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                   UNIVERSITY PROCEDURE


       Document No:          CU/11/AII/P/1.0
       Policy Ratified by:   Safety Health and Environment Committee
       Date:                 July 2011
       Area Applicable:      All Cardiff University Staff
       Review Year           2013
       Impact Assessed       YES

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1.0 Introduction

One of the hardest lessons to be learned in accident prevention comes from the
investigation of accidents and incidents that have caused serious injury or loss.
Facing up to those lessons can be traumatic for all concerned, which is one reason
why investigations are often incomplete. The depth required for an investigation
must be sufficient to obtain information that is of value to line management and
others that may wish make use of the information, such as the University
Occupational Safety, Health and Environment Unit (OSHEU), the University Insurers
or the Health & Safety Executive (HSE).

An effective investigation requires a methodical, structured approach to information
gathering, collation and analysis. The findings of the investigation will form the basis
of an action plan to prevent the accident/incident from happening again, and for
improving the overall management of risk. The findings will also point to areas of the
risk assessment that may need to be reviewed. It has to be remembered that the
link with risk assessment(s) is a legal duty. Conducting an effective accident
investigation can be expensive in time, but the rewards can also be great.

2.0 Investigation of Accidents

2.1 Purpose

The main reason for investigating accidents is prevention. The purpose of the
investigation is to establish whether a reoccurrence can be prevented, or its effects
lessened, by the introduction of additional safeguards, procedures, information
instruction and training, or any combination of these.

2.2 The Procedure

There should be a defined procedure for reviewing or investigating all accidents,
however serious or trivial they may appear to be. The use of a form/checklist will
help to concentrate the attention on the important details.                       Line
Managers/Supervisors of the workplace where the accident occurred must complete
the initial investigation; for less serious accidents they may be the only people who
take part in the investigation and reporting procedure. Workers’ representatives,
senior management, and safety personnel may also be involved at any part of the
process as part of the investigating team.

2.3 Who should carry out the investigation?

Front line managers/supervisory staff should carry out the initial investigation. This
demonstrates commitment and removes any temptation to leave ‘health and safety’
to others.

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3.0 Investigation Process

      Level         1. Consequence of what happened and what                   2. Investigation Team                            3. Findings and action plan (SMART)         4. Close out
                              could have happened.

      1              Minor injury/Likely potential outcome no more          Supervisors/line managers          Report any findings on Accident form.
     Low              than first aid
                                                                          *Safety Representative
                     Local containment of an environmental
                      incident within area of operation.

     2               Likely potential harm/First Aid or more                As level 1                         Record findings as level 1 and also on the Incident
   Medium                                                                                                       Investigation Form (IIF).

                                                                                                                                                                                   Monitor and Review recommendations
                                                                              Departmental Safety Officer
                     Wider containment of an          environmental
                      incident within University.                         *Safety Representative                 Areas to consider include:

                                                                                                                         Immediate cause
                                                                                                                         Root cause
                                                                                                                         Underlying cause
                                                                                                                         likelihood of reoccurrence and severity of harm
                                                                                                                         control measures

      3              High adverse effect/Likely consequences                As level 1 & 2                     Record findings as level 1 and also on the Incident
     High             could have been serious injury or fatality.            OSHEU                              Investigation Form (IIF).

                     Wider containment of an environmental               *Safety Representative                 Areas to consider include:
                      incident. Statutory requirements breached.
                      Impact outside of the University.                   External                                       Immediate cause
                                                                                                                         Root cause
                                                                          HSE/Environment Agency.                        Underlying cause
                                                                                                                         likelihood of reoccurrence and severity of harm
                                                                                                                         control measures

    *Safety representatives may be part of the team as specified in Safety Representatives and Safety Committees Regulations.

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4.0 Carrying out the Investigation

The first steps in any investigation will be to preserve the accident/incident scene,
record the names of the people involved, the equipment involved, and the names of
any witnesses.

Information obtained during investigations is usually given verbally, but may also be
provided in writing. Written documentation should be gathered to provide evidence
of policy or practice followed in the workplace and witnesses should be talked to as
soon as possible after the accident. The injured person should also be interviewed
as soon as is practicable.

Key points to note about investigations are:
        events and issues under examination should never be prejudged.
        total reliance should not be placed on any one sole source of evidence.
        the value of witness statements decreases with time, it is a proven fact that
         theorising by witnesses increases as time passes and memory decreases.
        try to ensure that you ask “open questions”.
        the first focus of the investigation should be on:
           o when
           o the exact time and date
           o where – the building, floor, room, location in room etc.
           o to whom – name, job title etc.
           o and the outcome of the accident/incident – injury, property damage etc.
        the second focus should be on how and why, giving the immediate cause of
         the injury or loss e.g. slipped on spilled substance on floor, and then the
         secondary or underlying causes e.g. no procedure for dealing with spillages,
         procedure in place but ignored by staff, unsuitable footwear, carry large load
         which obscured vision.
        the amount of detail required will depend on a) the severity of the injury
         and/or property damage and b) the use to be made of the investigation and
         the report. The report should be as short as possible and as long as
         necessary for its purpose(s).

