ACCIDENT & INCIDENT INVESTIGATION

Transcription

1 ACCIDENT & INCIDENT INVESTIGATION Course Directors Lyn Harris & Graham Richens

2 Welcome Fire Alarm Meals, Breaks, Toilets Smoking area Mobile Phones Dress Code, Behaviour.

3 Aim To familiarise safety leaders with the principles of Accident & Incident Investigation.

4 Objectives Discuss causes of accidents & incidents Be aware of investigation policies Consider different approaches to investigations Help to prevent reoccurrences Understand reasons & benefits of investigations Gain Experience by Case Studies & Practicals.

5 Brief Introductions Name Branch Board 1 thing you would change in your Force?

6 List 10 causes of accidents in the Police? 1. Lack of Information 2. Lack of Instruction 3. Training 4. Supervision 5. Human Error / Failings 6. Criminality 7. Poor Policies, Procedures, Practices 8. Inadequate Equipment or Resources 9. Tiredness 10. F Factor.

7 Reasons for Investigations? Legal? Criminal Civil Moral Ethical Financial Efficiencies.

8 Legal Reasons For Preventing Accidents Compensation claims in civil courts Out of court settlements Enforcement notices Corporate fines Personal fines Imprisonment. }civil } Criminal 10

9 Benefits of Good Health & Safety Standards accidents injuries sick leave claims costs staff turnover performance productivity morale legal compliance reputation. 11

10 HSE Statistics 2013 Fatalities = 148 Major/Specified = 19,707 Over 7 day = 175,000 (formerly 3 day) Other Injuries = 78,222 Work illness = 1.1 Million Work costs = 13.8 Billion.

11 Police Service Injury & illhealth statistics 2010 Fatal Injuries 2 Major/Specified 777 Over 3 day Total 3 119

12 Cost to Greater Manchester Police Police Officer strength x 250 x 8.5 days = 16,983,000 Support Staff strength x 150 x 9.5 days= 6,203, Officers per 100,000 populous Home Office Statistical Bulletin 30 th September 2008

13 Worst Industries? Agriculture Construction Manufacturing Waste Recycling Services

14 RIDDOR Reportable Outcomes Enforcing Authority to be notified of: Fatalities result of work accident Specified injury Hospitalisation of person Off work over 7 Days Industrial Diseases Dangerous occurrence Form of Report Online Phone Accident Book BL510.

15 Accident & Near Miss Accident = Event that results in injury, ill health or loss Near Miss (HSE) = An event that, while not causing harm, has the potential to cause injury or ill health. h/wid/1_fz9k2t30 Dangerous Occurrence (RIDDOR): If something happens which does not result in a reportable injury, but which could have done, it may be a listed dangerous occurrence

16 What are your Forces investigation policies, procedures, or practices? Does your force investigate Acc s & Near misses? Do they Review Risk Assessments after? Is Reporting Encouraged or Discouraged? Do they seek to Blame, or Learn & Develop? Do they work Together with all Parties? Is there a Positive Health & Safety Culture?.

17 Which events should be investigated? Consider: Potential consequences Likelihood of adverse event recurring Not simply the injury / ill health suffered on this occasion Include Near Misses.

18 Consider different approaches to investigations HSG245 Accident & Incident Investigation Form Protocol for Liaison (Work-related deaths)

19 Help to prevent re-occurrences Immediate Response Inform All Stakeholders Gather & Analyse Information Identify Possible Causes Suitable Risk Control Measures Agree Action Plan & Implementation Monitor & Review.

20 Benefits arising from an investigation? Understanding of how / why things went wrong True snapshot of what really happens, and how work is Actually done Identifies deficiencies in risk control management Prevention of further similar adverse events Prevention of losses Improvement in morale and attitude towards H&S.

21 Accident Investigation In addition, investigation will enable services to: Report certain accidents and dangerous occurrences to the HSE, Reporting Injuries, Diseases & Dangerous Occurrences Reg s 2013 (RIDDOR); Comply with Social Security (Claims and Payments) Reg s Preservation of data about injured persons, Enables claims for industrial disability to be processed.

22 Rights, Wrongs, & Entitlements? 1. What Must the Force do? 2. What should Safety Reps Do / Not do? 3. Accidents Good/Bad Practice? Reg 6-7 Safety Reps & Safety Committees Reg 6 = Inspections after A.I.O.& D s Reg 7 = Provision of Information JBB Circular 30 / 2010 Computer Data.

23 Accident / Incident Investigation, Issues to be covered Circumstances of accident / incident What preventive measures were in place before the accident Breaches of relevant legislation What measures are necessary to prevent recurrence of accident/incident Person(s) who can implement changes.

24 A.I.I. Form Reported by: Date/time of event: Incident Ill Health Minor Injury Serious Injury Major Injury Brief details (What, where, when, who and emergency measures taken): Accident and Incident Investigation Form Overview Ref no:

25 Accident / Incident Investigation Step 1: Gather Information Step 2: Analyse the information Step 3: Identify risk control measures Step 4: Action plan & implementation.

26 Step 1 - Information Gather information Where & When did the event happen Who was injured / involved How did the event happen What activities were being carried out Anything unusual Were safe working procedures foiiowed Injuries / ill-health effects caused.

27 Step 2 - Analysis Should be objective and unbiased Identifies consequence of events that led up to accident / incident Identifies the immediate causes Identifies the underlying & root causes Achieved by asking WHY?.

28 A typical ladder accident

29 Fall from a ladder: what happened and why? John breaks his leg John is on ladder Fall due to gravity John falls off Access to the roof The ladder slips To replace tiles Ladder not secured

30 Immediate and Underlying Causes Underlying causes: organisation and management Immediate causes: personal and job factors

31 Causes Immediate causes Premises, Equipment, Procedures, People Underlying causes Planning, Risk Assessment, Organisation, Attitudes, Morale, monitoring, review.

32 Human failings/factors human failings skill-based errors rule/ knowledge based mistakes slip lapse mistake wrong rule no rule violation rule breaking

33 Attitudes & Behaviours to H&S I have to I should I want to It s automatic I m told I must The company says so It s best for me I just do it

34 Case Study Assault Step 1 - Gather Information Step 2 Analyse.

35 Case Study: Assault John is assaulted John is at his desk Flying monitor John struck by monitor To deal with the public Thrown by assailant He is unprotected His duty Angry man Unsecured monitor Screen removed

36 Step 3 Risk Controls Identify risk control measures missing, inadequate or not used Compare actual conditions/practices with those required by legal requirements, codes of practice and guidance Provide meaningful recommendations that can be implemented.

37 Step 4 Implementation Action Plans with SMARTA objectives Specific, Measurable, Achievable, Relevant, Timescales, Agreed Management, safety professionals, employees & reps should discuss the contents of the action plan Prioritise the implementation of risk control measures, according to risk assessment.

38 Case Study Assault Step 3 - Risk Control Measures Step 4 Action Plan.

39 Case Study: Assault Steps 3 & 4 Fit rising screen to front desk Secure computer monitor to counter Secure chairs in the area Install CCTV camera in front desk area Train receptionists to defuse potentially dangerous situations.

40 HSE References HSG48 - Reducing error and influencing behaviour HSG245 Investigating A&I s HSG65 Successful H&S Management Stat s Police, Security, Law & Order INDG453 Reporting Accidents & Incidents at work.

41 Questions? Safe Journey Home!

42 Happy Ending!