NEBOSH
National Diploma
Part 1
Unit 1A4
Accidents & Ill-health - causation, investigation and prevention: reporting & recording
Accident Causation
* An accident is an unplanned, uncontrolled event
which may cause minor or major injury, disease,
illness, death, damage or other loss, such as delays
incurring production costs *
Accidents can be categorised as follows:
1. No injury - no property damage
2. No injury - property damage
3. Injury - no property damage
4. Injury and property damage
In many organisations only those instances where injury is caused are recorded in the accident book and category 1 or 2 happenings, i.e. incidents, are not recorded and analysed.
Incidents are near misses which have the potential to cause injury and are a source of valuable information for pro-active accident prevention strategies (See 1A5)
Working in groups reflect on the question below calling on your experience of any
jobs you have had.
‘Have there been any accidents/injuries in your workplace (or in your experience
e.g. at home) and what do you think might have caused them or been contributing
factors)
Causes of workplace accidents
Since the turn of the century many people have researched the causes of accidents resulting in a range of accident causation models.
Pure chance theory
This theory treats all accidents as Acts of God and everyone has an equal chance of having an accident. Therefore any steps to prevent accidents are a waste of time.
The biased liability theory
Once a person has had an accident, the probability of the same person having another accident is either decreased (Burned Finger Hypothesis) or increased (Contagion Hypothesis)
Accident proneness theory
The concept that some people are more susceptible to accidents than others has been the subject of much research. However the findings have been inconclusive and therefore accident proneness is not considered to be a significant causative factor in accidents.
The Domino Theory
This was first proposed by Heinrich in 1959 and says that there are five main factors contributing to accidents:
Ø Ø Ø Ø Ø
Social Personal Unsafe act , Accident Injury, damage
Environment Fault omission or near miss
condition
It is called the ‘domino’ theory because once the first stage ‘falls’ the other stages will follow in sequence automatically unless any of the subsequent stages in the process have been removed.
An example of this is as follows:
A worker has developed through his ancestry/upbringing (Social Environment) a negative attitude towards instructions from management (Personal Fault). Despite being told to move a ladder from an unsafe position (Unsafe Omission), he leaves it in position and a passer-by trips over the ladder (Accident) and breaks his arm (Injury).
Heinrich believed that 88% of accidents were caused by unsafe acts of persons, 10% by mechanical or physical conditions and 2% by ‘acts of God’. It followed from this that if the third stage in the process above (unsafe act, omission or condition) was removed, the sequence would be interrupted and the accident/injury prevented.
However the above theory relied on finding someone to blame for the accident and did not take into account management failures.
Updated Domino Theory
Bird and Loftus updated the domino theory of Heinrich to reflect the influence of management in accidents as follows:
Ø Ø Ø Ø Ø
Lack of Unsafe Unsafe acts, Accident Injury, damage
Management underlying omissions near miss
Control causes or conditions
More emphasis was placed on management failure which according to the HSE accounts for at least 75% of accidents. However little emphasis was placed on individual failure and the approach was still basically a single causation approach.
Multicausality theory
There may be more than one cause of an accident and these causes relate to stage three of the domino theories being a series of unsafe acts (or omissions) or conditions. Each of the causes can itself have multiple causes and the process of accident investigation by following each cause back to its roots is sometimes known as fault tree analysis. This is shown diagrammatically below:
Sub causes Ô Unsafe Acts è
ê
Accident Ô Injury/loss
é
Sub causes Ô Unsafe conditions Ô
Each of the sub causes can in turn have many underlying causes of which combine together resulting in an accident.
Some example of unsafe acts/omissions and conditions are shown in the table below:
| Unsafe Acts/Omissions | Unsafe conditions |
|
· operating without authority
· using faulty equipment
· failing to follow manufacturers instructions
· horseplay
· failure to use PPE
· operating at an unsafe speed
|
· inadequate/missing guarding
· poor housekeeping
· defective equipment
· inadequate lighting
· unsuitable/damaged PPE
· trip hazards
· badly maintained equipment
· |
Notes
Look at the following accident report from Julie Green and identify all the underlying unsafe acts/omissions and conditions:
I was late in on the morning of the accident and my supervisor Miss Thomas was quite annoyed with me. She told me to go to the basement and bring up a pack of A3 copy paper for an urgent job. The paper is normally collected by one of the men from the post room and I was not sure whether I would be able to handle it properly. Miss Thomas said that because of the rush job there was no time to get someone else to help me and I would just have to manage on my own. As I was heading towards the basement Miss Thomas said that she needed a full pack of paper and to get a move on. It was a real struggle to get the paper up the stairs and as I tried to man oeuvre through the fire door at the top of the stairs, I stumbled on some loose carpet. The weight of the paper put me off balance and I fell down the stairs and broke my ankle. The loose carpet had been reported at least twice in the last two months and had been identified on the department safety check list but had not been dealt with. At first no one knew what to do as Mary the first-aider was on holiday. Miss Thomas had been promising to get someone else trained up but never did anything about it.
