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UNIVERSITY PROCEDURE
ACCIDENT / INCIDENT INVESTIGATION

Document No:

CU/11/AII/P/1.0

Policy Ratified by:

Safety Health and Environment Committee

Date:

July 2011

Area Applicable:

All Cardiff University Staff

Review Year

2013

Impact Assessed

YES

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1.0 Introduction
One of the hardest lessons to be learned in accident prevention comes from the
investigation of accidents and incidents that have caused serious injury or loss.
Facing up to those lessons can be traumatic for all concerned, which is one reason
why investigations are often incomplete. The depth required for an investigation
must be sufficient to obtain information that is of value to line management and
others that may wish make use of the information, such as the University
Occupational Safety, Health and Environment Unit (OSHEU), the University Insurers
or the Health & Safety Executive (HSE).
An effective investigation requires a methodical, structured approach to information
gathering, collation and analysis. The findings of the investigation will form the basis
of an action plan to prevent the accident/incident from happening again, and for
improving the overall management of risk. The findings will also point to areas of the
risk assessment that may need to be reviewed. It has to be remembered that the
link with risk assessment(s) is a legal duty. Conducting an effective accident
investigation can be expensive in time, but the rewards can also be great.
2.0 Investigation of Accidents
2.1 Purpose
The main reason for investigating accidents is prevention. The purpose of the
investigation is to establish whether a reoccurrence can be prevented, or its effects
lessened, by the introduction of additional safeguards, procedures, information
instruction and training, or any combination of these.
2.2 The Procedure
There should be a defined procedure for reviewing or investigating all accidents,
however serious or trivial they may appear to be. The use of a form/checklist will
help to concentrate the attention on the important details.
Line
Managers/Supervisors of the workplace where the accident occurred must complete
the initial investigation; for less serious accidents they may be the only people who
take part in the investigation and reporting procedure. Workers representatives,
senior management, and safety personnel may also be involved at any part of the
process as part of the investigating team.
2.3 Who should carry out the investigation?
Front line managers/supervisory staff should carry out the initial investigation. This
demonstrates commitment and removes any temptation to leave health and safety
to others.

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3.0 Investigation Process

Level

1
Low

1. Consequence of what happened and what

could have happened.

Minor injury/Likely potential outcome no

more than first aid

Local containment of an environmental

incident within area of operation.

2. Investigation Team

Supervisors/line managers

3. Findings and action plan (SMART)

4. Close out

Report any findings on Accident form.

*Safety Representative

Likely potential harm/First Aid or more

Wider containment of an environmental
incident within University.

As level 1
Departmental Safety Officer

*Safety Representative

Record findings as level 1 and also on the Incident

Investigation Form (IIF).
Areas to consider include:

3
High

High adverse effect/Likely consequences

could have been serious injury or fatality.

Wider containment of an environmental

incident. Statutory requirements breached.
Impact outside of the University.

*Safety Representative

Immediate cause
Root cause
Underlying cause
likelihood of reoccurrence and severity of harm
control measures

Record findings as level 1 and also on the Incident

Investigation Form (IIF).

As level 1 & 2
OSHEU

External
HSE/Environment Agency.

Areas to consider include:

Immediate cause
Root cause
Underlying cause
likelihood of reoccurrence and severity of harm
control measures

*Safety representatives may be part of the team as specified in Safety Representatives and Safety Committees Regulations.

Monitor and Review recommendations

2
Medium

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4.0 Carrying out the Investigation

The first steps in any investigation will be to preserve the accident/incident scene,
record the names of the people involved, the equipment involved, and the names of
any witnesses.
Information obtained during investigations is usually given verbally, but may also be
provided in writing. Written documentation should be gathered to provide evidence
of policy or practice followed in the workplace and witnesses should be talked to as
soon as possible after the accident. The injured person should also be interviewed
as soon as is practicable.
Key points to note about investigations are:
events and issues under examination should never be prejudged.
total reliance should not be placed on any one sole source of evidence.
the value of witness statements decreases with time, it is a proven fact that
theorising by witnesses increases as time passes and memory decreases.
try to ensure that you ask open questions.
the first focus of the investigation should be on:
o when
o the exact time and date
o where the building, floor, room, location in room etc.
o to whom name, job title etc.
o and the outcome of the accident/incident injury, property damage etc.
the second focus should be on how and why, giving the immediate cause of
the injury or loss e.g. slipped on spilled substance on floor, and then the
secondary or underlying causes e.g. no procedure for dealing with spillages,
procedure in place but ignored by staff, unsuitable footwear, carry large load
which obscured vision.
the amount of detail required will depend on a) the severity of the injury and/or
property damage and b) the use to be made of the investigation and the
report. The report should be as short as possible and as long as necessary
for its purpose(s).
4.1 Equipment
The following are considered essential basic tools in the competent investigation of
accidents and incidents:

