Effective Accident Investigation

“Effective Accident Investigation”

• HSE Inspectors receive approximately 5

solid weeks of classroom training purely on
investigation procedure and techniques in
their first four or five years of service .
• Today, we have approximately 40 minutes…
• I hope to encourage you to think about
some of the main issues to do with
Investigating.
• Feel free to ask questions or challenge what
I’m saying
Effective Accident Investigation

“I keep six honest serving men; they

taught me all I knew; their names are
what and why and when; and how and
where and who.” – Rudyard Kipling:
from “Elephant Child”
Effective Accident Investigation
Six honest, serving men.

Ask yourselves these questions ABOUT

your accident investigation: -
• Why?
• When?
• Where?
• Who?
• What?
• How?
WHY are YOU doing an Accident
Investigation? – 1st Honest Man
Generally people are PAID to do accident
investigations in order to achieve three
key objectives

1) Find out what happened

2) Prevent the accident happening again
3) Report back to your employer on …
Is the reason why I’m doing an
Investigation important?

Yes – All “effective” accident investigations will

split the “find-out-what-happened” objective
in to two DISTINCT phases
1. Information gathering/Evidence collection
2. Analysis

The “Report-back-to-your-employer” objective

can affect how you do the information
gathering and the analysis - prejudice!
Prejudice

• Prejudice will potentially affect your information

gathering and your analysis. This could stop
you from preventing a reoccurrence of the
accident.
• “…as soon as possible in the investigation
procedure determine the root cause of the
accident – this will maximize the efficiency of
the investigation…” – extract from a large
nationwide employer’s investigation policy –
not good!
“Find-out-what-happened”
When, Where and Who?

• When should I investigate? – Mandatory

Investigation? Quality of evidence.
ASAP? Stop dangerous practice.
• Where should I investigate? – Safe
area? Potential Trauma? Preservation
of Evidence?
• Who should investigate? – Training?
Expertise? Prejudice? Experience?
“Find-out-what-happened”
When?
“Find-out-what-happened”
Where?
“Find-out-what-happened”
Who?
“Find-out-what-happened” – WHAT?
Structure – 5th Honest Man

• What am I trying to find out? – Needs a

structured approach!
• For example: HSG65 Appendix 5
• A twelve stage approach to accident
investigation.
• Very thorough
• Might not be appropriate to your
investigation
• Good starting point/Aide Memoir
“Find-out-what-happened” – What?
Structure – Fit for purpose?

• HASAW Act 1974 Section 2(1)

• Safe Place of Work
• Safe Plant and Equipment
• Safe Systems of Work:
• Information
• Instruction
• Training
• Supervision
“Find-out-what-happened” – WHAT?
Information / Facts / Evidence

• Information is defined as facts about a

situation, person or event

• A Fact is something that is known to have

happened or to exist.

• Evidence is one or more reasons for

believing that something is true or not true

• Admissible evidence… No opinion, No

hearsay, no rumour.
“Find-out-what-happened” - HOW?
6th Honest Man

• How should I gather information?

• Physical evidence and analysis –
specialist/expert witness
• Documentary evidence – procedure
• Video / CCTV recordings – “video time”
• Measurements, sketches, photographs
– experience
• Verbal evidence – Statements – training
& experience needed (question sets?)
“Find-out-what-happened”
Verbal Evidence - Statements

• Who do you take statements from?

• Question sets?
• Witnesses who have spoken to other
witnesses or managers – false memory
syndrome.
• Stress/Duress – quality of evidence
• Fit for purpose
“Find-out-what-happened”
Verbal Evidence – Not easy!
.
• “…you did have your headlights on when
you hit him, didn’t you?...”

• Leading questions. False Memory Syndrome

• Any better suggestions?

• Funnelling
“Find-out-what-happened”
Verbal Statements - Funnelling
• TED - “Tell me…Explain…Describe”
• “Tell me about your journey to work…”

• Open Questions – 6 Honest Men

• “when do you use your headlights?”
• Closed Questions – yes/no
• “So on that morning, because it was
raining you had your headlights on?”
“Find-out-what-happened”
Analysis - Schedule of Facts

• What information/facts/evidence do you

have? Where did it come from and how
reliable is it?
• “Miss Scarlet was in the library” –
Confirmed by Professor Plum and
Colonel Mustard.
• Have you pursued all reasonable lines
of enquiry?
“Find-out-what-happened”
ANALYSIS – ECFA, Fault Tree, etc

• What are “all reasonable lines of enquiry”

• Event and Causal Factor Analysis: - (Events,
Conditions, Queries)
• e.g. Finger Amputation in a vertical spindle
moulder.
• Event – Finger comes in to contact with
moving blade.
• What conditions are necessary for this to
occur?
“Stop it happening again”

• If your “find-out-what-happened” objective has

been effectively met then you will probably
already have instigated measures to stop the
accident happening again.
• It is still important to stop at this point and ask
yourself the question “could this happen
again?”
• There can be some of this involved in the
report
“Stop it happening again”
Remedial Actions – Report Part 3

• Accident reports should be in at least

two parts (see next slide).
• YOUR accident reports may well be in
three parts (or more)
• Part 3 – Remedial Actions to prevent a
reoccurrence of this accident and
address any underlying failings in
hardware or software.
• Ownership, Timescales, Circulation
“Report-to-your-employer”
Report – Part 1

• Factual - Present the evidence that you

have collected – no conclusions, no
opinion. E.g. “…the guard was not in
place at the time of the accident…”
“Report-to-your-employer”
Report – Part 2
• Analysis – Present reasoned arguments,
with justification, for what you believe
happened.
• E.g. “The machine was properly guarded
until the injured person removed the front
guard to clear a blockage…three
witnesses remember seeing the IP taking
the guard off on that morning…”
“Report-to-your-employer”
Feedback and Critique

• It is important that your reports and

indeed your investigations are reviewed
by somebody not directly involved with
the investigation.
• Investigation technique is something that
is learnt over a long period of time, there
will always be things that you could have
done better
Effective Accident Investigation
Fit for Purpose

• You had (hopefully) three objectives in

doing this investigation.
• You should have set yourself three
targets at the beginning.
• Have you achieved those targets?
• Are there any remaining lines of
inquiry?
Any Questions?