4.1 Equipment

The following are considered essential basic tools in the competent investigation of
accidents and incidents:

        report form, a check-list as a routine prompt for basic questions
        notebook or pad of paper
        pen

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Specialist equipment, e.g. camera, monitoring equipment, building plans, video
recorder, measuring tape, which should be reasonably long and robust etc. may be
obtained via OSHEU.

4.2 Recording findings and the Investigation Form

An action plan should be put together in light of an Incident. It should be specific and
well defined; measurable in attaining the goal; achievable with stakeholders; realistic
with the availability of resources and time-bound to a reasonably practicable amount
of time (SMART).

For all purposes, the report that emerges from the investigation must provide
answers to the following:

1. What was the:

    Immediate cause:      the most obvious reason why an event happens. There
                          may be more than one immediate cause identified.

    Root cause:           an initiating event or failing from which all other causes or
                          failings spring. Eg. Management, planning, organisational
                          failings etc.

    Underlying cause: the less obvious system or organisational reason for the
                      accident happening.    Eg. The hazard has not been
                      adequately considered via a suitable and sufficient risk
                      assessment, lack of experience or information, instruction
                      and training.

    Impact on the Environment: An incident that caused or had the potential to
                      cause damage to the environment either via the water
                      system, atmospheric release or to land contamination
                      including interference with Flora and Fauna.

2. What is the likelihood of it happening again?

       Certain:           it will happen again.
       Likely:            it will probably happen again.
       Possible:          it will possibly happen again.
       Unlikely:          it is unlikely to happen again.

3. How do we prevent a reoccurrence, what is the necessary corrective action?

4. If we do not have suitable procedures in place, what new procedures are either
   necessary or desirable to prevent a reoccurrence?

5. If procedures are in place, what reviews are needed of for example information,
   instruction and training, the risk assessment or work equipment?

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6. What realistically could be the result if no action is taken e.g. If the incident was
   a near miss what could have been the result?

It is not the task of the investigation report to allocate blame, although some
discussion of this is almost inevitable. Reports are usually ‘discoverable’; this means
they can be used by parties in any action for damages. It is a sound policy to
assume that accident investigation reports will be seen by solicitors and experts
acting on behalf of any injured party. They are entitled to see the report and this will
include anything in it that may later prove embarrassing – it should never contain
comments on blame.

The report and supporting documentation for serious accidents should contain:
     a summary of what happened, with detail of any person(s) injured
     a summary of events prior to the accident
     information gained during investigation
     details of witnesses, and witness statements
     information about any injury or loss sustained
     conclusions and recommendations
     supporting materials (photographs, diagrams to clarify the situation)
     relevant policy / procedural documents
     relevant risk assessments
     training records
     the date – and signature(s) by the person(s) carrying out the investigation.


Accident: An unplanned, uncontrolled event that has resulted in an injury or damage
to property.

Near miss: An unplanned, uncontrolled event that, under slightly different
circumstances, could have resulted in an injury or damage to property.

Serious or Potentially Serious (SoPS) Incidents: Those incidents (injuries, near
misses, vehicle incidents, fire incidents) that did, or had the reasonable potential
to, result in significant and permanent harm to staff, contractors, tenants, users,
visitors at CU sites or for staff while travelling and working on CU business away
from CU sites.

Environmental Incident: An incident that caused or had the potential to cause
damage to the environment either via the water system, atmosphere or to the land
(Flora and Fauna).

RIDDOR Incident: An injury specified in Schedule 1 of RIDDOR 1995.
E.g. fatality, fractures, amputations or dislocations or where a person has been
admitted to hospital for more than 24 hours.

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OR An Incident that is specified in Schedule 2 of RIDDOR 1995. E.g. Failure of a
load bearing part of a crane, explosion or bursting of a pressure system, electrical
failure causing a fire, collapse of a large structure or accidental release of a
biological agent.

OR An injury which, although not a major injury, has resulted in the injured person
being away from work or unable to carry out the full range of his/her duties for more
than seven days (including weekends and rest days but excluding the day of the
accident). Changes in the reporting process to the HSE require three day injuries to
be recorded but not reported to the HSE.

5.0 Further Information

   1. HSE Publication - Investigating Accidents and Incidents. A workbook for
      employers, unions, safety representatives and safety professionals.


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