All accidents and near misses should be investigated. Google Heinrich's Triangle and Bird's subsequent update plus work by the HSE. Todays cut finger could be tomorrows amputation. Todays racking impact by FLT could be tomorrows fatal pedestrian collision. It is the degree of investigation and formality that changes with the severity.

But, you also need to consider whether it's actually true that today's cut finger could be tomorrow's amputation - many incidents that result in minor consequences are NOT precursors of a fatality. Example. If I scrape the high pavement where I park this is not a precursor of whiplash. It's an almost inevitable consequence of the narrowness of the street if I don't want to lose my offside wing mirror (yes, it does get folded in!). Conversely, if a Taggart production lorry slides down the same street in icy conditions and takes out nine other vehicles - it happened a few years ago, same location and precursor of fatality. Other problems with Heinrich insufficient recognition that all accidents are multi-causal and thence tendency to home in behaviours (Heinrich 88%, Du Pont 96%) at the expense of unsafe conditions. In turn this leads to a tendency to inadequately address low probability, high consequence events (Process Safety) and occupational health risks.

We've always used the statutory accident book as the first step in accident investigation. They generally include space for 'what steps have been taken to prevent further danger / reoccurrence. This implies someone should have investigated what has caused the accident. In many cases the response can be limited to a couple of lines of text (i.e. Spill cleaned up). At our site this was often left blank but I encourage the IP / First Aider or supervisor to provide input, review and decide on further action if necessary. Analysis of accident data may show trends in minor accidents that warrant further investigation, procedure changes etc. More serious accidents obviously a more structured investigation. For this we form a small working group based around for example the IP's team. Incidentally accident investigation is one of the key areas identified by HSE for worker involvement. We use the same process for investigation on non injury incidents.

Putting aside the theory for a moment, it may be possible to have a hierarchy approach to investigations. An immediate investigation should be completed by a responsible person who is responsible for that areas or task, which may warrant a further and more detailed investigation by a safety person; and finally, a formal investigation for the more serious incidents. In order to be economical with one's time it is important to recognise those incidents which have the potential for a more serious incident. I, like Peter, do not subscribe to the notion 'that today's cut finger could be tomorrow's amputation' in all cases.

RayRapp If you read/follow the HSE document I provided the link to earlier, it recommends a hierarchial approach to investigating accident depending upon the potential consequences of a near miss / incident etc i.e. supervisor, line anager, safety manager.

Stevie, when I copied and pasted that quote for Peter's post I was not even aware you had used it in an earlier posting, so thanks for clarifying the issue. ITER, thanks but I did/have not read the document, but it is generally the way most organisation conduct investigations. I think the point I was trying to stress is that there should not be a 'one size fits all' approach, otherwise near misses would be given the same priority as accidents - which is clearly not normally the case.

Sorry will pressed a button and posted early further suggestions for a policy Managers and supervisors should investigate and own close out actions. You can put a legal caveat on them "investigated in preparation for legal proceedings" will stop them being disclosable until a court deems them such - this needs to be done in discussion with legal/insurance types - stopping anyone like unions or staff getting hold of them for claim purposes. You can arrange your accident investigation process to support the risk management strategy for the company - reduce losses and still make it a good pro active intelligence gathering system. Finally keep all injured persons or first aiders away from the accident record book - managers only to fill this in - anything the IP or the first aider write on that is disclosable. Regards Martin

Sorry will pressed a button and posted early further suggestions for a policy Managers and supervisors should investigate and own close out actions. You can put a legal caveat on them "investigated in preparation for legal proceedings" will stop them being disclosable until a court deems them such - this needs to be done in discussion with legal/insurance types - stopping anyone like unions or staff getting hold of them for claim purposes. You can arrange your accident investigation process to support the risk management strategy for the company - reduce losses and still make it a good pro active intelligence gathering system. Finally keep all injured persons or first aiders away from the accident record book - managers only to fill this in - anything the IP or the first aider write on that is disclosable. Regards Martin

Hi Phil I am not trying to convince you about anything, ive seen enough of your posts to ascertain you are sensible enough to make your own mind up about any given subject. I use the the posts to assist other professionals or people needing assistance not to try to persuade anyone round to my way of thinking. The approach is not secretive it is simply good governance from a civil litigation perspective as many claimants solicitors use a companies proactive approach of investigation and listing of close out actions as evidence of liability. This is especially so in a heavily unionised environment within high hazard industries. Allowing IPs to fill in accdent reports in my experience adds little or no value to an accident investigation and will contribute a great deal to any resultant claim. As noted its not a secretive approach just one that looks at a wider risk management approach. Regards Martin

quote=Oldroyd19659]Hi Will First of all its worth noting that there is no legal obligation to investigate any accident or incident , however before i get a post avalanche, all accidents and incidents should be investigated as part of a mature HSE system and lessons learnt and from there controls put in place to prevent a re-occurence and close out the investigation.

The approach taken in my company is that the IP completes the accident book/ report (unless they are incapacitated), the line manager then receives a copy of any report(s) so 'local' investigation can take place in conjunction with the IP and any 'serious' or 'critical' incidents - using RIDDOR reporting criteria - and 'near misses' are seen independantly by the H&S manager. This seems to work well in giving all incidents attention and prioritising the more serious.

