Accident investigationRoot Cause Analysis (RCA)

OrWalk Down

J. McCann

Legal requirement

• To ensure you are operating your organisation within the law. • The Management of Health and Safety at Work Regulations 1999,

regulation 5, requires employers to plan, organise, control, monitor and review their health and safety arrangements. Health and safety investigations form an essential part of this process.

• Following the Woolf Report 6 on civil action, you are expected to make full disclosure of the circumstances of an accident to the injured parties considering legal action. The fear of litigation may make you think it is better not to investigate, but you can’t make things better if you don’t know what went wrong! The fact that you thoroughly investigated an accident and took remedial action to prevent further accidents would demonstrate to a court that your company has a positive attitude to health and safety. Your investigation findings will also provide essential information for your insurers in the event of a claim.

‘Awareness’ of Duties as an employer.

(a)the provision and maintenance of plant and systems of work that are, so far as is reasonably practicable, safe and without risks to health;(b)arrangements for ensuring, so far as is reasonably practicable, safety and absence of risks to health in connection with the use, handling, storage and transport of articles and substances;(c)the provision of such information, instruction, training and supervision as is necessary to ensure, so far as is reasonably practicable, the health and safety at work of his employees;(d)so far as is reasonably practicable as regards any place of work under the employer’s control, the maintenance of it in a condition that is safe and without risks to health and the provision and maintenance of means of access to and egress from it that are safe and without such risks;(e)the provision and maintenance of a working environment for his employees that is, so far as is reasonably practicable, safe, without risks to health, and adequate as regards facilities and arrangements for their welfare at work.

‘Situational awareness’

It is not only employees that should be “aware of their environment at all times” managers also have a duty to be ‘situationally aware’;- aware of their employees working environment at all times. Example;- Sect 2 : 2 Para “C” HASAW Act Ask yourself if you have provided

• Instruction(s); Are they Easily understood? Available? & up to date? Were they followed or not, a lack of instruction and training may mean that tasks are not done properly; misunderstandings, which arise more easily when employees lack understanding of the usual routines and procedures in the organisation;

• Training; Have you provided Training?, Is it sufficient? Could it be better? Was the training followed or not, lack of skills or knowledge may mean that there is a lack of respect for the risks involved, due to ignorance of the potential consequences;

• Supervision; Is your supervision adequate? Do supervisors check that employees follow instructions etc. standards of supervision and on-site monitoring of working practices may be less than adequate;- nobody intervenes in the event of procedural errors;

Awareness of other provisions e.g. Regulations Etc.Of course there are other sections of the HASAW Act that you may have to consider, also;.• relevant Regulations• Codes of practice• Standards. Ergonomics etc.

A good understanding of Health and safety is paramount.“ignorantia legis neminem excusat” ignorance of

law excuses no one.

‘Reasonably practicableHow is ‘reasonably practicable’ defined?

• ‘Reasonably practicable’ is used to qualify duties to ensure health and safety and certain other duties in the Health and Safety at Work Etc Act 1974 and Management Regulations.

• In this context, reasonably practicable means that which is, or was at a particular time, reasonably able to be done to ensure health and safety, taking into account and weighing up all relevant matters including:

• (a) the likelihood of the hazard or the risk concerned being realised• (b) the degree of harm that might result from the hazard or the risk• (c) what the person concerned knows, or ought reasonably to know, about the

hazard or risk, and ways of eliminating or minimising the risk• (d) the availability and suitability of ways to eliminate or minimise the risk, and• (e) after assessing the extent of the risk and the available ways of eliminating or

minimising the risk, the cost associated with available ways of eliminating or minimising the risk, including whether the cost is grossly disproportionate to the risk.

What is ‘reasonably practicable’ “an objective test”

• What is ‘reasonably practicable’ is determined objectively. This means that a duty-holder must meet the standard of behaviour expected of a reasonable person in the duty-holder’s position and who is required to comply with the same duty.

• There are two elements to what is ‘reasonably practicable’. A duty-holder must first consider what can be done - that is, what is possible in the circumstances for ensuring health and safety.

