Module Title: Safety Engineering: © Teesside University 2011

MODULE TITLE : SAFETY ENGINEERING
TOPIC TITLE : THE CHARACTER AND TREATMENT OF

HAZARDS
LESSON 7 : INCIDENT INVESTIGATION AND REPORTING
SE - 2 - 7
Teesside University 2011

Published by Teesside University Open Learning (Engineering)
School of Science & Engineering
Teesside University
Tees Valley, UK
TS1 3BA
+44 (0)1642 342740
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1
________________________________________________________________________________________
INTRODUCTION
________________________________________________________________________________________
This lesson concludes the subject of Topic 2 (The Character and Treatment of
Hazards) but links closely with our final topic dealing with safety protective
measures. Accidents and incidents, much as they need to be avoided, play an
important rle in the measurement of safety performance, but it is important to
first gain an understanding of how they are caused and to appreciate that a
reporting procedure should be common to all types of incident within a given
organisation. The purpose and form of workplace monitoring methods can
only be satisfied by setting standards which, in turn, emanate from dealing
with unscheduled events and are continually reviewed as a result of the
experience thereby gained.
________________________________________________________________________________________
YOUR AIMS
________________________________________________________________________________________
At the end of this lesson you should be able to:
describe the learning process underlying incident occurrence and the

means of avoiding or minimising repetition
outline the statutory reporting requirements for incidents
understand the need for developing a procedural format specific to

each workplace
demonstrate knowledge of the recorded information typical of

competent investigations of events causing loss of and damage to
people and property.
Teesside University Open Learning Teesside University 2011

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________________________________________________________________________________________
MOTIVATION AND INFORMATION FEEDBACK

________________________________________________________________________________________
In a previous lesson, which dealt with the legal aspects of health and safety in
the workplace, we referred to the written policy statement required of all
employers. This statement implies that monitoring must be an essential
ingredient of any approved measures adopted to apply the policy meaningfully.
Such monitoring provides the most useful guidance base for dealing with and
learning from untoward incidents on a specific site.
Additionally, from what has been learned from 'hazard analysis', four useful
parameters for reducing incident propensity emerge.
Reduce or eliminate the risk to the general public and/or reduce the
risk to employees, e.g. by appropriate choice of site, or by reducing
the magnitude of the consequences or, with regard to employees, by
containment such as fire walls and blast walls.
Reduce the predicted hazard rate by reducing the frequencies of the

potential causes of the incident by tackling these causes at source
(e.g. put the standby pump on autostart instead of manual if
circulation pump failure is potentially hazardous).
Reduce the predicted hazard rate by improving the chance of

remedial operator action as the potentially hazardous condition is
developing (e.g. by installing additional instrumentation or alarms
and/or by improved operator training).
Reduce the predicted hazard rate by installing additional protective

systems and/or improving the reliability of existing ones (e.g. by
providing duplicate control loops or by more frequent testing).

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However, there are very wide differences not only in the quality of
implementation of objectives such as these but also in the quality of incident
investigation and hence in the benefits derived therefrom.
THE LEARNING CHALLENGE OF SOME INDUSTRIAL SYSTEMS
In most systems, there are also other weaknesses which impede learning from
incidents, particularly in understanding the nature of the accident process itself.
An accident normally occurs only when a number of conditions are fulfilled. If
some of these conditions are not met there may be an incident or "near miss".
Fortunately, the ratio of near misses to accidents is very high, as evidenced in
civil aviation practice which stipulates the reporting of "near misses". Process
plants have the inherent problem, usually proportional to their complexity, of
allowing very little opportunity for learning gradually by trial and error. This is
precisely why it is necessary, at the outset, to try to eliminate failures or reduce
hazards to predictable levels. Attention needs to be focussed on the weaknesses
within a system, a proportion of which will result in an accident. Many
accidents display repetitive factors which are familiar to the engineering
professions and, since it is impossible and unnecessary for those responsible to
maintain an incisive awareness of all incident scenarios, widely accepted
methods of monitoring, such as check lists and safety audits, embrace, in most
readily usable forms, much of what is required to be known.
The learning process, therefore, demands two principal means of obtaining

information:
1. accident/incident reporting and investigation
2. making sure that the results of report analyses are utilised to up-date
working and safety practices.

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However, although it is desirable that discussions on safety matters are held at

both local and national levels, many industrial concerns, particularly those
with the potential to transmit important and relevant information, are reluctant
to publicise their experiences because of feared damage to their public image
and prejudice to their customers' interests.
________________________________________________________________________________________
INCIDENT REPORTING
________________________________________________________________________________________
LEGAL REQUIREMENTS
Of a large number of statutory reporting requirements covering a very wide

range of industrial circumstances, the main ones are contained in those
measures (particularly in the Factories Act of 1961) listed in an earlier lesson.
Since 1995 another piece of legislation in this regard has been added to the
Health and Safety cannon called The Reporting of Injuries, Diseases and
Dangerous Occurrences Regulations 1995 (RIDDOR). This places a legal
duty on:
employers
self-employed people
people in control of premises
to report work-related deaths, major injuries or over-three-day injuries, work

