​1. Why do we need to investigate incidents?

Investigating incidents is good management practice and a STFC requirement, for the following reasons:

• To identify both the immediate and underlying causes (there is rarely a single cause)
• To learn from the incident and put measures in place to prevent, where possible, a recurrence
• To reappraise existing risk assessments
• To review risk control measures and their effectiveness
• To identify activities or jobs causing the greatest number of incidents
• To satisfy legal requirements for accident reporting and recording
• To satisfy the expectation of the public and injured parties, who expect action following a serious incident and
• To obtain details which might be needed if the incident later becomes subject to an insurance claim or legal action

Line managers/Supervisors are responsible for conducting local investigations of incidents, although they may need additional expertise from the SHE or Occupational Health staff, technical staff, suppliers or engineers, and others depending on the type of incident.

The level of involvement by others will generally be related to the actual or potential significance of the incident.  In any case the line manager should carry out an immediate investigation to ensure that the situation is made safe and important evidence is not lost.

2. Establishing the right context and environment for a successful incident investigation

• Set aside sufficient time to do an investigation properly - demonstrating to those involved that it is important and that it will be done well.
• Undertake investigations promptly – ideally within a couple of days of the incident – information trails go cold quickly and people will forget.​
  
• Conduct investigations in a neutral non-confrontational environment – don’t invite staff to have discuss incidents in the Director’s office, visit their workplace, the site of the incident etc.
• The best way to illicit information for an investigation is by face to face discussion with individuals or small groups – try to avoid phone and e-mails, or turning up with an inquisition team.
• At the start of any investigation it is vitally important to set out:
  • what your objectives are, the primary purpose of an investigation is to determine what happened and how we can prevent other such incidents happening again – not to find scape goats;
  • highlight the fact that you are investigating the processes, procedures and systems employed rather than the individuals – as this is most likely where improvements will need to be made;
  • how you would like the investigation to proceed – in an open manner consistent with a ‘no blame’ culture;
  • If the incident being investigated is a ‘Serious or Potentially Serious’ (SoPS) incident be careful not to set alarm bells ringing with those involved with the word ‘Serious’;
  • how you will use the information gathered; and
  • only if it is apparent that individuals are concerned that the investigation might lead to disciplinary action – reassure them that this is not the purpose of the investigation except in the very extreme instances noted at the end of this appendix.
    

3. Checklist for Investigating Incidents

Obtain the basic facts

• Date and time of incident
• Names and contact details of injured / affected person(s), age, sex, occupation, company / university (if a user)
• The nature of any injury / ill health / assault / environmental or property damage sustained, details of treatment received, from whom, hospital attended, length of stay, length of absence from work
• Location details and layout of the area in which the incident occurred
• Details of witnesses / people first on the scene of the incident / first aiders who attended
• Condition and description of plant or equipment involved (before and after the incident) - including make, model, serial number, safety devices provided etc.
• If appropriate, take photographs, draw sketches and take measurements to record the scene of the incident before things are moved, repaired and cleaned up. The Council and/or regulatory authorities (HSE, EA) may need this evidence later.
• Any hazardous substances in use or present (obtain Safety Data Sheets if they are not already available), if applicable to the incident
• Names, contact details of any contractors involved, you may need to contact them later.
  
  

Establish the circumstances of the incident

• Events leading up to the incident
• What was being undertaken at the time, was this unusual or different from normal?
• What were the imediate causes of the incident – how did it happen?
• If investigating a case of disease or ill health, is there any evidence linking this to work activities?
• What instructions were given to those involved, before the incident?
• What were the established methods of work and procedures?
• What was the behaviour and actions of individuals before, during and after the incident?
• What was the role of supervisors and managers in the activities concerned?
  