• They must then consider whether it is reasonable, in the circumstances to do all that is possible.

• This means that what can be done should be done unless it is reasonable in the circumstances for the duty-holder to do something less.

• This approach is consistent with the objects of the Management of Health and safety at work regulations and ‘1974 Act’ which include the aim of ensuring that workers and others are provided with the highest level of protection that is reasonably practicable.

BLAME ‘v’ Safety culture

• Not addressing the ‘human’ factors greatly reduces the value of the investigation. The objective of an investigation is to learn the lessons and to act to prevent recurrences, through suitable risk control measures. You will not be able to do that unless your workforce trusts you enough to co-operate with you.

• Laying all the blame on one or more individuals is counter-productive and runs the risk of alienating the workforce and undermining the safety culture, crucial to creating and maintaining a safer working environment.

ACCIDENT WALK DOWN

Root Cause AnalysisUsing a FISHBONE Diagram or other RCA tools• Gathering the information• Analysing the information• Identifying risk control measures• The lessons learned and their implementation

TERMINOLOGY.‘Adverse event’ includes:accident: an event that results in injury, damage or ill health; incidents:- Near miss / dangerous occurrences: an event that, while not causing harm, has

the potential to cause injury or ill health.; undesired circumstance: a set of conditions or circumstances that have the potential to cause injury or ill health, E.g.. Untrained officer manually handling large gates: 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, products or the environment, production losses or increased liabilities.

• Immediate cause: the most obvious reason why an adverse event happens. There may be several immediate causes identified in any one adverse event.

• Underlying or Root cause: Basic; fundamental: the underlying cause of the problem.

• Contributing Factors; something that is partly responsible for a development or phenomenon Stress, both human and mechanical, may also be a contributing ⇒factor.

AccidentInjury, illness or

damage

Immediate cause; i.e. collision

Poor instruction and training

Lack of supervision

Poor Safety management

Immediate cause; i.e. broken hinge

Damage

Poor Maintenance

Poor defect reporting

No inspections

Immediate cause

Poor operationLack of training, supervision and

instruction

Risk assessment not

suitable or sufficient

Fatigue

Poor systems of Work

Consequence:• fatal: work-related death;• major injury/ill health: (as defined in RIDDOR, Schedule 1),

including fractures (other than fingers or toes), amputations, loss of sight, a 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;

• serious injury/ill health: where the person affected is unfit to carry out his or her normal work for more than three consecutive days;

• 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, the environment or production

• Likelihood that an adverse event will happen again i.e.1. rare: so unlikely that it is not expected to happen again2. unlikely: it is not expected to happen again in the foreseeable

future;3. possible: it may occur from time to time;4. likely: it will reoccur, but not as an everyday event;5. certain: it will happen again and soon;

FISHBONE DIAGRAM

• The fishbone diagram helps identify many possible causes for an effect or problem.

• It can be used to structure a brainstorming session. • It immediately sorts ideas into useful categories.You are looking for ALL causal relationships.

First used by Dr Kaoru Ishikawa of the University of Tokyo in 1943 - hence its frequent reference as a "Ishikawa Diagram". This diagram is used to identify all of the contributing root causes

likely to be causing a problem.

Accident or

near miss

RISK ASSESSMENT

SAFE EQUIPMENT SAFE SYSTEM OF WORK

Fish bone diagram

SupervisionAdequate/poor

TrainingSufficient/poor

MaintenanceGood/bad

Design Good/bad

Materials Good/bad

New Hazard Y/N

Up to date Y/N

Suitable and Sufficient Y/N

InstructionGood/bad

Checklist/questions - analysis of the causes

• Work through the questions about the possible immediate causes of the adverse event (the place, the plant, the people and the process) and identify which are relevant.

• Record all the immediate causes identified and the necessary risk control measures. • For each immediate cause, the analysis may suggest underlying causes which may

have allowed the immediate causes to exist. • Consider the underlying/root cause questions suggested by the immediate causes.

