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							Incident Investigation Guidance Note for Managers
Introduction
Accidents & incidents may be caused by a combination of unsafe acts, unsafe conditions and personal factors. As part of the safety management system the aim of the investigation process following an accident, incident or occurrence of work related ill health is to establish the cause of what went wrong, and then put corrective measures in place to ensure a similar event does not occur again. A timely, thorough investigation, where remedial measures are implemented, can help demonstrate to staff a positive approach and commitment to health and safety. The aim of this guidance is to describe the line manager’s actions needed to successfully investigate accidents and incidents in the workplace. ALL DEPARTMENTS SHOULD HAVE A ROBUST SYSTEM IN PLACE TO ENSURE ALL SUCH INCIDENTS ARE RECORDED ON THE NORFOLK COUNTY COUNCIL INCIDENT REPORT FORM IN THE CASE OF SIGNIFICANT INCIDENTS, DEPARTMENTAL SAFETY ADVISERS MUST BE INFORMED IMMEDIATELY THE INCIDENT HAS OCCURED. What should be investigated? All incidents occurring on NCC premises or during the course of NCC activities should be investigated. This includes those involving our staff, visitors and contractors. Incidents include:  Accidents leading to injury or ill health  Near misses/dangerous occurrences which did not lead to injury but which could have done  Acts of violence or aggression, both physical and verbal  Cases of work related ill health  Incidents resulting in damage to our buildings, property, equipment etc. Some Definitions  Accident/Incident: an event that results in injury or ill health.  Near Miss: an event that, while not causing harm, has the potential to causes injury or ill health.  Undesired circumstances: a set of conditions or circumstances that have the potential to cause injury or ill health.  Dangerous occurrence: One of a number of specific, reportable adverse events as defined in the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR).  Hazard: The potential to cause harm, including ill health and injury, damage to property, plant, or equipment.  Risk: The level of risk is determined from a combination of the likelihood of a specific incident occurring and the severity of the consequences (i.e. how often is it likely to happen, how many people could be affected and how bad would the likely injuries or ill health effects be?).
Reference: HS/Corp/Inc-Inv/01DW Date Issued: June 2008

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Immediate cause: The most obvious reason why an incident happens, e.g. the guard is missing, the employee slips etc. There may be several immediate causes identified in any one adverse event. Underlying cause: The less obvious ‘system’ or ‘organisational’ reason for an incident happening, e.g. pre-start machinery checks are not carried out by supervisors; the hazard has not been adequately considered via a suitable and sufficient risk assessment; production pressures are too great etc. Root cause: An initiating event or failing from which all other causes or failings spring. Root causes are generally management, planning or organisational failings. Fatality: work related death. Major injury/ill health: Including fractures (other than fingers or toes), amputations, loss of sight, burn or penetrating injury to the eye, any injury or acute illness resulting in unconsciousness, requiring resuscitation or requiring admittance to hospital for more than 24 hours. (Reportable under RIDDOR) Serious injury/ill health: where the person affected is unfit to carry out his or her normal work for more than three consecutive days. (Reportable under RIDDOR) Minor injury: all other injuries, where the injured person is unfit for his or her normal work for less than three days. Damage only: damage to property, equipment, etc. Certain: it will happen again and soon. Likely: it will reoccur, but not as an everyday event. Possible: it may occur from time to time. Unlikely: it is not expected to happen again in the foreseeable future. Rare: so unlikely that it is not expected to happen again.

Responsibilities for incident investigation
Department Heads: Have overall responsibility for ensuring arrangements are in place in their areas of control for the effective investigation and reporting and monitoring of incidents. Line managers: Are responsible for ensuring incidents are reported and investigations are carried out where there has been an incident or case of work related ill health reported within their area of control without delay. Health and Safety Adviser: After more serious incidents (or those that had the potential to be), your departmental health and safety adviser may need to carry out an investigation. Advisers need to be informed of all RIDDOR reportable incidents as soon as possible so that they can assess the severity (including potential severity) and significance of the incident and whether their involvement is necessary. Enforcement agencies: After the most serious incidents, dangerous occurrences or cases of work related disease; an enforcement agency such as the HSE may also need to investigate. Where an investigation is likely to be required by the health and safety adviser or an enforcement agency, it is important they are notified as soon as possible after the occurrence. Once contacted, the H&S adviser will usually inform the enforcement agency unless they have already been contacted by any emergency services in attendance. Union representatives – Union representatives are also entitled to carry out inspections following notifiable (under RIDDOR) accidents, dangerous occurrences and diseases.
Reference: HS/Corp/Inc-Inv/01DW Date Issued: June 2008

Ideally, this should be in conjunction with the line manager and/or safety adviser’s inspection. All employees have a duty to co-operate with any investigation.