I have only been with the company a few months to earn enough money to start my own business teaching people to dance. My doctor says that my ankle may now not be strong enough to take the strain of the dance routines and I am obviously very upset.
Unsafe Acts/Omissions Unsafe Conditions
Accident ratio studies
Various studies into accident prevention have been carried out and the results have been recording using accident triangles:
e.g. the Bird triangle showed that for every 600 incidents with no injury or damage (near misses) there were 30 property damage accidents, 10 minor injury accidents and 1 serious or disabling injury.
Although the figures vary from study to study the basic underlying principles remain the same i.e. The ‘no injury’ or ‘near misses’ in each case had the potential to become events with more serious consequences.
Not all near misses involve risks which might have caused a more serious accident but all the events do indicate a failure of control.
The near misses at the base of the triangles offer opportunities for preventative action and if action is taken at this level the chances of more serious accidents/injuries will be greatly reduced.
How do you record and analyse near misses in your organisation/
Cost of accidents
The HSE publication ‘The costs to the British economy of work accidents and work-related ill-health’ identifies the net cost to individuals of work related accidents and ill-health of almost £5 billion per year.
The latest British Safety Council survey (1998) found the following:
· Poor safety management costs the country £16 billion per year
· The above equates to £200 per employee
· Three in ten organisations have no health & safety budget
· One third of all organisations said that their managers failed to understand the importance of good health and safety practice
·
£16 billion per year is approximately 2% - 3% of GDP
The HSE publication The costs of accidents at Work [HS(G)96] gave the results of studies into losses suffered by five organisations through accidents and ill-health and the key findings were:
| Organisation | Annualised Loss | Representing |
|
Construction site
Creamery
Oil platform
Hospital
Transport company |
£700,000
£975,336
£3,763,684
£397,140
£195,712 |
8.5% or tender price
1.4% of operating costs
14.2% of potential output
5% of running costs
37% of profits
|
The study also showed that for losses between £8 and £36 only £1 was recoverable through insurance and this resulted in increased premiums.
Notes
The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995
These regulations commonly known as RIDDOR 85 place duties on employers, the self-employed and those in control of work premises.
There is a requirement to appoint a responsible person to report certain injuries, diseases and dangerous occurrences to the HSE or Environmental Health Officer.
The responsible person is normally the injured persons employer.
If sub contractors are involved or there is a multiple-occupancy situation, the question of who is responsible for reporting can be confusing. The key test is that whoever had control at the time of the accident is responsible for the reporting.
On construction sites this will be the main contractor.
The following should be reported under RIDDOR:
· Death of any person within one year as a result of an accident
· A major injury - see list below
· Any injury resulting in more than 24 hours in hospital
· Any specified dangerous occurrence whether or not injury is involved
· Any accident where an employee is away from work for more than three days or is unable to carry out their normal duties for more than three consecutive days
· Any specified disease where the disease can be linked to the employees work
· Injuries resulting from acts of non-consensual violence
In the case of death, major injury or dangerous occurrence the responsible person must inform the enforcing authority (HSE or EHO) by the quickest practicable means e.g. by telephone followed up by a written report on Form F2508 within 10 days.
Major injuries
These include:
· fractures apart from fingers, toes or thumbs
· amputations
· dislocations of hip, knee, spine, shoulder etc
.
· temporary loss of sight
· electric shock or burn requiring resuscitation
· chemical., hot metal or penetrating injury to the eye
· loss of consciousness caused by asphyxia, chemical or biological agents
· any injury leading to hypothermia, heat induced illness or unconsciousness
· any injury requiring hospitalisation for more than 24 hours
For injuries which result in more than three days absence from work or inability to carry out normal duties, only the written report is required.
