Posted By Shane Johnston
I actively want to involve line managers in accident investigation, and we have a system whereby serious incidents are investigated by a safety professional, indpendant line manager and Unions (if they want to be involved), however the line manager for the area still undertakes his own separate mini-investigation on the back of the accident report form.

Here is the problem, many line managers inadvertantly accept liability, even where the injured party may have contributed to the accident. For example the injured party deviates from the Safe System going against all the training he has received. The line manager, not wanting to belive that "honest Fred" would deviate from safe practice, states on his mini-investigation that the underlying cause of the accident was an interlock failure ..... "after all how else could Fred get his hand into the dangerous part of the machine .. the interlock must have failed"?

If we now conduct a serious accident investigation, in which the facts are estabished (Fred developed a way of by-passing he interlock), would the fact that we have conflicting reports threaten our defence? If so would adding "in my personal opinion, the cause of the incident was .." to the begining of the line managers report make any difference ?

Posted By Sean Fraser
Shane,

Tricky one this. On the one hand you want people to be honest in their assessments and statements and making them write caveats into every sentence will simply discourage them from participating. On the other hand, you are concerned that internal contradiction of the cause will give the court a possible means with which to crucify you. But what you need to focus on are two things:

1] Have you actually come to a conclusion about what the ACTUAL CAUSES were? and

2] What ACTION was taken to address it?

Forget the fact that the incident took place - it has already happened. What your incident reporting system needs to be able to determine is what the FACTS are - how the incident actually occurred - and how that situation was able to develop to the point where an injury could be sustained. As we discussed recently on the forum, there is seldom one single cause but usually a combination of factors. Encouraging line managers to contribute is laudable - excluding them from the fact-finding process would breed suspicion and fear - and perhaps instead of writing on the offical report they can supply a deposition to contribute to the investigation process. Provide them with effective training that demonstrates how an investigation is conducted, what sort of information is required and how conclusions are drawn. Once they see how it is meant to be done then they can make a more meaningful contribution and will recognise that mistakes in terminology could be mis-represented at a later date.

Perhaps you could restrict the report writing to the "senior" investigator who references evidence supplied but only receords what the investigation team consider to be the facts, using the terminology you would expect to see. That way you have one official record with supporting evidence.

In the example cited, Fred was injured by by-passing the system. What is important is accurately identifying how and why the guarding was by-passed and that action is taken to prevent recurrence. Semantics in the reporting then becomes a minor consideration.

Posted By Paul Craythorne
Shane,

What training has been provided to your line managers with regard to accident and incident investigation?

If the answer is little or none then can you really expect them to carry out an effective investigation without the underpinning knowledge and training?

Paul Craythorne

Posted By Raymond Rapp
Using my company as an example, we operate two types of investigation processes. The first is an immediate (local) investigation, and the other a formal investigation with H&S advisor(s). In effect the immediate investigation is superceded by the formal if the seriousness should warrant it. Therefore preventing the conflicting situation you describe.

As the previous responder suggested, if line managers do not have the appropriate training then they are likely to arrive at an unsatisfactory conclusion. Better training is the only answer.

Ray