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Work
Instruction 1
Planning
The procedure states that investigations must be planned
to the extent necessary to ensure:
| (1) |
investigations meet the objectives set for them;
|
| (2) |
FOD's
dealings with dutyholders and stakeholders are
professional; and |
| (3) |
HSE
resources are used effectively and efficiently. |
It
goes on to state that:
"Planning will help determine how an investigation
is carried out so as to ensure a structured approach
to its conduct."
It
says that:
"All
investigations will require some planning, but in
the majority of cases not a complex plan. For many
investigations, a simple written plan involving
a few notes in a notebook prior to a visit, may
be useful as a reminder or a prompt."
There
are five 'key activities' - or KAs - concerned with
'planning'. They are:
Key activity 1:
ESTABLISH THE OBJECTIVES OF THE INVESTIGATION
| 2 |
Planning
should begin prior to any site visits, but may
need to be revised in the light of findings which
emerge as an investigation progresses. To facilitate
appropriate planning, discussions may be necessary
with the line manager, so that the objectives
of the investigation can be determined. |
| 3 |
All
investigations must meet the following generic
objectives
| (1) |
identify
immediate and underlying causes; |
| (2) |
ensure the dutyholder takes appropriate
remedial action to prevent reoccurrence; |
| (3) |
evaluate compliance with the relevant statutory
provisions; |
| (4) |
apply
the principles of EMM and take enforcement
action if appropriate. |
|
| 4 |
In
addition, when selecting an incident for investigation,
the line manager may set more specific objectives,
for example, to:
| (1) |
provide a training opportunity; |
| (2) |
gather
intelligence for sectors or other parts
of HSE when new technology is involved or
to increase knowledge of causes of sector-specific
accidents. |
| (3) |
probe
management arrangements for the control
of a specific risk. |
Further
objectives should be recorded in the decision
recording box (DRB). |
| 5 |
Inspectors
and line managers should ensure that they agree
and record on the FOCUS investigation core record
(see FOCUS Data Handbook) the objectives of an
investigation before, or as soon as possible after,
an investigation begins. |
| 6 |
As
an investigation proceeds, inspectors should ensure
that it continues to meet its objectives. Periodic
investigation reviews may be necessary with the
line manager for this purpose. Investigation reviews
should take place, after 2 months and thereafter
at 2-monthly intervals until completed (see Work
instruction 8 Key activity 2). |
| 7 |
The
purpose of such a review is to determine whether
the investigation continues to be proportionate.
If the objectives of an investigation cannot be
achieved without disproportionate effort, consideration
should be given towards aborting the investigation.
'Insufficient evidence of a breach' and 'not in
public interest' are examples of when aborting
an investigation may be justified. The timing
and reasons should be discussed and supported
by a line manager. As a minimum, FOCUS entries
should be used to record any decision to abort
(see Work instruction 9). |
| 8 |
Other
factors to consider when determining the level
of investigation will depend on:
| (1) |
the
patent complexity of the investigation; |
| (2) |
whether
there is prima facie evidence of a breach
of the law such that enforcement action
might be appropriate; |
| (3) |
the
experience of the inspector(s) involved. |
|
| 9 |
Planning should also identify:
| (1) |
the
urgency of HSE's response; |
| (2) |
the relevant FOD health and safety policy
supplement; |
| (3) |
the
logical stages of the investigation and
the activities falling into each; |
| (4) |
any
history of previous advice, enforcement
action or similar incidents involving the
dutyholders identified by, e.g. the incumbent
overview; |
| (5) |
the likelihood of media interest and the
arrangements for handling the media (see
Work instruction 3
Key activity 9); |
| (6) |
the
possible need for a holding position when
the inspector for that area is not available
to visit and attendance on site is needed
to establish physical evidence. The line
manager should
| (a) |
decide
whether another inspector should be
sent, or |
| (b) |
instruct
that the scene should be left undisturbed
until a visit is possible, or |
| (c) |
contact the police on site or the
dutyholder to instruct them to preserve
evidence and take photographs and
measurements. |
|
|
| 10 |
Inspectors
should prioritise their workload to ensure that
they deal with investigations according to their
importance and that of other work, and to reflect
any priorities and time-scales agreed with their
line manager. If greater priorities develop and
the band 2 agrees to cancel the investigation,
then they should complete the decision recording
form (DRF) as detailed in the Incident Selection
Procedure (Work instruction
1, paras 22-23). |
| 11 |
Inspectors should plan other visits round an investigation
in a way that achieves efficiency and economy,
except:
(1) where there is a need for an immediate visit
and such planning is not possible; or
(2) additional visits would create the potential
for unnecessary excessive pressure of work. |
| 12 |
Inspectors
should consider using the investigation as the
basis for a preventive inspection, or conducting
a preventive inspection at the same time as an
investigation, so as to maximise the effect of
the intervention with the dutyholder. |
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Key activity 2
VERIFY THE CURRENT STATUS AND DETAILS OF THE INCIDENT
| 13 |
Before planning can begin it may be necessary
to verify the current status of the incident,
so as to gauge the urgency of HSE's response and
determine the likely resource needed. In some
cases, it may be necessary to clarify or verify
details supplied by the responsible person by
phone and to forewarn them to have relevant documentation
and witnesses available for any forthcoming visit.
Should it become apparent that FOD is not the
correct enforcing authority (EA), the inspector
should forward the incident to the correct EA
and arrange to cancel the investigation core.