related diseases and dangerous occurrences (near miss incidents).
More specifically, an employer is required to report:
(a) any accident which causes death or which results in disablement

necessitating more than three days absence from a person's regular job

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(b) certain dangerous occurrences whether or not anyone is injured
(c) certain industrial diseases
(d) use of certain substances and equipment (e.g. blue asbestos, radiation
sources).
The second requirement, (b) above, is expanded in earlier legislation which is

now incorporated in the 1974 HASAW etc. Act, e.g.
(i) bursting of mechanically-driven equipment such as mixers and

grindstones
(ii) failure or overturning of lifting equipment or electrical short circuit
(iii) fire or explosion due to gas, vapour or dust which renders a

workplace unsafe
(iv) explosion or collapse of a pipeline or a pressurised receiver

containing air or gas.
Precautions against accidents are also stressed in the Chemical Works

Regulations of 1922 which represent the application of the general approach
taken in the various Factories Acts to the chemical industry.

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However, the CIMAH Regulations (Control of Industrial Major Accident

Hazards) of 1984 and COMAH (Control of Major Accident Hazards 1997
Ammended 2005) Regulations reflect the growing stringency of care and
oversight which is progressively extending throughout all industrial
occupations. In addition to requirements already stipulated, these measures
demand information upon:
(a) the circumstances of an accident
(b) the effects of an accident upon persons and the environment
(c) the emergency measures taken
(d) steps proposed for alleviating medium or long-term effects and to

prevent recurrence
(e) plans to be followed in the event of a major incident.
INDUSTRIAL LAW
Industrial law is a combination of common law and statute law; we have

surveyed the most relevant parts of the latter but common law also prescribes
certain obligations, such as a general duty of care by an employer for an
employee, which can be challenged in a civil action. "The categories of
negligence are never closed" is an adage always to be respected and, when
carrying out reporting procedures, this aspect of responsibility calls for highly
judicious regard, particularly if technical competence reasonably expected of a
profession or skill is being questioned. In essence, one faces the "challenge of
perception" (discussed in an earlier lesson) because liability also depends upon
the foreseeability of a hazard.

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EU DIRECTIVES
As we move towards a totally integrated European Union, pressure to unify the

respective legislative provisions of member states is imposing even higher
standards on our industrial practices. EU Directives relevant to safety and loss
prevention are covering areas which have not previously figured prominently
in a legal liability context in the U.K. These include, for example, the
packaging and labelling of dangerous substances (COSHH Control of
Substances Hazardous to Health 2002), waste disposal, pollution and
common provisions for methods of inspecting pressure vessels.
COMPANY PRACTICE
Bearing in mind these statutory reporting requirements (not forgetting the

implications of common law practice) each organisation should set and
establish its own level at which the investigation and reporting procedures
come into operation. It should define incidents which need to be notified into
the following categories:
1. personal injury accidents

2. plant/property damage incidents
3. dangerous occurrences
4. near-misses.
Also, within these categories with an added benefit of increasing knowledge

additional classification might well follow a technical pattern (depending
upon the class of business carried on), e.g.
leaks of flammable materials

leaks of toxic substances
pump, gland and joint failures resulting in leaks and/or fires
burner malfunctions

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storage tank faults

failure of protective devices, e.g. vents, relief valves and trips
all incidents involving human error.
________________________________________________________________________________________
INVESTIGATION PROCEDURES
________________________________________________________________________________________
WHAT IS AN INVESTIGATION SEEKING?
Its aims are to:
collect data relating to the event
check the validity of the evidence
select evidence pertinent to the investigation objective
analyse the evidence without making assumptions
decide the most likely (or possible) causes
notify, as soon as practicable, those responsible for taking necessary

corrective action
record faithfully all findings and consequences
publicise the event to all personnel, however remotely related to the

event.

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ACCIDENT INVESTIGATION TRAINING
The ability to satisfy these needs is now a widely-appreciated training

function; even the need for better report writing is gaining credibility in many
areas of industrial activity. Hence, if only to determine an appropriate level of
competence, certain questions need to be answered.
(a) Who will investigate which events?
(b) Will the investigators act as individuals or teams?
(c) Is individual or team status related to event severity?
(d) What qualifications (from first-aider to company safety manager) are

required?
(e) Will the attendance of a legal representative (e.g. company solicitor)

be required?
Regrettably, search for truth and unbiased input is an ever-present challenge

largely brought about by the necessary interfaces between management, trade
unions, workforce representatives and the legal process. The superimposition
of training for improved competence cannot affect all parties equally; a great
proportion of the responsibility for impartial assessment should lie with a
company's safety representatives and the safety committee, a structure
provided for under the 1974 Act, and it is these personnel for whom
investigative guidance proves most beneficial.