The three days are calculated as follows:
- Exclude the day of the accident.
- Count the next three days irrespective of whether or not they would have been normal working days.
- If the employee is not back at work on the fourth day, or would not have been capable of working on the fourth day, the accident is reportable under RIDDOR 95.
e.g. If an employee who normally works Monday to Friday has an accident on a
Thursday, Thursday is not counted and the three days are Friday, Saturday and
Sunday. Therefore the employee should be back in work or capable of work on
the following Monday and if not the accident is RIDDOR 95 reportable.
If there is non-consensual physical violence at work resulting in death, serious injury or more than three days absence from normal duties, this is reportable under RIDDOR if it is in connection with work. e.g. if two employees come to blows over who’s turn it is to use the photocopier, this is reportable. However if the same two employees have an argument over who is the best country and western singer, it is not to do with work and is not reportable.
However all acts of violence are potentially criminal assaults and could be the result of police action whether of not they are RIDDOR reportable.
Reportable diseases
For reportable diseases e.g. occupational asthma or dermatitis, the responsible person must report in writing using form F2508A within 10 days. This is only required once a registered medical practitioner has confirmed in writing to the employer that the employee is suffering from the disease and that it was likely to have been caused as a result of the employee’s work.
A full list of reportable diseases can be found in RIDDOR 1995.
All the above reporting procedures apply to employees only.
Notes
Injuries to non-employees
If a member of the public or other visitor to the site suffers an injury and is taken immediately to hospital this is reportable using the above procedure. The method of transport to hospital is not relevant e.g. the person could drive themselves, go by bus or taxi or by ambulance.
Dangerous occurrences
These include such events as:
· collapse of a crane or hoist
· overturning of a fork lift truck
· failure of a pressure system
· a fire/explosion caused by an electrical short circuit
· collapse of scaffold under certain circumstances
· a major gas leak
· collapse of a building
The tunnel collapse at Heathrow Airport when Balfour Beatty were constructing the extension to the Jubilee line was a dangerous occurrence.
Although no injuries were sustained, the cost to the company in fines and costs alone was in excess of £1.2 million before the costs of loss of construction delays and penalty payments were taken into account.
Notes
Social Security
The legislation governing the present social security benefit system is complex and is continually being changed and updated.
The most recent major changes to the system were made by the Social Security (Incapacity for Work) Act 1994 and related regulations which applied to industrial injury benefits from April 1995.
Other relevant legislation includes:
- Social Security (Contributions and Benefits) Act 1992
- Statutory Sick Pay Act 1994
The main forms of benefit currently available to those injured at work (in addition to statutory sick pay) are industrial injuries disablement benefit, constant attendance allowance and exceptionally severe disablement benefit. All these are non taxable unlike statutory sick pay.
To be eligible for industrial injuries benefit, a claimant generally has to show that he or she is suffering from a prescribed disease, that the disease is prescribed for the particular occupation followed and that the disease was caused by the occupation.
The Social Security (Industrial Injuries) (Prescribed Diseases) Regulations 1985 have been amended progressively since their introduction keeping up to date the list of prescribed industrial diseases for which there is an entitlement to benefit for those suffering from the listed disease.
Accident Investigation
The main reason for investigating accidents is to find out the root causes in order to prevent a re-occurrence.
· Accident investigation is not to find someone to blame! *
From an internal point of view an accident investigation will help an organisation to see how and why risks occur. By analysis of accidents trends can be identified and measures put into place to reduce accidents. This is particularly important with near-misses which have yet to result in injury or damage but have the potential to do so.
Thorough investigation and subsequent action will help to reduce costs from lost production, reduce damage payments to employees for injuries, maintain the reputation of the organisation and reduce insurance premiums.
A thorough and open investigation of every accident, followed up by a good and widely distributed report and appropriate action, will demonstrate to all employees that the organisation takes health and safety seriously.
Any of the following people may have an interest in the results of the investigation and therefore all investigations must be well planned and follow a clear procedure bearing in mind their different requirements :
· Managing Director
· Finance Director
· Line Managers
· HRD Staff
· Legal Staff
· Factory Inspector/Environmental Health Officer
· Insurance Company
· Employees involved
· Employees representatives including trade unions
· Family of injured employees
As there may be legal proceedings following an accident and compensation claims if injuries have been sustained, it is important to keep your report confidential until it has been approved for distribution by an authorised person e.g. your line manager.