report form, a check-list as a routine prompt for basic questions

notebook or pad of paper
pen

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Specialist equipment, e.g. camera, monitoring equipment, building plans, video

recorder, measuring tape, which should be reasonably long and robust etc. may be
obtained via OSHEU.
4.2 Recording findings and the Investigation Form
An action plan should be put together in light of an Incident. It should be specific and
well defined; measurable in attaining the goal; achievable with stakeholders; realistic
with the availability of resources and time-bound to a reasonably practicable amount
of time (SMART).
For all purposes, the report that emerges from the investigation must provide
answers to the following:
1. What was the:
Immediate cause:

the most obvious reason why an event happens. There

may be more than one immediate cause identified.

Root cause:

an initiating event or failing from which all other causes or

failings spring. Eg. Management, planning, organisational
failings etc.

Underlying cause: the less obvious system or organisational reason for the
accident happening.
Eg. The hazard has not been
adequately considered via a suitable and sufficient risk
assessment, lack of experience or information, instruction
and training.
Impact on the Environment: An incident that caused or had the potential to
cause damage to the environment either via the water
system, atmospheric release or to land contamination
including interference with Flora and Fauna.
2.

What is the likelihood of it happening again?

Certain:
Likely:
Possible:
Unlikely:

it will happen again.

it will probably happen again.
it will possibly happen again.
it is unlikely to happen again.

3. How do we prevent a reoccurrence, what is the necessary corrective action?

4.

If we do not have suitable procedures in place, what new procedures are

either necessary or desirable to prevent a reoccurrence?

5.

If procedures are in place, what reviews are needed of for example

information, instruction and training, the risk assessment or work equipment?

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6.

What realistically could be the result if no action is taken e.g. If the incident
was a near miss what could have been the result?

It is not the task of the investigation report to allocate blame, although some
discussion of this is almost inevitable. Reports are usually discoverable; this means
they can be used by parties in any action for damages. It is a sound policy to
assume that accident investigation reports will be seen by solicitors and experts
acting on behalf of any injured party. They are entitled to see the report and this will
include anything in it that may later prove embarrassing it should never contain
comments on blame.
The report and supporting documentation for serious accidents should contain:
a summary of what happened, with detail of any person(s) injured
a summary of events prior to the accident
information gained during investigation
details of witnesses, and witness statements
information about any injury or loss sustained
conclusions and recommendations
supporting materials (photographs, diagrams to clarify the situation)
relevant policy / procedural documents
relevant risk assessments
training records
the date and signature(s) by the person(s) carrying out the investigation.
Definitions
Accident: An unplanned, uncontrolled event that has resulted in an injury or damage
to property.
Near miss: An unplanned, uncontrolled event that, under slightly different
circumstances, could have resulted in an injury or damage to property.
Serious or Potentially Serious (SoPS) Incidents: Those incidents (injuries, near
misses, vehicle incidents, fire incidents) that did, or had the reasonable potential
to, result in significant and permanent harm to staff, contractors, tenants, users,
visitors at CU sites or for staff while travelling and working on CU business away
from CU sites.
Environmental Incident: An incident that caused or had the potential to cause
damage to the environment either via the water system, atmosphere or to the land
(Flora and Fauna).
RIDDOR Incident: An injury specified in Schedule 1 of RIDDOR 1995.

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E.g. fatality, fractures, amputations or dislocations or where a person has been

admitted to hospital for more than 24 hours.
OR An Incident that is specified in Schedule 2 of RIDDOR 1995. E.g. Failure of a
load bearing part of a crane, explosion or bursting of a pressure system, electrical
failure causing a fire, collapse of a large structure or accidental release of a
biological agent.
OR An injury which, although not a major injury, has resulted in the injured person
being away from work or unable to carry out the full range of his/her duties for more
than seven days (including weekends and rest days but excluding the day of the
accident). Changes in the reporting process to the HSE require three day injuries to
be recorded but not reported to the HSE.
5.0 Further Information
1. HSE Publication - Investigating Accidents and Incidents. A workbook for
employers, unions, safety representatives and safety professionals.