Carrying out an Investigation
Scale of investigation Having been notified of an incident and been given basic information on what happened, the decision must be made on what depth of investigation is appropriate. It is the potential consequences and the likelihood of the incident recurring that should determine the level of investigation, not simply the actual injury or ill health suffered on this occasion. For most minor incidents, a simple investigation may be all that is needed to establish the facts and put effective remedial actions in place. Where an incident is (or could have been) more significant, a more in-depth and/or wider scale investigation needs to be undertaken that could involve several parties as highlighted in the ‘Responsibilities for Investigation’ section. Where the potential consequences of the incident are minor, or where the consequences are more serious but the likelihood of the incident recurring are low, investigations can be carried out by the line manager and recorded on the incident report form. Minimal and low level investigations can normally be undertaken by line managers alone, although advisers are available to assist where necessary. For all other incidents your departmental health and safety adviser must be informed of the incident as soon as is practicable. The level of their involvement will depend on the nature and severity (including potential severity) of the incident. Some such incidents may still be investigated by the line manager alone but under the advice and of your departmental health and safety adviser. All such investigations should follow and be recorded on the detailed incident investigation form (Appendix 1), a copy of which should be forwarded to your adviser on completion.

The Investigation
Making safe and preserving the scene following a serious incident Following significant incidents it is important that after injured parties are dealt with and the situation made safe (where it is possible and safe to do so), you try and leave the scene as it is to ensure those investigating are able to observe the scene as it was. This might require closing off the area by barriers, locking doors, putting up notices to restrict access etc. For example, if asbestos-containing material is damaged access should be prevented by locking doors to the room. The safety of the investigator should also be considered and if there is any doubt whether the area is safe to enter then access to the site is to be controlled until a competent person has assessed the site as safe to enter.

Reference: HS/Corp/Inc-Inv/01DW

Date Issued: June 2008

Timing of the investigation Investigations should be carried out as soon as possible after the incident, though this may not be possible after traumatic events or where serious injury has occurred. It is important employees involved in traumatic events are made aware of the means of support available to them such as Norfolk Support Line. Gathering information – All incidents The incident report form sets out the type of information that needs to be recorded. The information and degree of detail needed will depend on the incident but may include:  Information such as environmental conditions (noise, temperature etc) at the time of the incident  The names of any witnesses to the incident (and testimonies where appropriate)  The activity (and chain of events) at the time the incident occurred  Any working procedures relevant to the activity e.g. risk assessments, safe systems of work  Physical features of the workplace that may have contributed e.g. cluttered flooring, over stacked shelving etc  Photographic evidence of the work area etc at the time of the incident  Physical details of the scene such as sketches showing the position of people, equipment etc. Measurements may also be helpful  Relevant records e.g. for training, inspection, servicing and maintenance  Establish the statutory and other notifications of the accident/incident have been made to the appropriate person(s) or authority.

The principles of incident investigation
Be objective and avoid blame An incident investigation should be undertaken with an open mind as to how it occurred. Though the investigation may point towards an act or omission by a member of staff, the purpose of investigating incidents is not to establish blame. Where staff feel this is likely to be the outcome of an investigation they are less likely to report incidents meaning unsafe acts or conditions may continue. This means that what is initially a minor incident, may potentially end up as a much more significant one. Staff are also less likely to be open, honest and give an accurate account if doing so has been held against them in the past. Seek to determine the underlying causes – Ask „who, what, why, where and how?‟ Good investigations identify both immediate and underlying causes, including human factors. Immediate causes include the job being done and the people involved. Underlying causes are the management and organisation factors that explain why the event occurred. The investigation should to identify the underlying causes of the incident. For example, though the trailing cable may have been the immediate cause of a trip and subsequent injury, why was it there? An investigation of the underlying causes would look at the reasons behind the trailing cable e.g. poor housekeeping, insufficient plug sockets etc. Then ask why was housekeeping insufficient and why are there insufficient plug sockets? Keep asking why until you no longer generate any more useful information. When trying to identify the underlying causes consideration should be given to:  The place or premises where the incident happened: Areas to consider include; access and egress, suitability of the workplace for the task, segregation of people
Date Issued: June 2008

Reference: HS/Corp/Inc-Inv/01DW

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and equipment, environmental factors such as lighting, heat and ventilation, workstation design, housekeeping, and signage. The plant, equipment and substances used or generated: Areas to consider include; design, suitability, maintenance, correct use of plant, equipment, materials, substances and personal protective equipment. The process, procedures, instructions and information provided: Areas to consider include; the presence of safe working procedures and instructions that if followed would have prevented the incident from occurring, the implementation of any procedures or instructions, monitoring of systems, the level and appropriateness of supervision, instruction and training, control systems for contractors involved. The people involved in the incident: Areas to consider include; suitability of people to do their job, including age, competence, abilities, human error.

