reducing error and influencing behaviour HSG48 (Second edition) HSE Books
1999 ISBN 0 7176 2452 8
Improving maintenance: A guide to reducing human error Guidance HSE Books

2000 ISBN 0 7176 1818 8

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Adverse event report and investigation form

Part 1 Overview
Ref no
The purpose of this form is to record all adverse events. The term accident is used where injury or ill
health occurs. The term incident includes near-misses and undesired circumstances, where there is
the potential for injury. Part 1 should be filled out immediately by the manager or supervisor for the work
activity involved. Part 2 should be completed by the person responsible for health and safety. Part 3
should be completed, where appropriate, by the investigation team. Part 4 should be completed by the
investigating team, together with managers who have the authority to take decisions. When completing
Parts 2, 3 and 4 refer to the guidance under ‘A step by step guide to health and safety investigations’.
Part 1 Overview
Reported by: Date/time of adverse event

R Osmund 23.06.03 10.00am
Incident Ill health Minor injury Serious injury Major injury

X
Brief details (What, where, when, who and emergency measures taken)
Norman Brown was trying to fix a problem on the edge gluer when the machine operated. Norman cut
his right hand quite badly. He was given first aid and taken to hospital.
The fuses have been taken out of the edge gluer and a sign hung on it.
Forwarded to: Date 23.06.03

Richard Wills
Time 11.00am

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Part 2 Initial assessment (to be carried out

by the person responsible for health and
safety)
Type of event Actual/potential for harm
Accident X Fatal or major
Ill health Serious X
Near-miss Minor
Undesired circumstance Damage only
RIDDOR reportable? Y/N Date/time reported

Y 15.03.03
Entry in accident book Y/N Date entered/reference

Y 15.03.03 123/03
Investigation level
High level Low level
Medium level X Basic
Initial assessment carried out by: Date

Richard Wills 23.06.03
Further investigation required? Y/N Priority

Yes Immediate
For investigation by:

Peter Peterson (fitter), John Evans (foreman) and Richard Wills

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Part 3 Investigation information gathering

Woodmachine shop
Monday 23rd July 2003 at 11.00 am
2 Who was injured/suffered ill health or was otherwise involved with the adverse event?
Norman Brown – Injured person woodmachinist
No witnesses
3 How did the adverse event happen? (Note any equipment involved).
Norman discovered a defect in the edge gluing machine. He opened the

interlocked lid where the skirting boards are sawn off and planed down.
Norman put his pencil into the interlock switch, so he could operate
the machine with the guard open, so he could see what was wrong.
The cross cut saw operated and cut Norman’s hand.
Wilmatron 440 edge gluing machine series No 1234/23 1998.
Sharpcut Mk1 200mm diameter circular saw blade.
Norman was working on the edge gluing machine on a batch of

aluminium skirtings.
Yes. This machine normally is used with mdf skirtings, not aluminium.
No. Machines should be isolated before carrying out repairs.

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Severe laceration to the top of the right hand at the knuckles resulting in severing of tendons.
The rotating blade of the cross cut saw.
Yes, but Norman thought he would be OK having a look inside the guard.
10 Did the organisation and arrangement of the work influence the adverse event?
No, but Norman had been having trouble with the machine all morning. After the coffee break, he
decided to get it fixed.
Yes

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Norman was a qualified wood machinist with 9 years’ experience. He had
worked on the edge gluing machine for 3 years.
Yes – access to the edger is difficult. Access to the viewing window in the guard is difficult.
Yes – the machine was being used with aluminium rather than the normal
mdf skirtings.
15 Did difficulties using the plant and equipment influence the adverse event?
Yes, in that the edge gluer was malfunctioning.
No – the interlock switch was of a type easily defeated.

