Accident Reporting & Investigation

Paul Craythorne Health, Safety & Environmental Advisor

Accident Reporting & Investigation



Course Objectives
 to

understand:
accident definition accident causation accident costs accident prevention accident reporting/notification accident investigation

Accident Reporting & Investigation



Common Uninformed Comments

 accidents

just happen  we dont have many accidents  safety is expensive  the insurance will pay  safety is just common sense

Accident Reporting & Investigation



Accident Definition
 what

is an accident?

unplanned & uncontrolled event that led to, or could have led to:
injury to persons, damage to property/plant/equipment, impairment to the environment or some other loss to the company

Accident Reporting & Investigation



Accident Definition
accident types
minor dangerous occurrence near miss plant/equipment damage minor injury lost time injury disablement/fatality

Accident Reporting & Investigation

 Accident

Definition

Frank Bird (Accident Triangle)

600 near misses 30 property damage 10 minor injuries 1 serious injury (lost time or fatal)

Accident Reporting & Investigation

 Accident

Causation

environment personal fault unsafe act unsafe condition accident injury/damage

Accident Reporting & Investigation

 Accident

Causation

causal factors
individual job organisation

Accident Reporting & Investigation

 Accident

Causation

causal factors
individual knowledge skills training experience personality attitude risk perception

Accident Reporting & Investigation

 Accident

Causation

causal factors
job task workload equipment controls procedures environment

Accident Reporting & Investigation

 Accident

Causation

causal factors
organisation culture leadership resources work patterns communications

Accident Reporting & Investigation

 Accident

Causation

Kings Cross Fire (1987) - 31died

discarded cigarette accumulation of rubbish poor cleaning regime wooden escalator failure of fire fighting equipment lack of emergency training poor safety culture

Accident Reporting & Investigation

 Accident

Causation

Herald of Free Enterprise (1987) 189 died

failure to close bow doors no checking/reporting system commercial pressures internal friction disease of sloppiness

Accident Reporting & Investigation

 Accident

Causation

Clapham Junction (1988) - 35 died & 500 injured

signal failure incorrect maintenance degradation of working practices training problems communication problems poor supervision excessive working hours failure to learn lessons

Accident Reporting & Investigation

 Accident

Causation

Piper Alpha (1988) - 167 died

maintenance error inexperience poor maintenance procedures communications breakdown permit to work system fault safety procedures not practised

Accident Reporting & Investigation

 Accident

Causation

Automotive Supplier (1999) - 1 died

poor safety culture lack of guarding lack of training poor perception of risk no safe systems of work no risk assessment programme no effective accident system no communication

Accident Reporting & Investigation

 Accident

Costs

insured costs uninsured costs

Accident Reporting & Investigation

 Accident

Prevention

reasons
humane economic legal

Accident Reporting & Investigation

 Accident

Prevention

control measures
safety procedures/work instructions adequate training effective communications good housekeeping guards/safety devices/warning signs adequate working environment regular safety inspections risk assessment

Accident Reporting & Investigation

 Accident

Reporting/Notification

internal report form HSE RIDDOR report injury claim requirement

Accident Reporting & Investigation

 Accident

Investigation

reasons
identify root causes identify faults identify corrective/preventative action prevent recurrence

Accident Reporting & Investigation

 Accident

Investigation

investigation team
supervisor safety rep engineer manager safety officer

Accident Reporting & Investigation

 Accident

Investigation

investigation objectives
establish chain of events identify root causes identify faults identify corrective/preventative action

Accident Reporting & Investigation

 Accident

Investigation

investigation techniques
attend promptly ensure medical attention leave scene undisturbed take photographs/sketches take measurements take samples gather documentation interview witnesses

Accident Reporting & Investigation

 Accident

Investigation

investigation techniques
interviewing witnesses explain purpose their version of events do not listen to hear say ask open questions avoiding leading or implying do not apportion blame express appreciation

Accident Reporting & Investigation

 Accident

Investigation

investigation report
identify team summarise consequential events identify root causes describe other weaknesses identify corrective/preventative action allocate responsibility & timescale