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ACTION PLAN FOR TEAM INVESTIGATIONS
The qualifications needed by the members of an investigation team include:
technical knowledge
objectivity (This is usually very difficult to maintain; good

chairmanship is essential.)
inquisitiveness
knowledge of the job, process or operation
tactful communicating manner
intellectual honesty
an analytical approach to problems.
Management should adopt a written action plan for team investigations. The
plan should provide for:
identification of the individual who is in charge and assignment of

responsibilities
authority to conduct the investigation
prompt notification of team members that specifies when and where

they should report
instructions on the personal protective clothing or special equipment

to be worn or brought to the scene

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provisions for a work area and administrative support
transportation and communication, if needed
securing the accident site for the duration of the investigation after
rescue and damage control are complete
provision for access of the team members to the accident site
photographic support or capability
procedures and equipment to ensure the observation and recording of

fragile, perishable or transient evidence (for example, instrument
readings, control panel settings, weather and other environmental
conditions, chemical spills, stains, skid marks)
development of a comprehensive report.
SELECTING CORRECTIVE ACTIONS
Most investigations will suggest several recommended corrective actions.

Some are bound to be more effective than others and some are bound to be
more costly than others. Factors that usually influence the selection include:
effectiveness
cost
feasibility
effect on productivity
time required to implement
extent of supervision required
acceptance by employees
acceptance by management.
Corrective actions that best fulfil these criteria offer optimum possibilities for
reducing risk.

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________________________________________________________________________________________
DOCUMENTATION
________________________________________________________________________________________
In the appendices to this lesson there is an example of a comprehensive

accident investigation questionnaire (Appendix 1). Some of the points
contained therein relate to safety monitoring methods which we have yet to
consider.
Also attached are specimen report forms for
Injury (Appendix 2)
Minor accident (Appendix 3)
Major accident (Appendix 4)
Fire (Appendix 5)
together with definitions covering personal injury, disease, notifiable

occurrences and accident statistics (Appendix 6).
The Health and Safety Executive continually monitors national accident and
ill-health data and conducts ad hoc studies, using the information it obtains to
help formulate policy on future legislation, produce advice for industry,
identify problems and assist in determining the allocation of its resources
across the range of health, safety and welfare issues.
The Self-Assessment Question which follows is different from others which

you have previously attempted. Its purpose is to prove that it is not always
easy to establish the facts and that very often we fall into the trap of making
false assumptions.

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13
________________________________________________________________________________________
SAQ: ACCIDENT AND INCIDENT INVESTIGATION AND REPORTING

________________________________________________________________________________________
Read the story below. You have 10 minutes to record, in the space provided against
each statement, whether you think it is "True", "False", or you "Don't Know".
(Mark with an X.) Check your score at the end. How many in each column?
A businessman had just turned off the lights in the store when a man
appeared and demanded money. The owner opened a cash register. The
contents of the cash register were scooped up and the man sped away. A
member of the police force was notified promptly.
Statements about the Story DON'T

TRUE FALSE
KNOW
1. A man appeared after the owner had turned off his store lights.
2. The robber was a man.
3. The man who appeared did not demand money.
4. The man who opened the cash register was the owner.
5. The store-owner scooped up the contents of the cash register and ran
away.
6. Someone opened a cash register.
7. After the man who demanded the money scooped up the contents to the
cash register, he ran away.
8. While the cash register contained money, the story does not state how
much.
9. The robber demanded money from the owner.
10. The robber opened the cash register.
11. After the store lights were turned off a man appeared.
12. The robber did not take the money with him.
13. The robber did not demand money from the owner.
14. The owner opened a cash register.
15. The age of the store-owner was not revealed in the story.
16. Taking the contents of the cash register with him, the man ran out of the
store.
17. The story concerns a series of events in which only three persons are
referred to: the owner of the store, a man who demanded money, and a
member of the police force.
18. The following events were included in the story: someone demanded
money, a cash register was opened, its contents were scooped up, and a
man dashed out of the store.
TOTAL

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________________________________________________________________________________________
ANSWERS TO SELF-ASSESSMENT QUESTION

________________________________________________________________________________________
DON'T
TRUE FALSE
KNOW
1. X
2. X
3. X Your own score may be very different and
4. X
you may now want to reconsider. You may
5. X
not agree with some of the "don't knows" but
6. X
at least the exercise demonstrates the
7. X problem of establishing the facts of an
8. X incident, e.g. who did what and in which
9. X order, and was the man who turned off the
10. X lights the owner of the store? Also, was the
11. X
owner a man and can we be certain that the
12. X
13. X cash register actually contained cash? Only
14. X about a third of the statements are actually
15. X true.
16. X
17. X
18. X

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________________________________________________________________________________________
SUMMARY
________________________________________________________________________________________
This lesson has dealt with incident investigation and reporting.
We have now completed the second topic of this course by considering the
'software' of hazards, i.e. human reliability in terms of responsibility for
hardware integrity and human vulnerability with respect to involvement with
unplanned events. You have also been given practical guidance for dealing
with incidents and for improving the safety record of a working environment.
In the next lesson we will consider a number of ways in which protective and
preventive measures can be devised and maintained on industrial sites.

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________________________________________________________________________________________
APPENDIX 1 EXAMPLES OF AN ACCIDENT INVESTIGATION

QUESTIONNAIRE
________________________________________________________________________________________
People Duties
1. Was the person concerned carrying out a task that was part
of his/her normal duties? YES/NO
IF NO, STATE:
What was abnormal or different? ................................................