No

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Analysis and further action

Analysis (see ‘Analysis’ under ‘Step two’)
Norman Brown lacerates

Why? his hand on the edge
gluing machine
Because
Why? Norman was working on The saw blade made a Norman’s hand was in
the machine stroke the danger area
Because Because Because
Why? Norman was investigating The machine was ‘live’,

The guard was open
a fault under power
A B C
C

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Why? Norman was investigating

a fault
Because
There were no procedures

Why? There was a fault on the
for reporting/repairing
machine
faults
Because Because
There were no
The machine was being Duties/responsibilities not
Why? arrangements for carrying
used for aluminium clearly set out
out maintenance

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Why?
The machine was live
Because
Why?
The machine was not The interlock had been
isolated defeated
Because Because
Norman not Norman decided

Why?
No isolation Interlock of a type
aware of need to to defeat safety
procedures easily defeated
isolate system
Because Because
Because
Risk assessment Risk assessment
did not deal with did not anticipate
this risk violations
Norman not
competent for
Because
maintenance
work
Supervision was Poor attitude to
poor health and safety

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C
C
Why? The guard was open
Because
Norman wanted to see

Norman was investigating Access to the viewing
the machine operate
a fault port was obstructed
under power
Because
Workplace layout was

inadequate

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How/Why
1 Edge gluer was used for aluminium without adjusting to suit

2 The saw blade was tearing the end of the sections
3 The operator decided to investigate the cause
4 The operator decides that to find the cause he has to run the machine
5 The operator is unable to see through the viewing port
6 The operator opens the guards and defeats the interlock
7 The machine makes a cutting stroke
8 The operator’s hand is cut by the saw blade
Immediate causes
1 Not enough room around the machine to do the job

2 The saw set up was not suitable for use on aluminium
3 The interlocks fitted were of a type easily defeated
4 There were no safe working procedures for the job
5 Operative not fully competent
Underlying causes
6 Poor workplace layout

7 No risk assessments for use/maintenance of machine
8 Risk assessments didn’t address use of other materials
9 Risk assessments didn’t address violations
10 SWPs were not prepared following risk assessments
11 Operators not trained on machine maintenance and safety devices
12 Level of supervision not adequate – should have detected violations
13 All staff to be reminded of their duties and essential health and safety
measures
Root causes
Management commitment to H&S not communicated to employees

Health and safety assistants not fully competent and resourced
Unclear lines of communication and responsibilities

Health and Safety
Executive

1
Replace interlock switch with tongue type switch
2
Rearrange machine to allow access to window
3
Procedures for isolation of machine
4
Procedures for reporting/repairing defects
5
Clear allocation of duties
6
Review risk assessment
Yes – there are similar interlock switches on the multi-headed

moulder/planer
No

Health and Safety
Executive
Part 4 The risk control action plan

22 Which risk control measures should be implemented in the long and short term?
Completion Person
Control measure
Date responsible
1 Replace interlocks Before use Peter (fitter)
John (foreman)
2 Rearrange workshop Before use
Richard (H&S)
3 repare SWPs for isolation and

P John (foreman)
1.12.03
reporting and repair/maintenance Richard (H&S)
ssess competence and training needs &

A 1.12.03 John (foreman)
4 deliver training 1.3.04 Richard (H&S)
5 Prepare/review risk assessments 1.03.03 Richard (H&S)
23 Which risk assessments and safe working procedures need to be reviewed and updated?
Name of risk assessment Completion Person

safe working procedure Date responsible
1st week in
1 Risk Assess. For workplace Richard (H&S)
July
1st week in
2 Risk Assess. For machinery Richard (H&S)
July

Health and Safety
Executive

24 Have the details of the adverse event and the investigation findings been recorded and
analysed? Are there any trends or common causes which suggest the need for further
investigation? What did the adverse event cost?
Details have been recorded – no trends or common causes – need to check quality of risk
assessments.
Estimated cost of accident £3,700
25 Signed on behalf of the investigation team
Name Signature
26 Members of the investigation team
Name Position
Richard Wills H&S Officer
John Evans Foreman
Peter Peterson Fitter

Health and Safety
Executive

27 The findings of this investigation need to be communicated to the following managers,
union and employee safety representatives
Person Signature Date
A. Director
W.K.S Manager
A. Rep

Health and Safety
Executive

Part 1 Overview
Ref no
Part 1 Overview

Adam Jones (Wages Dept) Unknown

X
Sick paper received from John Smith together with a note from his GP which states that he is
suffering from occupational asthma
Forwarded to: Date 09.11.03

Paul Melish
Time 10.30am

Health and Safety
Executive

by the person responsibile for health and
safety)
Injury Fatal or major
Ill health X Serious X
Near-miss Minor

Y 11.30 am

Y 09.11.03
Investigation level

Paul Melish 09.11.03
Further investigation required? Y/N Priority

Yes Immediate

P Melish, workshop manager and foreman

Health and Safety
Executive

Spray shop – sometime over last 6 months? John Smith was taken on
6 months ago as a paint sprayer
John Smith – paint sprayer
Also other sprayers Peter John and Roger Wilson
3 How did the adverse event happen? (Note any equipment involved).
John works in the paint spray booth.

