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mjr1991  
#1 Posted : 15 June 2022 14:24:45(UTC)
Rank: Forum user
mjr1991

I understand the level of investigation applied is discretionary, but I'm wondering what other people tend to base their decision on?

Since I started this role we have only had open and shut accidents e.g. someone walloped their thumb with a hammer. Few questions asked, accident form filled in, short toolbox talk, done. But at what point would I start to think about getting witness statements, detailed reports, photos, root cause analysis, etc?

Thanks

A Kurdziel  
#2 Posted : 15 June 2022 15:08:52(UTC)
Rank: Super forum user
A Kurdziel

At my last job we had criteria and did basically 3 levels: 1- the basic open and shut things that you describe Level-2-more serious issues requiring a bit of an investigation as to how they happened, they might involve some sort of operational failure; person not trained to do particular task or not wearing the correct PPE etc. some RIDDORS most first aid cases. Level-3 we need to go to town on this because it’s a RIDDOR and HSE may follow this up, the person has suffered  a serious injury and may sue  or its something that has the potential to really damage the business or has gone horribly wrong and we better investigate thoroughly and produce a serous looking report which goes into detail and clearly sets out corrective actions. The criteria were a bit more objective than that but I can’t remember the details of what we did but you need some flexibility so not every RIDDOR is a Level 3  and not all near misses are Level 1.

 

mjr1991  
#3 Posted : 15 June 2022 16:10:59(UTC)
Rank: Forum user
mjr1991

Originally Posted by: A Kurdziel Go to Quoted Post

At my last job we had criteria and did basically 3 levels: 1- the basic open and shut things that you describe Level-2-more serious issues requiring a bit of an investigation as to how they happened, they might involve some sort of operational failure; person not trained to do particular task or not wearing the correct PPE etc. some RIDDORS most first aid cases. Level-3 we need to go to town on this because it’s a RIDDOR and HSE may follow this up, the person has suffered  a serious injury and may sue  or its something that has the potential to really damage the business or has gone horribly wrong and we better investigate thoroughly and produce a serous looking report which goes into detail and clearly sets out corrective actions. The criteria were a bit more objective than that but I can’t remember the details of what we did but you need some flexibility so not every RIDDOR is a Level 3  and not all near misses are Level 1.

 

Thanks for this. Weirdly, no sooner had I posted this had someone (an apprentice, it's always a bloody apprentice) in the workshop ran a grinding disc up his hand. 3 inch gauge up the side of his hand, lovely. So he's off to hospital now to get it stitched up, and hopefully washed with iodine, that's what you get for not wearing your gloves and grinding one handed.

So now I have an idea how much investigation to do. Thanks again.

peter gotch  
#4 Posted : 15 June 2022 18:21:38(UTC)
Rank: Super forum user
peter gotch

Hi Mike 

I have always taken the view that the level of in house investigations should generally be determined by the reasonably forseeable potential outcome (NOT the worst case scenario which is almost invariably at least one dead body) rather than what the ACTUAL outcome was.

There ARE the "open and shut" cases where it is obvious that action is needed and it is perhaps not worth bothering with an in depth investigation - particularly if that action is to sort out an unsafe CONDITION. Sort the problem and perhaps leave identifying the underlying (usually management failings) for another day.

So, you can have a relatively serious outcome such as a RIDDOR where the outcome was more serious than could have been anticipated if NOT applying hindsight. Example, man working in final stages of refurbishment of a block of flats, necessarily lifted a single floor board and fell a maximum of 340mm - then a series of other things happened and he ended up dead 10 days later, but with a clear cause and effect between incident and outcome.

BUT, you can quickly establish that there were no reasonably practicable precautions to prevent the incident, so not worth spending any more time than needed to show compassion on the investigation.

Conversely, someone falls 6m from e.g. a scaffold and twists their ankle, no time lost - this merits an in depth investigation due to the easily foreseeable potential consequence.

thanks 2 users thanked peter gotch for this useful post.
Brian Hagyard on 16/06/2022(UTC), Evans38004 on 16/06/2022(UTC)
Brian Hagyard  
#5 Posted : 16 June 2022 08:15:46(UTC)
Rank: Super forum user
Brian Hagyard

" reasonably forseeable potential outcome (NOT the worst case scenario)"

Peter you must have been on my IOSH course yesterday as i use exactly those words when teaching Risk assessment and Accident investigation - any hazard/accident could potentialy lead to a death - but how realistic is it! The other part of the equation i would add is how how likely is the incident to recure.