.....................................................................................................
2. Was the task within Job Specification/Description of the

person concerned? YES/NO
IF NO, STATE:
(a) In what way was it outside Job Specification or

Description? .........................................................................
.............................................................................................
(b) Who should have carried out the task? ................................
.............................................................................................
(c) Why should that person perform the task? .........................
.............................................................................................
3. Was the person involved in an activity associated with work

but not directly related to a task? YES/NO
If YES, STATE:
The activity in which the person was engaged............................

.....................................................................................................

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People Supervision
4. Was the person's immediate supervisor present in the area

at the time of the accident? YES/NO
IF NO, STATE:
(a) The location of the supervisor at the time............................

.............................................................................................
(b) Any instructions given by the supervisor prior to leaving
the area .................................................................................
.............................................................................................
5. Was the accident reported immediately and to whom? YES/NO

.....................................................................................................
IF NO, STATE:
(a) Why was there a delay? .......................................................

.............................................................................................
(b) How long was the delay? .....................................................
.............................................................................................
People Information
6. Was the person concerned specifically warned of the hazards of

the task? YES/NO
IF NO, STATE:
(a) Were the hazards known at all? ...........................................

.............................................................................................
(b) Who knew them? .................................................................
.............................................................................................
.............................................................................................

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People Instruction
7. Was the person concerned instructed to carry out the

particular task/job? YES/NO
IF NO, STATE:
(a) Why was the task undertaken?.............................................

.............................................................................................
(b) Was there a change in intention? If so, state reason for
change ..................................................................................
.............................................................................................
.............................................................................................
(c) Was the task/activity part of a total job?
.............................................................................................
8. Had the person concerned been given written or verbal

instruction in the general hazards associated with the task/
job? YES/NO
IF YES, STATE:
(a) Method of instruction and when given ................................

.............................................................................................
(b) Outline the instruction given................................................
.............................................................................................
9. Was the work carried out according to instruction or normal

practice? YES/NO
IF NO, STATE:
In what way was the task carried out different to normal practice?
.....................................................................................................
.....................................................................................................
.....................................................................................................

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People Training
10. Was the task/job within the capability of the person concerned? YES/NO
IF NO, STATE:
(a) What additional training was required? ...............................

.............................................................................................
.............................................................................................
(b) What additional experience was required? ..........................
.............................................................................................
.............................................................................................
11. Was the person concerned familiar with type of plant/equipment,

tools, etc? YES/NO
IF NO, STATE:
What knowledge/skill was lacking?............................................

.....................................................................................................
.....................................................................................................
12. Had the person concerned been trained to carry out the task/job
safely? YES/NO
IF YES, STATE:
What training had been given?....................................................

.....................................................................................................
.....................................................................................................
13. Was the task/job carried out by prescribed method? YES/NO

IF NO, STATE:
What was the difference between the prescribed method and

the method used?.........................................................................
.....................................................................................................

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People Protection
14. Was the specified protective clothing being worn? YES/NO

IF NO, STATE:
Was it reasonable to wear protective clothing?

.....................................................................................................
.....................................................................................................
.....................................................................................................
15. Was protective clothing/equipment adequate to deal with the

hazard? YES/NO
IF NO, STATE:
Was protective clothing/equipment available?............................

.....................................................................................................
.....................................................................................................
Miscellaneous
16. Were any of the person's senses listed below obscured/nullified

which could have been a contributory factor? YES/NO
SIGHT
HEARING
SMELL
TASTE
TOUCH
IF YES, STATE WHICH ............................................................
17. List the names of others that might assist in this investigation.
.....................................................................................................
.....................................................................................................

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Plant/Equipment/Premises
Describe plant and equipment and/or premises together with

sketch, photos, etc., and attach.
18. Were plant/equipment/premises in normal condition? YES/NO

IF NO, STATE:
What modifications or alterations had been made?

.....................................................................................................
.....................................................................................................
.....................................................................................................
19. Were means for controlling emergency conditions, e.g.

emergency stops, located near to hand? YES/NO
IF NO, STATE:
Would such controls have reduced the consequences

or eliminated the accident?..........................................................
.....................................................................................................
20. Were guards, protective devices effective and/or secure? YES/NO

IF NO, STATE:
In what way was the guarding of the machine/plant insecure

or ineffective?..............................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................

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21. Were warning notices displayed, warning persons of hazards or

to use protective equipment, clothing etc? YES/NO
IF YES, STATE:
Type and content of notice ..........................................................

.....................................................................................................
.....................................................................................................
.....................................................................................................
22. Were operating controls, pipelines, tanks, etc., clearly marked? YES/NO
IF NO, STATE:
(a) Reasons not clearly marked? ...............................................

.............................................................................................
.............................................................................................
(b) What additional markings, etc., could be made?
.............................................................................................
.............................................................................................
.............................................................................................
23. Was there unobstructed access/egress to and from location? YES/NO

IF NO, STATE:
Cause of blockage or restriction..................................................