Booth – Windflow Mark 3 serial no 12345/97
Spray guns – Paintspraymaster model 2
Gun wash – Cleanomax mark 4 serial no 247/99
Half mask – Wearmask model 12 with AXP3 filters
Duties carried out would have been limited to the mixing and spraying
of isocyanate-based spray paint in the spray booth
Nothing different
As normal

Health and Safety
Executive

Reported Occupational Asthma
Exposure to isocyanate-based paint suspected

Also possible poor quality of air fed to mask
Risks of paint known – existing controls assumed to be sufficient

Poor air quality not known
No supervision or monitoring of paint spray shop – air-fed mask not

always used – for small jobs half-masks were sometimes used (suitable
for working with isocyanates but NOT suitable for spray painting)
Spray booth not examined for 2 years – compressed air quality to air-fed
masks not tested. Both subsequently found to be inadequate

Health and Safety
Executive

John Smith was an experienced paint sprayer with 21/2 years’ experience
with his previous employer
No
Yes solvent-based isocyanate paints are respiratory sensitisers
No

Spray booth air flow was found to be inadequate
Air quality to air-fed masks was poor – contaminated
Correct Respiratory Protective Equipment not always used.

No

Health and Safety
Executive

John Smith develops

occupational asthma
Because
He is exposed to He is exposed to His deteriorating health is

contaminated air isocyanate paint not detected
A B C

Health and Safety
Executive

He is exposed to
Why?
contaminated air
Because
The compressed air

Why? supply to his air-fed mask
is contaminated
Because
Contamination was being

Why? The air supply was not
fed into the air supply
tested for quality
(faulty pump)
Because
The risk No-one had

assessment did responsibility for
not identify the maintenance
risk management

Health and Safety
Executive
John Smith exposed to

Why?
isocyanate paint
Because
Why?
Spray booth extraction Sprayers sometimes used
inadequate inadequate RPE
Because Because
No information
Why?
Booth was not tested instructions or procedures Supervision inadequate
for use of RPE
Because Because
No one had overall

Risk assessment and
responsibility for
procedures inadequate
maintenance

Health and Safety
Executive

C
C
Deteriorating health not

Why?
detected
Because
No health surveillance
No health screening on
Why? including lung function
recruitment
test
Because
Risk assessment not Because

adequate

Health and Safety
Executive

How/why might he have been exposed to substances which caused

occupational asthma
1 The compressed air supply to the breathing equipment was contaminated

2 The spray booth extraction was not adequate
3 Sprayers sometimes used RPE which was not adequate
Immediate Causes
1 Spray booth performance had deteriorated – not tested/maintained

2 Air quality to air-fed masks had deteriorated – not tested/maintained
3 Incorrect RPE sometimes used
4 No safe working procedures for RPE and booth
Underlying Causes
1 Risk assessments inadequate for spraying operations

2 No one in overall charge of testing/maintenance
3 Supervision and monitoring of work practices inadequate
4 Sprayers not fully competent – training/instruction on use/choice of RPE
5 Risk assessment didn’t recognise risk from previous employment exposure
6 No arrangements for health screening
Root Causes
No senior partner in overall charge of H&S

H&S performance to be monitored
Responsibilities unclear

Health and Safety
Executive

1
Spray booth & air to be tested
2 Health surveillance & screening for sprayers
3
Responsibilities for maintenance to be allocated
4 Refresher training on hazards and PPE
5 Increased supervision and monitoring
6 Partner appointed to manage H&S
No
No

