Effective Accident Investigation
Published:  30 November, 1999

ROSPA - Royal Society for the Prevention of accidents

Roger Bibbings, RoSPA occupational safety adviser, for Plant and Works Engineering looks at why effective accident investigation is crucial if we are to learn from safety failures.

Employers have a duty to assess risks, looking forward to see what might happen and introducing reasonably practicable controls.

But much safety change only happens after things have gone wrong. Discovering, therefore, exactly what happened and why, whether it was an accident or instance of work-related ill health, or in the case of near misses, why something almost happened, has got a major contribution to make to effective health and safety management.

Learning from accidents and incidents not only helps employers to meet their moral duty to prevent pain and suffering to workers and their families, it also makes sound business sense since it helps to guard against costly future incidents.

Accident investigation has remained an underdeveloped element of the management system approach to health and safety. Most businesses think they investigate effectively but research shows that much investigation is superficial, of poor quality and does not help to identify underlying root causes.

For this reason, RoSPA has identified the need to improve accident investigation as one of its "key issues”.

Although accident investigation is not an explicit legal requirement, it is implicit in employers' duties to monitor health and safety, to keep risk assessments up to date and to protect workers and others affected by their undertakings. To make this clearer, the Health and Safety Executive (HSE) published guidance (HSG245) in 2004, introducing businesses to the benefits of carrying out investigations, and the methods for recording accidents, incidents and near misses, investigating them and acting upon the findings.

It is based on a four-stage approach: gathering information; analysing information; identifying risk control measures; and forming and implementing an action plan.

For an accident investigation to be effective, it is important that it searches for underlying contributory causes, rather than seeking to attribute blame. Often errors by front line staff that have led to an accident are simply the last link in a whole chain of causal factors, the control of any one of which could have produced a different outcome.

RoSPA and the Noordwijk Risk Initiative have developed the Definition of Organisational Readiness to Investigate (DORI, visit www.nri.eu.com/toppage4.htm) which helps businesses to assess the people, procedures, hardware and other forms of support they need to have in place to be able to respond effectively in the immediate aftermath of an incident. RoSPA strongly favours a team-based approach to investigation - to tap into key people"s knowledge and expertise and to involve them in learning from and championing the lessons that come out of investigations.

Of course, to be of value, accident investigation must be targeted, timely and carried out by competent people. RoSPA’s one-day Accident Investigation course aims to equip supervisory-level employees who have responsibility for investigating incidents with such skills.

For further information please visit: www.rospa.com/occupationaltraining

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