.....................................................................................................
.....................................................................................................
.....................................................................................................
24. Was there any failure of service, component, plant or machinery? YES/NO
IF YES,
Outline circumstances leading up to failure and consequences

.....................................................................................................
.....................................................................................................
.....................................................................................................

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Systems
25. Are procedures/instructions laid down for the task/job? YES/NO

IF NO, STATE:
What procedures could be laid down? ........................................

.....................................................................................................
.....................................................................................................
.....................................................................................................
26. Is there a system for monitoring that procedures/instructions

are followed? YES/NO
IF NO, STATE:
What method of monitoring could be used to ensure that

the procedures are followed?.......................................................
.....................................................................................................
.....................................................................................................
27. Is there an accepted safe method for carrying out the task/job? YES/NO
IF NO, STATE:
What method could be devised that would eliminate or reduce

accident potential?.......................................................................
.....................................................................................................
.....................................................................................................
28. Are procedures laid down for warning personnel of the hazards
of the task/job? YES/NO
IF NO, STATE:
What recommendations could be made to improve this

situation? .....................................................................................
.....................................................................................................
.....................................................................................................

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29. Are "permits-to-work"/"clearance-certificates" normally issued

for this type of work? YES/NO
IF NO, STATE:
Why are they not used? ..............................................................

.....................................................................................................
.....................................................................................................
.....................................................................................................
30. Was a "permit-to-work" issued? YES/NO

IF NO, STATE:
Why was a permit not issued? ....................................................

.....................................................................................................
.....................................................................................................
.....................................................................................................
31. Were "permit-to-work" conditions being followed? YES/NO

IF NO, STATE:
What conditions were not being followed? ................................

.....................................................................................................
.....................................................................................................
.....................................................................................................

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Environment
32. Did any of the following environmental factors contribute to the

accident? If yes, tick and state conditional factors. YES/NO
e.g. rain snow

ice fog
sun heat
cold humidity
fumes gas
vapour noise
restricted space
poor surface
radiation
Conditional factors ......................................................................

.....................................................................................................
.....................................................................................................
.....................................................................................................

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________________________________________________________________________________________
APPENDIX 2 EXAMPLE OF AN INJURY REPORT FORM

________________________________________________________________________________________
To be completed by the person rendering assistance
LOST TIME ACCIDENT NON LOST TIME ACCIDENT Please tick
1. PERSONAL DETAILS OF INJURED PERSON
SURNAME ......................................... FORENAME (S)........................................

HOME ADDRESS.....................................................................................................
....................................................................................................................................
AGE................. SEX ................. CLOCK NO ................. DEPT ........................
EMPLOYEE CONTRACTOR VISITOR OTHER
NAME OF SUPERVISOR OR ADDRESS OF EMPLOYER IF NON-COMPANY

EMPLOYEE
....................................................................................................................................
2. INJURIES
NATURE OF INJURIES............................................................................................
....................................................................................................................................
NATURE OF TREATMENT .....................................................................................
TREATED BY ...........................................................................................................

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3. THE INJURED PERSON WAS:
RETURNED TRANSFERRED TO OTHER WORK

TO WORK
SENT RETURNED TO WORK FROM HOSPITAL

HOME
SENT TO DETAINED IN HOSPITAL

HOSPITAL
4. INJURED PERSON'S DESCRIPTION OF ACCIDENT AND LOCATION

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
ACCIDENT/DATE....................................... TIME ................................................
TREATMENT DATE ................................... TIME ................................................
SIGNATURE OF PERSON RENDERING ASSISTANCE ......................................
5. FURTHER INVESTIGATION IS/IS NOT REQUIRED

SIGNATURE OF SUPERVISOR......................................... DATE .......................
SIGNATURE OF SAFETY REPRESENTATIVE.....................................................
DATE..........................................................................................................................

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________________________________________________________________________________________
APPENDIX 3 EXAMPLE OF A MINOR ACCIDENT REPORT

________________________________________________________________________________________
1. CLASSIFICATION OF ACCIDENT (TICK APPROPRIATE BOXES)
INJURY DAMAGE FIRE HAZARD
2. DESCRIPTION OF ACCIDENT AND LOCATION

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
NAMES OF INJURED PERSONS (IF ANY)...........................................................
(ATTACH COPIES OF INJURY REPORTS) ...........................................................
3. RECOMMENDATIONS TO REDUCE ACCIDENT POTENTIAL

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
SIGNATURE AND STATUS OF INVESTIGATORS
............................................... ............................................... DATE / /
............................................... ............................................... DATE / /
............................................... ............................................... DATE / /
4. COMMENTS BY DEPARTMENTAL MANAGER AND ACTION TAKEN

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
SIGNATURE..................................................... DATE ...........................................

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________________________________________________________________________________________
APPENDIX 4 EXAMPLE OF A MAJOR ACCIDENT INVESTIGATION

________________________________________________________________________________________
1. CLASSIFICATION OF ACCIDENT (TICK APPROPRIATE BOXES)
INJURY DAMAGE FIRE HAZARD
2. INVESTIGATION
DATE AND TIME OF INVESTIGATION................................................................