Health and Safety
Executive

Completion Person
Control Measure
Date responsible
1 Booth and air to be tested Immediate Maintenance fitter
2 Health surveillance and screening Jan 2003 Peter Riley
3 Maintenance schedule Jan 2003 Maintenance fitter
4 Training PPE Jan 2003 Peter Riley
5
Supervision/monitoring Jan 2003 All foreman/Peter Riley
6
Partner appointed to review Jan 2003 P Melish

safe working procedure Date responsible
1 Spray painting Jan 2003 Peter Riley

Health and Safety
Executive

No trends
Estimated total cost £2,700
Name Signature
Paul Melish
Name Position
Paul Melish Partner
A Coome Work Manager
P Berry Foreman
T Roberts Employee rep

Health and Safety
Executive

A. Manager
A. Supervisor
A. Representative

Health and Safety
Executive

Part 1 Overview
Ref no
Part 1 Overview
Forwarded to: Date
Time

Health and Safety
Executive

by the person responsible for health and
safety)
Accident Fatal or major
Ill health Serious
Near-miss Minor
Investigation level
Further investigation required? Y/N

Y/N Priority

Health and Safety
Executive

3 How did the adverse event happen? (Note any equipment involved.)

Health and Safety
Executive


Health and Safety
Executive


Health and Safety
Executive


Health and Safety
Executive


Health and Safety
Executive

Completion Person
Control measure
date responsible

safe working procedure date responsible

Health and Safety
Executive

Name Signature
Name Position

Health and Safety
Executive


Health and Safety
Executive
Adverse event analysis: Rooting out risk

Using the information gathered during your investigation, go through each of the four sections on the immediate
causes (the Place, the Plant, the Process and the People). If the answer to any of the questions is ‘no’, then
this is an immediate cause of the adverse event under investigation. After identifying the immediate causes,
direct your attention to the potential underlying causes (which are set out to the right of the immediate causes
identified) and consider the questions under the relevant headings. For example if the answer to the first
question below ‘Were the access and egress adequate?’ is ‘no’, you should consider whether the design of the
workplace and the risk assessment for workplace access/egress were adequate.
Immediate causes
1 The place or premises where the incident happened
Risk assessment
Communication
Implementation
Co-operation
The place or premises where the incident happened.
Competence
Design
If there was anything about the condition of the workplace that contributed to the
Control
adverse event, answer the following question, which will suggest other areas to
consider. If not, go to ‘Plant, equipment and substances’.
1 Were the access and egress adequate?

2 Were the access and egress points being used?
3 Was the workplace suitable for the task in hand?
4 Was there sufficient space for the task in hand?
5 Was the workplace being used as intended?
6 Were people segregated from hazardous areas/processes/machinery?
7 Was the work environment (lighting, temperature and ventilation) suitable?
8 Did the ergonomics of the workstation suit the person using it?
9 W
as the work area clean and tidy? (Routine cleaning programme and dealing
with spills.)
10 Were weather conditions a factor?
11 Were the noise levels within acceptable levels?
12 Were the appropriate warning signs in place?
13 Were contractors provided with adequate information on access/egress and
the hazards within the premises?

Health and Safety
Executive
Immediate causes
2 The plant, equipment and substances (used or generated)
Risk assessment
Communication
Implementation
Co-operation
Competence
The plant, equipment and substances (used or generated).
If the equipment being used, or the substances/materials used or generated,
Control
contributed to the adverse event, answer the following questions, which will
suggest other areas to consider. If not, go to ‘Process/procedures’.
1 Were the most suitable plant and equipment available for the job?
2 Were the plant and equipment used suitable for the person using them?
3 Were the plant and equipment used suitable for the job?
4 Had the plant and equipment been chosen, or modified, so that its health
and safety efficiency could not be improved?
5 W
ere plant and equipment in working order and adequately maintained? Was
there a routine maintenance programme? Was there a procedure for repair
when a defect was discovered?
6 Were the plant and equipment being properly used?
7 Were there adequate controls or guards for the safe use of the equipment?
8 Were the controls or guards fitted, maintained and properly used?
9 Were the controls well laid out and easy to understand?
10 Were the most suitable materials or substances available for the job?
11 Were the correct materials being used?
12 Were the materials as specified?
13 Were the materials or substances used suitable for the job and person?
14 Were the materials or substances being properly used?
15 W
as exposure to hazardous materials and by-products adequately
controlled?
16 If the need for personal protective equipment (PPE) had not been identified,
was it safe to do the job without PPE?
17 If necessary, was suitable PPE available?
18 If necessary, was the correct PPE used?
19 If the correct PPE was used, was it used correctly?

