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Conducting investigations, an introduction

Updated: Oct 19, 2023

It can be extremely daunting when something goes wrong, but we should be prepared for when it does, and have a procedure in place that we can rely on when needed. It can be overwhelming and fraught with panic if it is serious in nature, and it is vital we have the right people available with the right training as timing is critical.

When you first have an incident occur, the first few hours are the most important. It is at this time you have the opportunity to gather information, preserve the scene, stop things being moved or disturbed and start building a picture of what could have happened.

It is the training and experience of an accident investigator that is worth its weight in gold here, being able to identify signs, knowing what to check, and starting the process correctly in this all important window.

Do all accidents/incidents need a full investigation?

Not always, no. The level of investigation should be proportionate to the potential severity. A near miss that could have caused a fatality could require deeper investigation than an occurrence that only had caused or could cause minor harm.

How would we know?

As a company in the UK, you have a legal duty to know your obligations. This means you need to be aware of what a hazard, near miss, accident, incident or dangerous occurrence is. You also need to be aware of when something meets the criteria for reporting to the HSE under RIDDOR (Reporting of Incidents and Dangerous Diseases Regulations), as not doing so when required can be classed as an offence and lead to prosecution or hefty fines.

Having someone with accident and investigation training will ensure the causes are correctly determined. If, in investigating an incident the process is not methodical, thorough and without prejudice or personal emotion, then it can lead you down the wrong path in terms of the causes, and thus results in the incorrect remedial action.

Do we need training?

If you don’t have an external competent investigator available to you, then it is a good idea to ensure someone within your organisation undertakes training and it can work particularly well if this person has some underpinning health and safety knowledge.

Chameleon doesn’t currently offer accident and investigation training but many courses can be found online – both virtual and classroom based.

The course syllabus should include investigating in accordance with HSG245, what ‘legal privilege is’ and how to form fact based reports free of emotion or personal opinion.

What do we need to consider in investigations?

Firstly, make sure everyone in the organisation knows what to do and who to contact if something goes wrong.

Do they have a means of reporting hazards? Reporting hazards can prevent near misses or more serious occurrences. Ensuring people report incidents straight away gives you the best chance of preserving the scene where required.

CCTV is a great tool in investigations. People WILL talk, and it isn’t practical most of the time to keep those involved apart so they will corroborate. It is natural human behaviour that we can skew our own memory of what has happened by hearing other versions of events, and it often isn’t malicious.

For example, John drives a forklift truck along an aisle and hits a stack of boxes, which fall onto a warehouse operative, Andy. Simon is in the warehouse at the time and does not see it, and Graham and Danny see it fully.

After it has happened, they all talk about what has happened for some time, naturally with a little animation as they are shocked and surprised by what has happened.

When questioned, Simon gave his account of what happened and he provides a written statement saying he saw it happen and John was ‘clearly speeding’ and ‘not looking where he was going’ when he struck the boxes.

As part of the investigation, the CCTV is checked and Simon is looking in the opposite direction, but this may NOT be falsified information, Simon has merged his memory of events with accounts given by others and genuinely may believe he recalls seeing the incident. Upon playing the CCTV back to Simon, he is shocked that it shows he was unable to see the events happen as he was looking in the opposite direction for the duration.

For instances where you only have a couple of witnesses, or none, CCTV can be especially useful.

Secondly, consider that if it is an occurrence involving injury, people could be in shock. Whilst it may feel essential to get witness statements as soon as possible, this may be counter productive. I was, some time ago, chastised by an HSE investigator for asking for witness statements whilst their memory was very fresh because those involved were shaken and upset. She declined to take statements the same day and returned the next day having allowed them to have a break first.

Preserve your scene, take photos. Determine whether the area needs cordoning off or if work can continue. Isolate any plant or area that is potentially still unsafe.

Ensure your report covers immediate, underlying and root causes (you will know how to do this if you are suitably trained). Getting these right is critical.

Don’t focus on blame. If someone wasn’t following a risk assessment, Why? Have they raised concerns before and been ignored? Were they not wearing PPE because there is poor supply? Or issues that have been reported and ignored? Have you assumed they know the content of the risk assessments but have no evidence they have been distributed? Have you suitably trained employees on the hazards? Is there pressure from a manager to just ‘get the job done’? Or maybe its common occurrence to work against the risk assessment or safe system of work, but the managers are aware and do so too, and it is accepted?

Is plant maintained? Do you have evidence?

Gain facts, documentation and form evidence. Never assume.

Ensure you report it to interested parties – directors, H&S Managers, the HSE or other enforcing authority where there is a duty.

What do we do following the investigation?

One of the biggest reasons for recurrence I see, despite a really good, detailed investigation being undertaken, is that either the actions listed to prevent recurrence are not appropriate (sometimes due to inaccurate identification of causes), or the actions are not followed up. This can be because of messy or missing procedures, lack of management support or resources, poor communication or more.

Ensure that there is a process in place to ensure any actions determined are put in place as soon as possible, and communicate this to those concerned.

Follow up with a review to see if the control measures put in place are effective, or if something else needs changing.

The penalties for having an incident may be fines, prohibition, prosecution, imprisonment… but if you allow the same or similar occurrence to happen twice, they will be much harsher.

For further advice and guidance, or for incident investigation, please feel free to contact us.

Written by: Hayley Tollervey

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