NAMES AND STATUS OF INVESTIGATING TEAM ...........................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
DATE AND TIME OF ACCIDENT..........................................................................
COMPLETE ACCIDENT INVESTIGATION QUESTIONNAIRE AND ATTACH

COPIES OF INJURY REPORT FORMS.
3. FINDINGS OF INVESTIGATION TEAM
3.1 TEAM'S DESCRIPTION OF EVENTS LEADING UP TO THE ACCIDENT

..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
3.2 TEAM'S DESCRIPTION OF THE ACCIDENT ITSELF

..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................

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3.3 TEAM'S VIEWS ON THE CAUSES OF THE ACCIDENT

..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
4. RECOMMENDATIONS TO REDUCE ACCIDENT POTENTIAL

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
5. ACCIDENT RECORDING AND BY WHOM
ACCIDENT BOOK BI5IO* BY ................................ DATE..................................

GENERAL REGISTER BY ....................................... DATE..................................
FORM F43 H & S INSPECTORATE
BY ..................................... DATE..................................
6. SAFETY ADVISER'S COMMENTS

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
SIGNATURE..............................................................................................................
7. WORKS MANAGER: COMMENTS AND ACTIONS TO BE TAKEN OR

RECOMMENDATIONS TO HIGHER AUTHORITY
.............................................................................................................
.............................................................................................................
.............................................................................................................
.............................................................................................................
.............................................................................................................
SIGNATURE..............................................................................................................
*This replaced by a new book in 2003 with an ISBN of 0717626032

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________________________________________________________________________________________
APPENDIX 5 EXAMPLE OF A FIRE REPORT

________________________________________________________________________________________
1. WHERE DID IT START?
WORKS............................................................. PLANT ........................................

LOCATION OF FIRE ................................................................................................
2. WHEN DID IT START?
DATE OF FIRE ............................................ TIME FIRE DISCOVERED ............

TIME ALARM SOUNDED ......................... TIME OF IGNITION .......................
TIME FIRE WAS OUT ................................
FIRE BRIGADE CALLED AT............. ARRIVED AT............ LEFT AT ...........
3. WHO PUT IT OUT?
PLANT PERSONNEL WORKS FIRE TEAM
FIRE BRIGADE OTHER (PLEASE STATE)

..................................................................
4. HOW WAS IT EXTINGUISHED?
HOSE REELS PORTABLE WATER FOAM

EXTINGUISHERS EXTINGUISHER
DRY POWDER CO2 WATER

EXTINGUISHER EXTINGUISHER SPRINKLER
SYSTEM

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5. WHAT STARTED THE FIRE (IF KNOWN)?
ELECTRICAL SPARKS FROM SMOKING

FAULT WELDING
HOT SURFACE FRICTION OPEN FLAME
HOT ASH OTHER SPARKS NOT KNOWN
ANY OTHER DETAILS ...........................................................................................

....................................................................................................................................
....................................................................................................................................
6. WHAT WAS BURNING?
MATERIAL FIRST IGNITED ..................................................................................
THIS MATERIAL WAS PRESENT BECAUSE OF:
LEAKAGE SPILLAGE HOUSEKEEPING
OTHER REASON (PLEASE STATE) ......................................................................

....................................................................................................................................

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7. WHAT DAMAGE WAS DONE?
LIST PEOPLE INJURED .....................................................................................

(Attach copies of .....................................................................................
Injury Reports.) .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
TO PLANT AND .....................................................................................
BUILDING .....................................................................................
(Attach accident report .....................................................................................
forms.) .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
REPORTED BY .....................................................................................
.....................................................................................

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________________________________________________________________________________________
APPENDIX 6 DEFINITIONS
________________________________________________________________________________________
1. Industrial Accident
Any unplanned unwanted event that could interrupt an activity or

function: such an accident may lead to injury to persons and/or damage to
plant or equipment.
2. Industrial Injury is when an injury occurs as a result of an industrial

accident, in most cases at a definite point in time, and, as a general rule,
means injuries whilst on duty or when on the company's premises.
2.1 Notifiable Accident/Injury
Accidents causing loss of life, or disabling a worker for more than

3 days from earning full wages at the work at which he or she was
employed, must be reported forthwith to the Inspector and entered
into the general Register.
2.2 Lost-time Accident/Injury
Within the Chemical Industries Association a lost-time accident is

defined as "when a person receives an industrial injury and as a
consequence is unable to attend work at the start of the next normal
work period ................; time lost on the day of the accident or shift
does not count".