Health and Safety
Executive
Immediate causes
3 The process/procedures
Risk assessment
Communication
Implementation
Competence
The process/procedures.
Control
Design
If the procedures, instructions or information (or the lack of them), contributed to
the adverse event, answer the following questions, which will suggest other areas
to consider. If not, go to ‘People’.
1 Were there safe working procedures and instructions for the tasks under
consideration?
2 If there were safe working procedures and instructions, were they up
to date?
3 If there were safe working procedures and instructions, were they realistic,
accurate and adequate?
4 If there were safe working procedures and instructions, did they deal with
the circumstances of the adverse event?
5 If there were safe working procedures and instructions, were the correct
ones followed?
6 If there were safe working procedures and instructions, were they provided
or readily available to those carrying out the work?
Include contractors.
7 If there were safe working procedures, were they policed?
8 Was the level of supervision adequate? Include contractors.
9 Were the training needs for this activity identified?
10 If there were safe working procedures and instructions, were they used as
part of training?
11 Were contractors working in accordance with agreed method statements
and safe systems of work?
12 Were contractors informed of the safe working procedures they should
adopt?

Health and Safety
Executive
Immediate causes
3 The people involved
Risk assessment
Communication
Implementation
Co-operation
Competence
The people involved.
Control
Design
If there was anything about the people involved that contributed to the adverse
event, answer the following questions which will suggest other areas to consider.
1 Were the people involved suited for their job?
■■ p hysically and emotionally (young people need special consideration)?

■■ competence (skilled, knowledgeable and experienced)?
2 Was the health of people who could be affected monitored?

3 Were the people performing their work as expected?
4 Were workers employed by contractors suitable and competent?

5 Was the event free of human failings?
Was it a mistake? If it was a mistake consider:
Was it a slip or lapse caused by:
■■ fatigue – not enough rest breaks, working excessive hours,

already tired?
■■ lack of motivation or boredom?
■■ being distracted?
■■ being preoccupied, eg angry, or excited?
■■ being under too much pressure, ie too much or too many things to do?
■■ too little time?
■■ taking substances, such as alcohol, medicines or drugs?
If it was a violation, ie breaking the rules or taking short cuts, consider:

Health and Safety
Executive
Underlying and Root Causes
If your answers to the Place, Plant, Procedures and People sections identified any
immediate cause, consider the relevant ‘Underlying and Root Causes’ section.
ORGANISATION – how we do things and how we make sure they are done
correctly
Control
1 W ere the workplace and work activities adequately supervised and monitored
in order to ensure that risk control measures were effective and implemented
as intended?
2 Did the supervisors have adequate resources to carry out their duties?
3 Were people held accountable for their performance in carrying out their
duties with regard to Health and Safety?
4 Were there adequate arrangements for overseeing and controlling
contractors?
Co-operation
1 W ere trade unions, employees and their representatives involved in

determining workplace arrangements, preparing risk assessments and safe
working procedures?
2 Did the individuals involved in the incident share information?
3 Were there arrangements for cooperation with, and co-ordination of,
contractors?
Communication
1 Were responsibilities and duties clearly set out?

2 Were they clearly understood by those involved?
3 Did everyone involved know who they report to and who reports to them?
4 Was there sufficient, up-to-date information to enable good decisions to be
made?
5 Were there adequate arrangements for passing on information at shift
changes?
6 Were written instructions, safe working
procedures and product information sheets practical and clear?
7 Were the instructions and procedures available to all who needed them?
8 Was communication between workers and supervisors effective?
9 Was the communication between different departments effective?
10 Were there effective communications with contractors?
Competence: Training and suitability
1 Were the people involved assessed as suitable for the work in terms of health
and physical ability?
2 Were the health and safety training needs of people identified?
■■ on recruitment;
■■ on changing jobs;
■■ when changes in the work are proposed;
■■ periodically as part of refresher training?
3 Were the training requirements for particular jobs identified?

Health and Safety
Executive
4 Was the training effectively delivered?