Mike. 

The HSE do produce a guidance document "Investigating accidents and incidents A workbook for employers, unions, safety representatives and safety professionals" Investigating accidents and incidents: A workbook for employers, unions, safety representatives and safety professionals HSG245 (hse.gov.uk) which contains some useful guidance - but in my opinion the accident investiagtion worked example they give with the edge cutter is only good to show how NOT to do it. Too many assumptions and misinterpritations.

Edited by user 16 June 2022 08:18:22(UTC)  | Reason: spotted one (of probably many) spelling mistake.

antbruce001  
#6 Posted : 16 June 2022 08:18:44(UTC)
Rank: Forum user
antbruce001

I completely agree with Peter. 

All good training on accident investigation, including the section in the NEBOSH General Cert states the level of investigation should be proportional to the potential consequences, not the actual outcome. This is particularly important for identifying the need for 'near miss' investigation. The only difference between a 'near miss' and an potentially serious accident is luck, and that can't be listed on a risk assessment as a control!

There is also a benefit to 'over investigating' some accidents or 'near misses' when accidents are a rare event, just to maintain the skills of investigators.

Hope it helps.

andybz  
#7 Posted : 16 June 2022 08:26:29(UTC)
Rank: Forum user
andybz

Mike

I know you were being a bit flipant in your second post but you have (inadvertently) highlighted at least two reasons to investigate:

1. If it is "always the apprentice" you want to investigate why that is the case. Are you achieving the right balance between allowing people new to work to experience it whilst managing the risks they are exposed to? What could have been done differently to allow the apprentice to use a grinding disc but with less likelihood of injury.

2. The accident was definitely not caused by failure to wear gloves. That may have led to more significant consequences, but there was obviously a loss of control that allowed contact to take place. Your investigation has to get beyond "injury to failure to wear PPE".

What others have said about potential rather than actual outcomes is spot on.

thanks 1 user thanked andybz for this useful post.
antbruce001 on 16/06/2022(UTC)
mjr1991  
#8 Posted : 16 June 2022 09:23:10(UTC)
Rank: Forum user
mjr1991

Originally Posted by: andybz Go to Quoted Post

Mike

I know you were being a bit flipant in your second post but you have (inadvertently) highlighted at least two reasons to investigate:

1. If it is "always the apprentice" you want to investigate why that is the case. Are you achieving the right balance between allowing people new to work to experience it whilst managing the risks they are exposed to? What could have been done differently to allow the apprentice to use a grinding disc but with less likelihood of injury.

2. The accident was definitely not caused by failure to wear gloves. That may have led to more significant consequences, but there was obviously a loss of control that allowed contact to take place. Your investigation has to get beyond "injury to failure to wear PPE".

What others have said about potential rather than actual outcomes is spot on.

Oh I totally get what you're saying. You're right, I was just being a bit flipant, this is the first accident this apprentice has had since I have worked here, the comment was more based on experience of working with many apprentices and having been one myself, they're young and invincible.

The main issue wasn't that he was wearing gloves, but that he was holding the workpiece with one hand, and the grinder with the other. His work wasn't secured and the grinder wasn't fully controlled. Gloves would have helped, but the accident still would have occurred.

Time to go ask some questions, I think.

peter gotch  
#9 Posted : 16 June 2022 10:23:57(UTC)
Rank: Super forum user
peter gotch

Morning Brian

HSE has been accused of making some of its guidance "lite" e.g. on CDM - possibly the influence of a deregulatory minded Government.

I think that "lite" would be a good description of the rewrite of HSG245 compared to the earlier version. Unfortunately, I don't have a copy of the original version.

Possibly one of the issues with HSG245 is that it is based on how HSE Inspectors tend to think rather than how in house investigators should be thinking- usually they should have entirely different objectives - the regulator is usually there to make quite rapid decisions on enforcement or not, whereas the primary objective of the in house investigators should be on identifying causes (including the underlying ones) and thence finding corrective actions - even if the reality might be that many in house actions spend more time looking for the potential defences to criminal or civil actions - something that usually should be left to a later time.

thanks 1 user thanked peter gotch for this useful post.
A Kurdziel on 17/06/2022(UTC)
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