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2.3 Alternate Work Accidents/Injury
Those accidents which result in injury or partial incapacity but do not

cause absence from work: the injured person's capacity to carry on in
normal work is impaired but he or she is able to undertake other
suitable work.
2.4 "Minor" Industrial Injury
Where the result of an accident is minor injury requiring first-aid

treatment or similar medical attention but does not cause absence
from work or affect the person's capacity to carry out the work being
done prior to the accident.
2.5 Unreported Injuries
Employees will have, on occasions, industrial accidents where the

resulting injuries are not reported. One of the main reasons for this is
that the person is unaware of the injury at the time or regards it as
insignificant and not worth reporting. Subsequently, the injury (e.g.
sprains, strains, minor cuts) becomes worse and it is at this stage that
it is reported. If, subsequently, the person loses time and is unable to
continue working at the work for which he or she is employed, then
the accident must be classified as above (in Section 2.1 2.4).
2.6 Hernias and Sprain Injuries
Hernias, strains and sprains which do not result from industrial

accidents should not be regarded as industrial injuries. There is no
doubt that there are some incidents where such injuries occur at a
definite point in time but the effects are not always obvious. It is
then difficult to establish that there has been a concrete happening. A

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36
strain, sprain or hernia should therefore be classed as an industrial

injury if, after full investigation, there is reasonable cause to suppose
that the injury was the result of an industrial accident although the
actual point of time may not be established.
2.7 Tenosynovitis Injuries
Tenosynovitis exists in two forms, the most common form being that
which is due to constant repetition of a stereotype movement
(repetitive strain injury RSI). In this form it should be considered
as an industrial disease.
A less common form is that which may follow a blow, e.g. by a

hammer, to the tendon sheath above the wrist. In this form it should
be recognised as an industrial injury.
3. Diseases
Under various regulations there is a need to report and/or record diseases

associated with industrial occupations. In general these diseases fall into
three categories:
3.1 Notifiable Industrial Disease
A "notifiable industrial disease" is one of a list of diseases monitored

by the Health and Safety Executive. Each case must be notified and
accepted by the Health and Safety Executive to be classified as such.
Some examples of industrial diseases are lead, arsenic or mercury
poisoning.

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3.2 Prescribed Disease
A "prescribed" disease means a disease prescribed in regulations

made by the Secretary of State, Department of Health. These
diseases are prescribed only in relation to insured persons, and only
in particular occupations or classes of occupation, e.g. industrial
deafness in the fettling industry.
3.3 Occupational Diseases
An occupational disease covers diseases not normally covered in

paragraphs 3.2 and 3.3 but which arise due to the nature of
employment.
4. Notifiable Dangerous Occurrences (Factory Act 1961)
These are listed on the reverse side of the official form issued by the
Department of Employment. The following are officially recognised as
dangerous occurrences:
4.1 Bursting of a revolving vessel, wheel, grindstone or grinding wheel

moved by mechanical power.
4.2 Collapse or failure of a crane, derrick, winch, hoist or other appliance

used in raising or lowering persons or goods (except the breakage of
chain, rope or slings), or the overturning of a crane.
4.3 Explosion or fire causing damage to the structure of any room or place
in which persons are employed or to any machine or part contained
therein and resulting in the complete suspension of ordinary work in
such a room or place or stopping of machinery or plant for not less
than five hours. Where such explosion or fire is due to:

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38
(i) the ignition of dust or gas or vapour

(ii) the ignition of celluloid or substances composed wholly or in
part of celluloid.
4.4 Electrical short-circuit or failure of electrical machinery, plant or

apparatus attended by explosion or fire or causing structural damage
thereto and involving its stoppage or disuse for not less than 5 hours.
4.5 Explosion or fire affecting any room in which persons have been
employed and causing complete suppression of ordinary work therein
for not less than 24 hours.
4.6 Explosion of a receiver or container used for the storage at a pressure

greater than atmospheric pressure of any gas or gases (including air)
or any liquid or solid resulting from the compression of gas.
5. Reportable Dangerous Occurrences (Near Misses) RIDDOR 1995
If something happens which does not result in a reportable injury, but

which clearly could have done, then it may be a dangerous occurrence
which must be reported immediately.
Reportable dangerous occurrences are:
Collapse, overturning or failure of load-bearing parts of lifts and

lifting equipment;
Explosion, collapse or bursting of any closed vessel or associated

pipework;
Failure of any freight container in any of its load-bearing parts;

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39
Plant or equipment coming into contact with overhead power lines;
Electrical short circuit or overload causing fire or explosion;
Any unintentional explosion, misfire, failure of demolition to cause

the intended collapse, projection of material beyond a site boundary,
injury caused by an explosion;
Accidental release of a biological agent likely to cause severe human

illness;
Failure of industrial radiography or irradiation equipment to de-

energise or return to its safe position after the intended exposure
period;
Malfunction of breathing apparatus while in use or during testing

immediately before use;
Failure or endangering of diving equipment, the trapping of a diver,

an explosion near a diver, or an uncontrolled ascent;
Collapse or partial collapse of a scaffold over five metres high, or

erected near water where there could be a risk of drowning after a
fall;
Collision of a train with any vehicle;
Dangerous occurrence at a well (other than a water well);
Dangerous occurrence at a pipeline;

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40
Failure of any load-bearing fairground equipment, or derailment or

unintended collision of cars or trains;
A road tanker carrying a dangerous substance overturns, suffers

serious damage, catches fire or the substance is released;
A dangerous substance being conveyed by road is involved in a fire

or released;
The following dangerous occurrences are reportable except in

relation to offshore workplaces: unintended collapse of any building
or structure under construction, alteration or demolition where over
five tonnes of material falls; a wall or floor in a place of work; any
false-work;
Explosion or fire causing suspension of normal work for over

24 hours;
Sudden, uncontrolled release in a building of: 100 kg or more of

flammable liquid; 10 kg of flammable liquid above its boiling point;
10 kg or more of flammable gas; or of 500 kg of these substances if
the release is in the open air;
Accidental release of any substance which may damage health.
Additional categories of dangerous occurrences apply to mines, quarries,

relevant transport systems (railways, etc.) and offshore workplaces. Detailed
information is provided in the relevant schedules to the regulations and the
Guide to RIDDOR.