There is an implicit requirement to at least take account of accidents in the ACOP to the Management regulations, paragraph 26. It is talking about reviewing and revising risk assessments and points out that an adverse event such as an accident or incident of ill health, or dangerous occurrence should trigger a review of the original risk assessment. Note the legal status of an ACOP 'If you are prosecuted for breach of health and safety law, and it is proved that you did not follow the relevant provisions of the Code, you will need to show thay you have complied with the law in some other way'

It is my view that Regulation 5 of the Management Regs is the most relavant reference for the implicit duty to investigate accidents. Regulation 5, under "Health and safety arrangements" requires employers to make and give effect for the effective planning, organisation, control, MONITORING and review of the preventive and protective measures. The ACoP to regulation 5 in para 36 is explicit that under the heading of "MONITORING" there is adequate investigation of the immediate and underlying causes of incidents and accidents to ensure that remedial action is taken, lessons are learnt and longer term objectives are introduced.

Jay Forgive me if i feel that this is another pedantic reply to me trying to help someone First point you are quite right regarding OSHA I should have put we use an "OSHA Derivitive" but would that really help a fellow practitioner who is looking for help to develop a policy - I think not - so a minimal overview was given. Secondly - your absolutely right regarding the fact that all person have a right to put entries in the accident book - that does not mean that they have a right to put it in themselves - from a management perspective the book needs filling in to match the questions and there is no macheavelian reasons why the manager/supervisor or other trained or competent individual should not do this rather than the IP. What you get when you allow unfetted access is opinion rather than fact. Third again you are correct regarding pre action protocols, these protocols actually apply to things that exist pre and post accident, and that relate to the accident but do not apply to anything that is written in defence of a claim such as a report undertaken by or for the solicitor/loss adjuster. This is none discloseable - There in lies the caveat that keeps it out of the pre action protocol arena. This does not stop the release to the plantiffs solicitors however it makes it harder for them to know if they are on a winner or not. Finally I am actually new to posting and have found that people seem to revel (not yourself) in pulling apart peoples posts rather than trying to assist the person in the first place.

rayrapp Your right I have fallen into the eddy myself and done exactly what I criticised others for doing. The problem we all have as practitioners is the all the legislative frameworks we work to are open to interpretation and whether we like it or not we all interpret differently. I recently became a Fellow and I think I just scraped in - one of the review panel rung me up and made several suggestions on how I could help others especially in the industry and one of the suggestions was taking active part in the discussion forums. I have a wider risk management role and tried to assist people from knowledge gained in Nuclear,oil,gas,petrochemical,mining,quarrying and other high hazard industries and it seemed some of my suggestions were taken as having a cover the back approach. This got me a bit hot under the collar given the pro active work we do but all this still has to wind back to the fact that HSE management is and should be part of a wider risk management approach. Just because a safety professional has an eye on claims management as well as proactive indicators does not mean that they do not care or that they are trying to cover their backs. In fact I have seen several pro active initiatives being rolled out as a result of latent analysis of claim data as well as data from pro active monitoring such as improvement observations. But it seemed to me that where you mention managing risk it fires up a maelstrom of derision. Some of the suggestions were not procedures we use but if one profers advice it should be a 360 degree sweep with every conatation available surely - no matter if you agree or not. I will take your wise council on board - as I have read many of your other posts and found all to be constructive- and try to get used to the flow of the posts, and ignore when criticised. I will finally say that within the organisation which I work there is a large number of safety practitioners who do support and assist each other to mutually add value, it would be nice if the forums felt the same- why do you think it is that they seem to be a atmosphere of "one upmanship" permeating through some of the posts which I would say could prevent some people making a valuable contribution. As I say I only say this as a new contributor. The profession is hard enough without pecking at each other. Anyway thanks for that.

Rayrapp Thanks - I feel like I have found a friend and again you hit the nail on the head - one discussion you invariably have within an organisation and the HSE proffer for a robust safety management system is the "cost of accidents" - this would not just be made up of management cost to investigate but also the cost of compensation and the legal costs associated. (Please do not think that the human cost to the IP and family are lost either). However if we offer this as a reason we offer a solution - boards do not want problems they want a problem/solution. Where you control access and functionally the accident investigation function this can allow you to not just gain improtant information that can be fed into the SMS but also let you decide at an early stage to settle genuine claims and give compensation (rightfully) to people who have been injured where your system has "swiss cheesed" and failed. However again it gives you an ability to identify any faulse claims. A fundamental driver (not the only one) over the last ten years has been the no win no fee, and the effect this has had on the promulgation of safety management systems and the rise of our profession as value adding. It is therefore short sited of our profession to not utilise the reduction of insurance premiums for a company as an argument to the board to invest in competent HSE advice - I have slipped the E on as this is fast on the tails of the safety risk. The moral of the story to newly starting practitioners has got to be take an holistic view and a risk based view to ensure when you ask for your resource you have all the information available to have a meaningful conversation with the provider of the resource. Whilst many many boards do put safety as a priority some have it down the list behind profit (that's life and that's where we come in as practitioners) so a wider approach can give you the information to engage and persuade in their terms. We as practitioners would love to have every request for resource actioned immediately but in the real world we have to line up with finance, quality, HR, Engineering, Marketing - the list goes on. Therefore it becomes all about where you are on the cultural ladder one's organisation resides. If you are the top there is a lesser need for information right the way down to claims than if you are at the bottom. I must also say that this posting seems to become quite addictive - I'll be tweeting next.