Interviews Interviews are to be conducted promptly before details fade or become confused and in a place where the injured person or witness feels comfortable. This, of course, depends on the condition of the injured person and witnesses. Always ensure that appropriate First Aid or medical treatment is rendered before trying to conduct the interview. If the injured person is fit to answer questions, adopt the following approach:      Put the injured person or witness at ease, remain calm and objective and be sympathetic, honest and courteous. Ask them to recount what happened in their own words and take notes – you should repeat back key points at the end of the interview to check the details are correct. Do not ask leading questions, interrupt or argue. Check the answers against your own observations and the review of documentary evidence. Distinguish between fact and opinion and remember eye-witnesses are not always reliable.

To assist in the compilation of the investigation report it may be prudent to obtain written statements from the injured person and eye-witnesses. A standard form for this purpose is provided at Appendix 2. You can either ask them to complete the witness statement answering the questions you have put to them or complete the statement for them, but you must make sure the statement is in their own words. In general, the statement should only contain information on what the witness saw, and not what others have said to him/her. However, it is important to record anything that may open up a new line of enquiry or help in corroborating other information. However the status of the information must be made clear: actual knowledge, belief, conclusion from other events, or information recieved from others. Staff have the right to have a friend, Trade Union or legal representative present during the interview.

Human Failings
Though incident investigation is not about blame, it is important to address the reasons for human failing. Human failings can arise due to error or violations and these need to be considered before assigning blame or punishment.

Reference: HS/Corp/Inc-Inv/01DW

Date Issued: June 2008

Errors usually lead to unintended and generally undesirable outcomes and are categorised as slips, lapses and mistakes. They are made more likely by stressors in the workplace such as:  Job/environmental e.g. excessive temperatures, noise, unreasonable workloads, high demand on concentration, poor layout of working area, inadequate equipment.  Organisational e.g. insufficient numbers of staff, unrealistic turnaround times, poor supervision.  Individual e.g. family problems, insufficient training and/or experience, physical attributes such as lack of stamina or strength. Violations are deliberate deviations from rules or procedures and can be divided into:  Routine – Where violations become the norm e.g. cutting corners to save time, perception that rules are restrictive, belief that rules no longer apply, lack of enforcement. New workers may also work to this as this is the established norm they observe within the workplace.  Situational – Where pressure of the task from insufficient staff, time, equipment, maintenance of equipment, poor weather etc leads to deliberate violations to get the job done.  Exceptional – These are rare but tend to happen when a procedure has already gone wrong and more mistakes are made as the employee continues to break rules to try and redress the situation. Your incident investigation should look at the reasons why errors or violations have occurred. It is important to note that violations often occur where employees perceive that managers are turning a blind eye to unsafe acts and therefore implying their approval. This means it is important when asking ‘why’ that any weaknesses in management systems such as supervision are also looked at.

Reviewing Control Measures
Where incidents occur the risk assessment and control measures need reviewing. The nature of the controls will need to be determined by making a judgement on the likelihood of the incident reoccurring and the potential severity of the incident. The need to review controls in place applies to work related ill health as well as accidents. For example, an employee suffering ill health at their workstation will need their workstation assessment reviewed. This individual case might also highlight the need to review all DSE assessments where this hasn’t been done recently, or where assessments have been inadequate. Just as the investigation should identify underlying causes, the review of the controls should seek to address them. Using the trailing cable example again, dealing with:  The immediate cause might mean moving the cable so it cannot cause further trips.  The underlying causes might mean issuing instructions to staff not to leave trailing cables, installing a new socket that is better placed etc.  The root causes might mean reviewing the resources allocated to health and safety and the commitment to providing a safe working environment. Examples of how controls might be reviewed Lower level changes:  Making adjustments to a workstation set up.  Replacing equipment or substances with safer alternatives.
Reference: HS/Corp/Inc-Inv/01DW Date Issued: June 2008

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Increasing the maintenance frequency for a piece of equipment. Providing written instructions for equipment with complex operating procedures. Reducing the period between risk assessment reviews. Reducing the time spent on single tasks to avoid boredom or ‘switching off’.