■■ with adequate resources?
■■ effectively?
■■ and assessed?
■■ were training records kept?
5 Was the competence of contractors, employees and agency workers
checked?
Planning and Implementation: How we prepare to do things

effectively and efficiently
Design
1 W ere the workplace and equipment layouts designed considering health and
safety?
2 Were the controls, displays etc of plant and equipment designed to reduce the
risk of, or prevent, human error? For example mis-reading dials or operating
the wrong switch
Implementation
1 W ere there arrangements for ensuring that sufficient, and suitable, plant,
equipment and materials were available?
2 Were there arrangements for ensuring that sufficient and suitable labour was
available?
3 Was there adequate cover for leave or sickness absence?
4 Were suitable contractors appointed?
5 Were there adequate arrangements for cleaning?
6 Were there adequate arrangements for reporting defects in plant and
equipment?
7 Were there adequate arrangements for carrying out maintenance work?
8 Were there adequate arrangements for reporting health and safety concerns?
9 Were there adequate arrangements for reporting near-misses and undesired
circumstances?
10 Were there adequate arrangements for carrying out health surveillance?
11 Were there adequate arrangements for carrying out air monitoring/sampling?
(If required)
12 Did production targets take account of health and safety?
13 Were there adequate arrangements for appointing and controlling contractors?
Risk assessment
Risk assessments involve identifying the hazards, identifying who may be affected
and putting in place suitable arrangements to eliminate or reduce the risks to an
acceptable level.
1 Were there risk assessments for the work in question?
2 Were they adequate?
■■ did they correctly identify the risks?
■■ were they up-to-date and reviewed as necessary?
■■ were correct technical standards used?
■■ were adequate risk control measures identified?
■■ were safe working procedures developed?
■■ were there clear conclusions and recommendations?


Health and Safety
Executive
■■ were employees involved in preparing them?

3 Did the risk assessments result in a risk control action plan with SMART
(Specific, Measurable, Agreed, Realistic and Timescaled) objectives?
4 Were responsibilities for implementing the risk control action plan set out?
5 Had the risk control action plan been implemented?
6 If there had been similar adverse events in the past, had they been
investigated?
7 Were adverse events recorded, investigated and the findings fed back into the
risk assessments?
8 Did the risk assessments include the risks from work carried out by
contractors?
A ‘no’ answer to any of the questions in the underlying or root cause section
identifies an underlying or root cause.
These underlying or root causes in turn point to failings in the health and safety
management system.
Senior management should consider all the questions in the following
‘Management’ section to identify weaknesses in the overall risk control
management of the organisation.
Management: How we create the environment and set the standards

under which all other health and safety activities take place
n Was there a written health and safety policy statement?

n Did all employees know and understand the health and safety policy
statement?
n Were named partners, directors and senior managers made responsible for
health and safety arrangements?
n Was there an adequate commitment to health and safety at a senior level?
n Was this commitment reflected in the actions of directors, partners and
managers?
n Were sufficient people appointed to assist with health and safety measures?
n Were the people appointed to assist with health and safety measures
adequately trained and competent?
n Did the health and safety assistants have sufficient authority to carry out their
duties?
n Were the tasks of carrying out risk assessments and preparing safe working
practices given to competent persons?
n W as the carrying out of risk assessments a high priority?
n Were adequate resources allocated to health and safety?
n Was it your policy to learn from adverse event investigations and improve your
health and safety performance?
n Were the recommendations and findings of the health and safety team acted
on?
n Was the work of the health and safety team (including managers, safety
officers, safety assistants, supervisors and safety representatives) monitored?
n Were the health and safety team held to account for their performance?
n Were there clear and integrated lines of communication and control?
n Was there a conflict between production and health and safety?
n Was health and safety performance measured and monitored?
n Did you seek to improve your health and safety performance as a result
of your dealings with the regulatory authorities and other health and safety
professionals?

