Investigating Incidents: Level of Investigation

#incident #investigations #accident #events #level of investigation

Which events should be investigated?

All events should be investigated.

For Example:

• Accident.
• Injury accident.
• Damage-only accident.
• Near-miss. (e.g. undesired circumstances, potential or significant NM)
• Dangerous occurrence.
• Work-related ill health.
• LTI (Lost Time Injury)
• MTC (Medical treatment Case)
• etc.

Who Should Investigate?

An investigation team must have competent members (KATES), have detailed knowledge of work activities, and be familiar with H&S good practices, standards, & legal requirements, including report writing ability.

Team members should have investigative skills like information gathering, interviewing, evaluating and analysing  the causes of accidents.

All minor incidents (trivals) can be investigated by the line manager or supervisor.

All major incidents, more complex events, or incidents with high potential are to be investigated by a team.

The team for a high level of investigation may consist of :

• Safety specialists / H&S professionals
• Senior manager / partners or Directors
• Technical specialist.
• Worker representative / Safety Representative / Union Safety safety representative.
• Witnesses / Workers
• Supervisor / Line Manager
• etc.

Before starting the investigation, the organization needs to identify the likelihood criteria and the consequences criteria as per HSG 245.

Level of Investigation

There are four levels of investigation:

1. Minimal level
2. Low-level
3. Medium level
4. High level

1. Minimal level: Immediate line manager/supervisor will look into the circumstances of the accident/incident and try to learn any lessons which will prevent future incidents. ( minimum 1 member required for investigation )

2. Low-level : The investigation will involve a short investigation by the relevant supervisor or line manager into the circumstances and immediate , underlying, and root causes of the accident/incident, to try to prevent a recurrence and to learn any general lessons. ( minimum 1 member required for investigation)

3. Medium Level : The investigation will involve a more detailed investigation by the relevant supervisor or line manager, and the health and safety adviser and employee representatives will look jointly for the immediate, underlying, and root causes. ( minimum 3 members are required for investigation.)

4. High level : a team-based investigation, involving supervisors or line managers, health and safety advisers, and employee representatives. It will be carried out under the supervision of senior management or directors and will look for the immediate, underlying, and root causes. ( minimum 5 members are required for investigation.)

Decide the likelihood that an adverse event will happen again:

1. certain: it will happen again and soon;
2. likely: it will reoccur, but not as an everyday event;
3. possible: it may occur from time to time;
4. unlikely: it is not expected to happen again in the foreseeable future;
5. rare: so unlikely that it is not expected to happen again.

How to apply the likelihood criteria:

Certain: A person wants to cross a very busy road; the person is not following the traffic rules and wants to cross the road during traffic while distracted by his mobile . There is a higher chance that person will collide with any fast moving car/vehicle. So, likelihood is CERTAIN.

Decide Consequences (as per HSG 245)

1. fatal: work-related death;

2. major injury/ill health: This includes, alongwith 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;

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

4. minor injury: all other injuries, where the injured person is unfit for his or her normal work for less than three days;

5. damage only: damage to property, equipment, the environment or production losses. (This guidance only deals with events that have the potential to cause harm to people.)

How to apply the consequence criteria:

It is evident from past historical data, that if any person is hit/collided with any fast moving car/vehicle, it will lead to fatalities or major injuries like multiple fractures, backbone injuries, neck injuries, crushing of body parts, etc.

The accident still did not occur, even though the investigation team should consider / apply the potential worst consequences at the highest level.

So in this example, , the person hit by a fast moving car will die (lead to Fatality).

Decision on level of Investigation:

Refer HSG245, www.hse.gov.uk

Case 1:

By referring to the above images / circumstances / conditions of likelihood and consequences, the following table is to be used:

It is clear that the likelihood of reference is certain (CERTAIN), as there is a busy traffic road and a worker using the mobile while crossing the road.

There are great chances that striking or colliding with a high-speed car / vehicle will lead to fatality (FATAL) in a worst case scenario.

So we draw a horizontal line on certain category and vertical line on fatal category. This lies in RED colour zone.

Further, , RED colour zone is linked to another table below, (as shown by line number 3) . So it can be ascertained that for the above-mentioned case , the investigation level will be at a HIGH LEVEL.

Group Discussion:

1. Who might investigate a minor injury to a worker, that had no real potential to be worse?
2. Who might investigate a major incident?
3. How many levels of investigation exist as per HSG 245.
4. Do likelihood and consequence criteria decide the level of investigation ? ( Ans: Yes / No)