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6. Serious Incident
This is an occasion when an unexpected mishap occurs and all the

essentials are there for an industrial accident with a potential for serious
industrial injury but where no one is injured. For example:
6.1 Lifting Devices
Failure of a lift, crane or hoist including the means of suspending the

load including the suspension fittings and certain parts of freight
containers.
6.2 Scaffolds
Collapse or overturning or failure which could result in injury to

persons employed or to members of the public.
6.3 Excavations
Collapses that take place without causing injury to persons.
6.4 Constructional Demolition
The collapse or partial collapse of buildings or structures under

construction or demolition.
6.5 Pressure Vessels and Systems
Failure of such systems of a substantial nature.
6.6 Flammable Materials
Large-scale release of flammable liquids or gases and/or fires in

process materials.

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6.7 Toxic Materials
Any uncovenanted release of toxic materials.
6.8 Electrical
Incident where electrical faults resulted in fire and explosion.
7. Accident Statistics
Numerous ways have been developed to measure safety performance.

The most frequently used are:
7.1 Lost Time Accident Frequency Rate (L.T.A.)
No. of L.T.A. 100 000 hours

The L.T.A. Frequency Rate =
Man hours worked in period
7.2 Incidence Rate
No. of L.T.A. 100 000

The Incidence Rate =
Average No. of employees during the period
Note:
The definition of lost time accidents must be determined, for

comparison purposes, within a company. The average time worked
per employee must remain constant if incidence rates are to be
meaningful.

(Engineering)

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MODULE TITLE : SAFETY ENGINEERING

TOPIC TITLE : THE CHARACTER AND TREATMENT OF

LESSON 7 : INCIDENT INVESTIGATION AND REPORTING

Teesside University 2011

All rights reserved. No part of this publication may be reproduced, stored in a

At the end of this lesson you should be able to:

describe the learning process underlying incident occurrence and the

outline the statutory reporting requirements for incidents

understand the need for developing a procedural format specific to

demonstrate knowledge of the recorded information typical of

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MOTIVATION AND INFORMATION FEEDBACK

Reduce the predicted hazard rate by reducing the frequencies of the

Reduce the predicted hazard rate by improving the chance of

Reduce the predicted hazard rate by installing additional protective

Teesside University Open Learning Teesside University 2011

THE LEARNING CHALLENGE OF SOME INDUSTRIAL SYSTEMS

The learning process, therefore, demands two principal means of obtaining

1. accident/incident reporting and investigation

Teesside University Open Learning Teesside University 2011

However, although it is desirable that discussions on safety matters are held at

Of a large number of statutory reporting requirements covering a very wide

to report work-related deaths, major injuries or over-three-day injuries, work

More specifically, an employer is required to report:

(a) any accident which causes death or which results in disablement

Teesside University Open Learning Teesside University 2011

(b) certain dangerous occurrences whether or not anyone is injured

(c) certain industrial diseases

The second requirement, (b) above, is expanded in earlier legislation which is

(i) bursting of mechanically-driven equipment such as mixers and

(ii) failure or overturning of lifting equipment or electrical short circuit

(iii) fire or explosion due to gas, vapour or dust which renders a

(iv) explosion or collapse of a pipeline or a pressurised receiver

Precautions against accidents are also stressed in the Chemical Works

Teesside University Open Learning Teesside University 2011

However, the CIMAH Regulations (Control of Industrial Major Accident

(a) the circumstances of an accident

(b) the effects of an accident upon persons and the environment

(c) the emergency measures taken

(d) steps proposed for alleviating medium or long-term effects and to

(e) plans to be followed in the event of a major incident.

Industrial law is a combination of common law and statute law; we have

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As we move towards a totally integrated European Union, pressure to unify the

Bearing in mind these statutory reporting requirements (not forgetting the

1. personal injury accidents

Also, within these categories with an added benefit of increasing knowledge

leaks of flammable materials

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storage tank faults

WHAT IS AN INVESTIGATION SEEKING?

Its aims are to:

collect data relating to the event

check the validity of the evidence

select evidence pertinent to the investigation objective

analyse the evidence without making assumptions

decide the most likely (or possible) causes

notify, as soon as practicable, those responsible for taking necessary

record faithfully all findings and consequences

publicise the event to all personnel, however remotely related to the

Teesside University Open Learning Teesside University 2011

ACCIDENT INVESTIGATION TRAINING

The ability to satisfy these needs is now a widely-appreciated training