  

Identify the underlying causes of the incident

There is often far more to incidents than simply unsafe acts by individuals or unsafe conditions, you need to consider why the circumstances leading to the incident occurred, and went unnoticed and unchecked. How did things get this far? A very effective means of structuring this analysis is a "Why, Why" tree (see below for an example). In completing a "Why, Why" analysis, consider the following:

• Has anything similar happened before? Check the accident records (available from the SHE Group), ask around
• Has the problem been mentioned before, when, by whom, what action was taken?
• Was this risk known and had a risk assessment been completed for this activity / substance / this area, is it suitable and sufficient?
• Were Council or local guidelines, policies or rules being followed?
• What control measures and safety equipment were identified by the risk assessment – are they still in place and effective (were the individuals doing the work aware of these)?
• Are any management or supervision failures evident?
• Was communication between the relevant parties adequate and effective?
• What was the level of competence of those involved – including the nature of any training, instruction or information provided, was it adequate?
• Are there any shortcomings in the original installation or design, if relevant?
• Were adequate performance standards set and monitored by management?
• Was there an adequate system for maintenance and cleaning of area or equipment?
• Were systems of work that individuals were expected to follow actually being followed in practice? Were these systems workable and realistic (if not, why not?)
• Was suitable personal protective equipment provided, was it effective (if not, why not?)
• Is record keeping adequate?

Establish whether the initial management and emergency response was adequate

• Was the initial response to the incident by STFC prompt and effective? Consider the actions taken to make the situation safe, or to deal with any continuing risks.
• Was the response to the incident by the Emergency Services or other external agencies, prompt and effective?
• Was the fire fighting and first aid response suitable, were correct spillage procedures known and followed?
• Was the incident promptly reported to the relevant parties (if not, why not)?
• How was the injured person treated and supported – was this adequate?
• Were the needs of witnesses adequately addressed (de-briefing, counselling etc)?
  
  

Identify any further action needed to prevent, where possible, a recurrence

You should assess or reassess the risks of this particular activity / equipment / area. When doing this you should question the adequacy of existing control measures and work methods and any discrepancy between these and what was intended.You will need to establish if the existing controls meet current standards and are adequate to effectively control risks. In particular, you may need to:

• Improve physical safeguards or safety features or modify design or workplace layout
• Improve existing work methods or introduce new safe working procedures
• Provide additional safety equipment e.g. lifting aids, personal protective equipment
• Produce or review risk assessments
• Update written health and safety rules, standards or policies, communicate these to employees / students, as appropriate
• Improve communications systems
• Make changes to or provide extra training, supervision or information sources
• Introduce better testing, maintenance or cleaning arrangements
• Introduce inspection, monitoring and audit systems
• Review similar risks in other sections
  
  

Once you have identified what action is required to prevent a recurrence of the incident in question, you should record your recommendations in the form of an action plan, making it clear what is required, by when and who will be responsible for implementing the improvements required. Remember:

• Always talk to the injured person and witnesses to get their account of events
• Verify the facts – do not make assumptions about what happened
• The most important thing is not to apportion blame, but to learn from incidents, so as to continually improve SHE standards.

The suggested format of the incident report is:

• 1. Incident title and reference number of the incident in ​Evotix Assur​e;
• 2. Contents/index
• 3. Executive Summary
• 4. Incident description
  • 4.1 Incident chronology/timeline for the incident and its immediate response (when)
  • 4.2 Incident location/map (where)
  • 4.3 Description of events (what/who/how)
    • 4.3.1 Pre incident
    • 4.3.2 The incident
    • 4.3.3 Post incident/how event was tackled
• 5. Incident investigation and analysis
• 6. Conclusions as to the root cause(s) of the incident
• 7. Recommendations to prevent, where possible, a recurrence of the incident or near miss in the form of an action plan detailing the actions, responsibility for their achievement and timescales over which they should occur.
• 8. Appendices: As appropriate and for evidence, explanatory plans, photographs.

Finally:

The view of STFC is that disciplinary action does not form part of the response to a report of an incident, except in cases where one or more of the following applies:

• Where there are repeated occurrences of an incident by the same individual, despite re-training and mentorship;
• Where the incident/event is viewed as malicious; this may include involvement of the police should a crime be suspected;
• When in the view of STFC and/or any professional registration body, the action causing the incident is far removed from acceptable practice;
• Where there is evidence that safety interlock systems have been deliberately defeated or tampered with, jeopard​ising their own safety and/or the safety of others; and
• Where a significant incident or event is not reported and attempted concealment of the event is apparent.

Simple Example of the use of a 'Why-Why' diagram (PDF - 72kB - link opens in a new window)