Adverse event
Ref no Adverse event analysis
Using the ‘Adverse event analysis: Rooting out risk’ checklist, consider the questions in the immediate cause sections. Enter each of the immediate causes
identified in the table and enter the risk control measures required. For each immediate cause the checklist suggests possible underlying/root causes. Consider
each of these potential underlying/root causes and enter those that are relevant.
Finally enter the remedial measures required to remedy the underlying/root cause.
1 Place or premises
Immediate cause: Point Risk control measure required Underlying/root causes Measures to remedy underlying/ root cause

Executive
Health and Safety
Page 74 of 89
Adverse event
2 Plant equipment and substances

Immediate cause: Point Risk control measure required Underlying/root causes Measures to remedy underlying/root cause
Point 5 Spray booth to be examined Risk assessment inadequate - Review risk assessments where
Equipment not being routinely immediately and air quality to did not recognise risks where deterioration in safety equipment will lead
maintained sprayers masks to be checked booth extraction and air quality to increased risks
had deteriorated
Point 15 Spray booth and air quality to be Control - No clear responsibilities Maintenance fitter to be made
Exposure to hazardous materials tested immediately to ensure safe for ensuring equipment working responsible for testing of spray booth and

not controlled effectively air quality
Point 18 Supervision and monitoring Ensure supervisors check that correct

Correct PPE not used Ensure only air-fed masks are used inadequate PPE is used - introduce monitoring of
for all spray painting actual use
Competence - sprayers not fully Instructions and training of sprayers on

aware of risks and limitations of risks and limitations of RPE
RPE
Executive
Health and Safety
Page 75 of 89
Adverse event
3 Processes and procedures

Point 1 Prepare SWPs and instructions for Risk Assessments and SWPs Review risk assessment and prepare
No safe working procedures the safe use of the spray booth inadequate SWPs for the maintenance and use of the
(SWPs) or instructions and the RPE required spray booth and air-fed masks

Executive
Health and Safety
Page 76 of 89
Adverse event
4 People
Point 1 Ensure that recruitment of sprayers Risk assessment inadequate and Ensure risk assessments recognise need
People not suited for the job includes health checks no health screening on to screen people for ill health which may
recruitment be made worse by their work
Point 2 Spray painters to have annual lung Risk Assessments inadequate Ensure that risk assessments recognise

No health monitoring function tests as a part of their where health monitoring can detect the
health monitoring onset of ill health and set up the
necessary arrangements
Executive
Health and Safety
Page 77 of 89
Adverse event
Health and safety management issues
This section should be completed by managers/directors/partners with the authority to make decisions on the management of health and safety. It should be
completed using the management section of the ‘rooting out risk’ checklist and with reference to the immediate, underlying/root causes identified earlier in the
analysis.
What weaknesses in the overall management of health and safety Remedial action
allowed the underlying/root causes of the adverse event to exist?
No one in overall charge of health and safety at senior level Appoint partner to take overall charge of managing Health
and Safety
The work of the people responsible for day-to-day health and safety Partner to monitor health and safety performance
arrangements was not monitored

No clear lines of communication and control Responsibilities and lines of communication on health and safety matter to be
established
Executive
Health and Safety
Page 78 of 89
Adverse event
1 Place or premises
Point 4 Re-arrange machinery to allow Planning - design of layouts Review risk assessments - look at safe
Not enough room for the job access to viewing port Risk assessments - not working access to all areas of machinery
adequate for operation and maintenance

Executive
Health and Safety
Page 79 of 89
Adverse event

Point 3 Machine not to be used on Risk assessment didn’t deal with Risk assess machine for use with
Equipment not suitable for the job aluminium until manufacturer’s use for other materials aluminium
literature checked and adjustments Procedures for use with aluminium to be
made produced and instructions/training given
Point 4 Arrange for interlocks to be Risk assessments not adequate Review how tamperproof safety
Equipment not most effective - changed for better design - didn’t anticipate violations equipment is

interlocks of a type easily defeated All employees to be reminded of Remind workforce of the importance of
need for interlocks safety measures and procedures and the
importance the business places on H&S
Executive
Health and Safety
Page 80 of 89
Adverse event

Point 1 Prepare SWP for working for Risk assessments and Update risk assessments and prepare
No safe working procedures (SWP) repairs, locking off and isolation procedures and communicate procedures for
for job procedures reporting of defects, repairs, locking off
Training and isolation - training
Monitor

Executive
Health and Safety
Page 81 of 89
Adverse event
4 People
Point 1 Training in need for interlocks and Competence - training Ensure all necessary information on
Competence - use of equipment isolation/locking off. Training on requirements not assessed or machinery is available and training needs
and hazards of job during hazards and accepted use of delivered are identified and suitable training given
maintenance machine
Point 4 Fit less easily defeated switches Control and communication Staff to be reminded of need for and