Higher level changes (addressing the root causes):  Improving how safety information is communicated/shared.  Improved monitoring e.g. additional supervision, reinforcing and demonstrating safe working methods.  Reviewing whether production targets are realistic and can be met with the current staff resources available, and working to the procedures in place.  Review how H&S is managed e.g. resources, training provision, responsibilities etc. Timing of necessary actions All unsafe acts/conditions should be rectified as soon as possible. Where significant remedial action is required to ensure there is no reoccurrence of an incident with the potential to cause harm, it may be that initial temporary measures are required before the full solution can be implemented. For example, following failure of the emergency lighting it might be that access to an area needs to be temporarily restricted, or torches and additional staff training utilised whilst waiting for new/upgraded emergency lighting to be installed.

Share information and providing feedback
Information gained from an incident and its investigation might prevent an incident occurring under similar circumstances elsewhere and so wherever possible relevant information should be shared. Feedback should be provided to relevant staff on the actions that have been taken to prevent a reoccurrence. Additionally, where human failings are identified, the incident should be discussed with the individual/s involved with a view to determining why they felt the incident occurred, why they had acted as they had and what they feel might help prevent this happening again.

Media communications
In the unlikely event that a serious incident occurs that is of a wider local/national interest e.g. where investigation is likely to be undertaken by an enforcement agency, you may receive requests for comments by the media. Before engaging in any interviews or providing information that may prejudice the outcome of any investigation, you should contact the Communications Team and your Health and Safety Adviser for guidance.

Further sources of information
   NCC Incident reporting Code of Practice Line managers training Norfolk Support Line – For counselling those affected by or involved in an incident

Records & Forms Details of accident investigation and associated supporting evidence shall be retained for a period of at least three years after closure.
Reference: HS/Corp/Inc-Inv/01DW Date Issued: June 2008

Where accidents may result in long-term ill health, the Incident Report Form shall be copied to the individual’s personal file. Appendices 1 and 2 provide standard forms to aid the investigation process. Competencies Line managers should be trained in basic accident investigation techniques and have a sound understanding of all relevant procedures.

Reference: HS/Corp/Inc-Inv/01DW

Date Issued: June 2008

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Incident Investigation Report Form
This report may be required for legal purposes. Evidence must be gathered thoroughly and any conclusions drawn must be supported by the findings. A copy of the relevant incident report form(s) should be attached to this report.

1. Investigation details
Investigation start date: Investigation finish date: If there has been a significant delay in investigating the incident, please give reasons for delay below:

Name(s) and position(s) of investigator(s):

Materials attached to the investigation report, etc. (Tick as applicable) Incident Report Form Audio tape recordings (describe below) (list ref. numbers below) Witness statements (list names and Physical evidence (list below) positions) Video tape (describe footage below) RIDDOR report form Photos (list total number below) Plan/Sketch of incident location Other (list/describe below)

2. Incident details
Type of incident Date of incident: Accident resulting in injury Time of incident: Near miss/dangerous Department: occurrence Violent incident Team/section/unit: Work-related ill health Incident location: (Address and post code)

Is the above location an NCC property?

Yes

No

Names and positions/status (e.g. employee, pupil, member of public, contractor etc.) of any injured person(s) and witnesses:

Team/section/unit/school:

Line manager for above team/section/unit: (Name and position.)

1

Reference: HS/Corp/Inc-Inv/01DW

Date Issued: June 2008

3. Narrative of events
Briefly provide a factual description of the events and circumstances of the incident based on your investigation findings. Any inconsistencies in accounts/evidence that cannot be resolved should be noted. Do not attempt to provide a definitive account if you do not have supporting evidence. Continue on a separate sheet if necessary.

Reference: HS/Corp/Inc-Inv/01DW

Date Issued: June 2008

4. Work environment
a. Access/egress b. Edge/fall protection c. Floor surface conditions d. Housekeeping/cleanliness e. Lighting/visibility f. Workplace inspection reports g. Temperature h. Traffic routes i. Weather j. Layout/space k. Warning signs l. Noise

Did anything about the work environment contribute to the incident? Details/comments (continue on separate sheet if necessary):

Yes - provide details No

5. Work equipment and machinery
a. Is there any evidence of defects or failure? b. Suitability for use and conditions? c. Were inspection, test and maintenance satisfactory? d. Written instructions, training and records? Yes - provide details No

Did equipment/machinery contribute to the incident?