Record those that are relevant and note the measures needed to remedy them. • The final step of your analysis is to consider the environment in which the

organisation and planning of health and safety was carried out. • The ‘Management’ section of the analysis must be carried out by people within the

organisation who have both the overall responsibility for health and safety, and the authority to make changes to the management system. Record the underlying failings in the overall management system (ie the root causes of the adverse event) and the remedial action required at management level. The root causes of almost all adverse events are failings at managerial level.

Contributory factors / check list questions

The existence of a written risk assessment for the process or task that led to the adverse event will help to reveal what was known of the associated risks. A judgement can be made as to whether the risk assessment was ’suitable and sufficient’, as required by law and whether the risk control measures identified as being necessary were ever adequately put in place.

1. The existing control measures are sufficient to reduce the Risk to ALARP; Was the risk known? If so, why wasn’t it controlled? If not, why not?

2. Where and when did the adverse event happen? 3. Who was injured/suffered ill health or was otherwise involved with the adverse event?4. How did the adverse event happen? Note any equipment involved. 5. What activities were being carried out at the time? 6. Was there anything unusual or different about the working conditions?7. Were there adequate safe working procedures and were they followed?8. What injuries or ill health effects, if any, were caused? 9. If there was an injury, how did it occur and what caused it?

Contributory factors check list questions

10. Did the organisation and arrangement of the work influence the adverse event? access to welfare facilities i.e. drinking water, missed breaks, exposure to adverse weather conditions etc.11. problems due to the immaturity, inexperience and lack of awareness of existing or potential risks among young people (under18).You must assess the risks to young people before they start work; 12. poor handling of dangerous items, equipment or tools, due to employees not being properly informed about how things should be done correctly. 13. People should also be matched to their work in terms of health, strength, mental ability and physical stature. 14. Did the workplace layout influence the adverse event? Ergonomics15. Did the nature or shape of the materials influence the adverse event? i.e. weight, sharp edges, hot cold etc.16. Did difficulties using the plant and equipment influence the adverse event? E.g. Poor maintenance 17. Was the safety equipment sufficient?18. Did other conditions influence the adverse event? i.e.. fatigue – not enough rest breaks, working excessive hours, Lack of motivation or boredom? being distracted? being preoccupied, e.g. angry, or excited? being under too much pressure, i.e. too much or too many things to do? too little time? taking substances, such as alcohol, medicines or drugs?

Causal chain

What you are looking for is a Cause or causes.• Something that you have or ought to have control over• Something that someone else had or ought to have control over • Something Which if put in place (or stopped) would have (or could have)

prevented the accident or near miss occurring, Or reduced the likelihood of the event occurring So far as is reasonably practicable.

In other words what you as a manager did or did not do that could have contributed to the event happening and if prevented, been done differently or stopped, the event would not have happened.This is not a blame culture it is taking responsibility, remove causes!

Type of common accidents at work

• Slip, trips and falls. The most common• Falls from height and objects falling from height• Nips, crush & falling against (static object)• Collision with & striking against (Moving Object and machinery)• Ejection from, struck by• Cuts. Lacerations• Manual handling• Dragging in and crushing• Burns• Electrical incidents (Reportable)• Poisoning (Reportable)Some of the most commonest injuries :• Sprains and strains• Back injury • Head injury • Neck injury • Repetitive Strain Injury

Medical attention & first aid

• Was medical treatment required i.e. Ambulance / hospital • Was first aid administered quickly or delayed• Were there any delays, if so record why • Time off from work due to the accident, How long• Were there any known existing medical conditions or disability• Were any reasonable adjustments required in place

And the point is?WAS it their own silly fault or did you as a manager or organisation contribute in any way?• To prevent adverse events, you need to provide effective risk control

measures which address the immediate, underlying and root causes. • Not to attribute blame but to prevent a reoccurrence • Learn lessons and put in place protective measures • Few accidents or near misses can be attributed to ‘own silly fault’ so

don’t prejudge or make assumptions, lessons can’t be learned from these and any reoccurrence may be a whole lot worse.

• If it is found subsequently that you could have prevented the event from happening, this is called Negligence. What you did or didn’t do is called vicarious liability i.e. on behalf of the organisation.