Procedures
Good practice dictates that all accidents should be investigated but in the case of minor accidents or ‘near misses’ often only a brief report is required for internal analysis. This will ensure that all minor accidents and near misses are tracked, analysed and action taken to prevent more major accidents.
All accidents reportable under RIDDOR must be thoroughly investigated together with any dangerous occurrences even if there have been no injuries.
Those involved in the investigation will depend on the seriousness of the accident. If a member of a trade union is involved in the accident then a recognised trade union representative is entitled to inspect the scene of the accident.
Accident investigation procedure
1. Aim to carry out the investigation as soon as possible after the accident otherwise vital evidence could be destroyed e.g. a machine repaired. Also the memories of witnesses fade as time passes and all witnesses should be interviewed if possible within 24 hours of the event leading to the accident.
2. Obtain as much verbal and written evidence form the witnesses as possible using a tape recorder if necessary. Some witnesses may be reluctant to give information on the grounds that they may be implicated. If this is the case always use a ‘soft’ interviewing technique rather than a threatening formal system. The most important thing is to get the facts and proceedings follow a witness can always be required to appear in court and give evidence.
3. Try and distinguish clearly fact from opinion and make sure that the witness actually witnessed the accident. Many people think that they are a witness when in fact they were only close to the scene e.g. someone walking down the street hears two cars collide and turns round to see what has happened. Seeing the crashed cars they then believe that they have witnessed the accident. They may of course have useful supporting information to give such as weather conditions.
4. Interview the injured person as soon as possible after the accident.
5. Visit the site of the accident and make sketches, take photographs, take measurements and if necessary take steps to ensure that the scene is not disturbed until the initial investigation has been completed.
6. Examine any equipment involved and ask for advice from experts at this stage e.g. maintenance staff.
7. Examine any written company policies, systems of work etc. and check whether or not these had been followed.
8. Checklists can sometimes be useful but the problem with these is that people only tend to check what is on the list.
9. If the accident is reportable under RIDDOR this must be done using form F2508.
Telephone reporting is required in some cases as well.
10. Prepare an interim report and discuss your findings with your line manager making
any additions, adjustments as necessary.
11. Issue your final report to all interested parties. In general accident investigation
reports should be freely available within the organisation.
Notes
Reports should be written in a standard format to enable comparisons with previous reports to be made. The usual structure is as follows:
· A clear title and dates of both the report and the investigation
· Author
· Main recipient
· Circulation List
· Executive summary (for complex reports)
· Introduction giving reasons for report
· Methodology
· Main report
· Conclusions
· Recommendations
· Appendices
All reports should identify the following:
· age, group and sex of victim
· work location
· immediate causes
· root/underlying causes
· hazards
· risks
· nature of injuries/illness
· parts of body injured in detail together with any treatment
· details of machinery/property damage
· any chemical or biological substances involved
· existing control measures
Lessons for risk management will only be learnt through systematic collecting and examining of data relating to accidents and incidents. Accurate data both from internal and external sources can be used to identify trends. This can assist in the measurement of performance and help to direct resources to priority areas.
It is important to involve managers, supervisors, experts etc. in the investigation process. Anyone carrying out an accident investigation will need information, instruction and training in the techniques and should be supervised during the initial investigations to ensure that the techniques are being properly applied.
* Accident investigation is a skill which must be learnt & practised *
Notes
Keeping of records
Copies of all forms F2508, F2508A and F2508G must be kept for at least three years and analysis of these will help to compare the organisations performance with national statistics supplied by the HSE using data from RIDDOR.
The details required are as follows:
- Dangerous occurrences
The date and time of the occurrence.
- Accident suffered by a person at work
- Full name
- Occupation
- Nature of injury
- Accident suffered by a person not at work
- Full name
- Status e.g. customer, visitor, bystander
- Nature of injury
- Place where accident or dangerous occurrence happened.
- A brief description of the circumstances.
- The date when the enforcing authority were informed.
- The method by which the event was reported e.g. by telephone, in writing.
Noise generated by human use of the oceans and
other waterways can be harmful to the marine environment. To help quantify this
noise, and establish appropriate standards for the generation, transmission, and
reception of underwater sound, ISO has formed a new subcommittee, SC 3, within
technical committee ISO/TC 43, Acoustics, devoted to underwater
acoustics.