A competent person must examine, and make a written statement detailing the condition of, any impounded equipment. Obtain photographs/video of any visible defects and copies or printouts of test/maintenance records and attach them to this report. Details/comments (continue on separate sheet if necessary):

6. Personal Protective Equipment (PPE)
a. Was PPE required? b. Did it perform adequately? c. Was the PPE suitable for the person? d. Was PPE in good condition? e. Was it suitable for the risks/circumstances? f. Had individuals received information/ instruction/training on the PPE? g. Was PPE properly worn/used? h. Was it tested and maintained? i. Was PPE the only control measure in place? No

Were PPE issues a contributory factor?

Yes - provide details

Details/comments (continue on separate sheet if necessary):

Reference: HS/Corp/Inc-Inv/01DW

Date Issued: June 2008

7. Systems of work
a. Is there a recognised safe way of doing the work? b. Was the work carried out in the recognised safe way? c. Do adequate clear, up to date written instructions exist? Were systems of work a contributory factor? d. Was supervision adequate for the level of risk? e. Were people adequately briefed/instructed? f. Is there any evidence of previous unsafe practices? Yes - provide details No

Details/comments (continue on separate sheet if necessary):

8. People involved
a. Were they fit and well immediately before the d. Were they sufficiently competent for event? the work? e. Was culture, attitude or risk perception b. Were they physically suitable for the work? an issue? c. Did they do (or fail to do) anything which f. Was the person rushing, or under time contributed to causing the event - were there pressures? errors, lapses or violations? Yes - provide Was human behaviour or individual characteristics a contributory details factor? No Details/comments (continue on separate sheet if necessary):

9. Training and information
a. Had people received relevant/adequate c. Are training needs properly information/training? identified? b. Is training properly planned and delivered? d. Are records of training adequate? Were training or information issues a contributory Yes - provide details No factor? Details/comments (continue on separate sheet if necessary):

Reference: HS/Corp/Inc-Inv/01DW

Date Issued: June 2008

10. Risk assessment,
a. Does a risk assessment for the work exist? (If no, identify reasons why not.) b. Does it identify the hazards involved in the incident? c. Were control measures identified in the assessment in place? d. Were the precautions identified adequate? Yes - provide details No

Were risk assessment issues a contributory factor?

Details/comments (continue on separate sheet if necessary):

11. Immediate response to the incident
Were first aid and other emergency response N/A Yes actions adequate? Details/comments (continue on separate sheet if necessary): No - provide details

12. Immediate causes
What were the unsafe conditions and/or unsafe acts on the day, which led to the incident occurring?

13. Underlying causes
What organisational factors led to the unsafe conditions and/or unsafe acts?

Reference: HS/Corp/Inc-Inv/01DW

Date Issued: June 2008

14. Action plan
The incident investigator should complete the 'recommended actions' and 'priority' columns. The relevant line manager should complete the remaining columns. The following questions must be considered: - Are there similar tasks/activities carried out elsewhere? - Is there any evidence of trends/common causes? Recommended actions Priority Person responsible Action taken, or Completion H, M, L reasons for date inaction

15. Communication
The findings of this investigation need to be communicated to the following people: Name(s) Position(s) Signature(s) Date(s)

Investigator’s name Manager’s name

Investigator’s signature Manager’s signature

Date Date

Reference: HS/Corp/Inc-Inv/01DW Date Issued: June 2008

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Injured Person/Witness Statement
Statement of: (please print) Surname: Forename(s): Age (If over 18 enter “over 18”): Employed at (Name & Address of Workplace): Staff number: Page of

Personnel status: (mark applicable box) NCC Employee Client Contractor Training Scheme Other please state: Job Title: Relationship to incident: Injured Person Date of incident: Location of incident: Line Manager Member of Public Work Experience

Pupil Voluntary Worker Other

Witness Time of incident:

Statement of Events This statement (consisting of a total of pages each signed by me) is, to the best of my knowledge and belief, a true and accurate record. Signature: Date:

Telephone number: Statement taken by: Date:

Signature:

Reference: HS/Corp/Inc-Inv/01DW Date Issued: June 2008

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Injured Person/Witness Statement (continued)
Statement of: Page of

Signature:

Date:

Reference: HS/Corp/Inc-Inv/01DW Date Issued: June 2008