Violation - defeating of interlock Instruction to all operatives consequences of interfering with safety
guards equipment
Levels of supervision and monitoring to
be increased
Executive
Health and Safety
Page 82 of 89
Adverse event
analysis.
Employees not fully aware of management commitment to health and Ensure all employees are aware of management commitment to health and
safety safety - as set out in our policy statement
Health and safety assistants not fully competent and resourced Ensure those responsible for preparing risk assessments/SWPs and in charge
of maintenance are adequately trained and have time to carry out their duties

No clear lines of communication and control and unclear responsibilities Ensure all staff aware of their own duties and how they fit into the organisation
Executive
Health and Safety
Page 83 of 89
Adverse event
1 Place or premises

Executive
Health and Safety
Page 84 of 89
Adverse event


Executive
Health and Safety
Page 85 of 89
Adverse event


Executive
Health and Safety
Page 86 of 89
Adverse event
4 People

Executive
Health and Safety
Page 87 of 89
Adverse event
analysis.

Executive
Health and Safety
Page 88 of 89
Health and Safety
Executive
Further information
For information about health and safety ring HSE’s Infoline Tel: 0845 345 0055
Fax: 0845 408 9566 Textphone: 0845 408 9577 e-mail: [email protected] or
write to HSE Information Services, Caerphilly Business Park, Caerphilly CF83 3GG.
HSE priced and free publications can be viewed online or ordered from
www.hse.gov.uk or contact HSE Books, PO Box 1999, Sudbury, Suffolk
CO10 2WA Tel: 01787 881165 Fax: 01787 313995. HSE priced publications
are also available from bookshops.
Published by HSE 01/10 Page 89 of 89

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What are the main reasons for investigating accidents and incidents?

What are the main reasons for investigating accidents and incidents?

What are the steps involved in investigating accidents and incidents?

What are the steps involved in investigating accidents and incidents?

Health and Safety

Investigating accidents and

ISBN 978 0 7176 2827 8

A workbook for employers, unions, safety representatives

Step one: Gathering the information

© Crown copyright 2004

First published 2004

ISBN 978 0 7176 2827 8

All rights reserved. No part of this publication may be reproduced, stored in

Applications for reproduction should be made in writing to:

Understanding the language of investigation 5

The causes of adverse events 7

A step by step guide to health and safety investigations 13

Gathering the information 14

References and further reading 27

Adverse event report and investigation form: Worked examples 29

Investigating accidents and incidents Page 3 of 89

Reducing risk and protecting

An effective investigation requires a methodical, structured approach to information

Investigating accidents and incidents Page 4 of 89

Understanding the language of

‘Adverse event’ includes:

n accident: an event that results in injury or ill health;

Dangerous occurrence: one of a number of specific, reportable adverse events,

damage only: damage to property, equipment, the environment or production

Figure 3 Undesired Likelihood that an adverse event will happen again:

Investigating accidents and incidents Page 5 of 89

Risk: The level of risk is determined from a combination of the likelihood of a

Underlying cause: the less obvious ‘system’ or ’organisational’ reason for an

Investigating accidents and incidents Page 6 of 89

The causes of adverse events

These causes can be classified as:

Figure 4 Sequence of dominoes

Investigating accidents and incidents Page 7 of 89

Legal reasons for investigating

n T o ensure you are operating your organisation within the law.

Information and insights gained from an investigation

n A n understanding of how and why things went wrong.

Benefits arising from an investigation

n The prevention of further similar adverse events. If there is a serious accident,

Investigating accidents and incidents Page 8 of 89

n The development of managerial skills which can be readily applied to other

It is often pure luck that determines whether an undesired circumstance translates

Which events should be investigated?

Who should carry out the investigation?

For an investigation to be worthwhile, it is essential that the management and the

Investigating accidents and incidents Page 9 of 89

In addition to detailed knowledge of the work activities involved, members of the

When should it start?

The urgency of an investigation will depend on the magnitude and immediacy of

In general, adverse events should be investigated and analysed as soon as

What does it involve?

An investigation will involve an analysis of all the information available, physical

It is important to be open, honest and objective throughout the investigation

What makes a good investigation?

Investigations should be conducted with accident prevention in mind, not placing