Verification of the details can also be important
in providing accurate information to others in
HSE, and to the media. |
| 14 |
Examples of further information which may need
verification include:
| (1) |
the
current status of the incident and whether
or not it has been brought under control
(remember HSE is not an emergency service); |
| (2) |
details of any pressures to clear the site,
and implications for preservation of potential
evidence (e.g. a scaffold collapse in a
city centre at rush hour); |
| (3) |
the exact location of the incident; |
| (4) |
the
identities of any employers, persons in
control of premises etc involved; |
| (5) |
contact
names, telephone and fax numbers; |
| (6) |
the
number of people affected by the incident,
if applicable; |
| (7) |
the status of those affected (i.e. employees,
member of the public, etc); |
| (8) |
the
precise nature of any injuries or ill health
sustained; |
| (9) |
as much detail as possible of the circumstances
(e.g. a fall from the third lift of a six-storey
scaffold, electrocution whilst working on
high-voltage switchgear); |
| (10) |
if possible, clear details of the equipment,
substances or organisms involved (e.g. a
hydraulic press-brake with photoelectric
safeguards, failure of a 2-tonne sling carrying
a 3-tonne load); |
| (11) |
the availability of the injured person (IP),
witnesses and other key staff who might
work shifts; |
| (12) |
whether
documentation relevant to the incident exists
and ensuring it is available during any
site visit, e.g. risk assessments, reports
of thorough examination, permit-to-work
systems, ELCI certificates etc; |
| (13) |
the
availability of any key employer contacts
such as directors, managers, supervisors,
occupational health professionals, contractor'srepresentatives. |
|
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Key activity 3
IDENTIFICATION OF INTERESTED PARTIES
| 15 |
Planning
should include consideration and identification
of the extent and limits of FOD's interests in
the investigation, the legitimate interests and
involvement of external stakeholders, and the
role of the investigating inspector in assisting
and co-operating with those identified. |
| 16 |
In considering and identifying the potential interests
of others in FOD and HSE, see Work
instruction 2 Key activity 2. |
| 17 |
In cases of suspected work-related death, inspectors
in England and Wales should make early contact,
at the planning stage, with the police. In certain
circumstances, inspectors may need to contact
the Crown Prosecution Service as well. See
OC 165/8 Work-related Deaths: Liaison with
the Police and Crown Prosecution Service, and
Enforcement Handbook - England and Wales Chapter
12. In Scotland, in cases of suspected culpable
homicide, the police and the Procurator Fiscal
have a central role, and this will be a central
part of the Procurator Fiscal's review of the
case. Inspectors should co-operate with the Procurator
Fiscal as required. See Enforcement Handbook -
Scotland. See also Work instruction 3
Key activity 8. |
| 18 |
Other
significant stakeholders who may well be involved
at this stage include in England and Wales, HM
Coroner (See Enforcement Handbook - England and
Wales, Chapter 12);
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Key activity 4
IDENTIFICATION OF STAFF COMPETENCIES
| 19 |
Line managers should ensure investigations are
matched to an individual inspector's level of
skill and knowledge. Inspectors conducting investigations
should possess appropriate competencies, achieved
by formal training where necessary. |
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Key activity 5
DIRECTING OR USING INVESTIGATIONS BY DUTYHOLDERS WHERE
APPROPRIATE
| 20 |
Inspectors should consider directing or using
a dutyholder's investigation, where appropriate,
to provide useful initial information to help
with planning prior to any HSE investigation.
Appropriate circumstances include:
| (1) |
complex
incidents where prior knowledge from a dutyholder's
report and/or their external expert's report,
would help focus effort and identify reasonable
lines of enquiry; |
| (2) |
investigation
of blocks of similar category incidents
e.g. slips, manual handling, where common
causes/failures may emerge; |
| (3) |
temporary
unavailability of an investigating inspector
where an early report will record essential
facts thereby avoiding any potential loss
of information; |
| (4) |
situations
where an inspector is familiar with an organisation
and their competence to carry out an effective
investigation providing the inspector confirms
the findings. This may reduce actual investigation
time and resource used. |
|
| 21 |
Inspectors
should refer dutyholders to HS(G)65 Appendix 5
so that immediate and underlying causes are identified.
Any existing investigation should be assessed
against these criteria to establish its worth.
See also Work
instruction 4 Appendix. |
| 22 |
Benefits of using a dutyholder's report include:
| (1) |
encourages ownership in that detailed investigation
may enlighten dutyholder as to causes and
prevention, and enable them to learn from
the experience to improve their management
arrangements; |
| (2) |
provides an impression of the dutyholder's
competence in health and safety matters,
and the extent of their understanding of
legal responsibilities and relevant benchmarks; |
| (3) |
provides an early insight into the dutyholder's
thoughts regarding cause and blame enabling
any potential defence or mitigation to any
subsequent proceedings to be identified. |
|
| 23 |
Inspectors should be aware of the disadvantages
which may include:
| (1) |
unreliable
and inaccurate investigations produced; |
| (2) |
risk that vital evidence will be removed
or disturbed; |
| (3) |
immediate
cause only identified, employees blamed; |
| (4) |
too much focus on severity of injury, potential
largely ignored; |
| (5) |
lack
of line management involvement (investigation
perceived as role of the safety professional); |
| (6) |
inappropriate circumstances when dutyholder
is a relative or close relation to the IP,
e.g. in agriculture; |
| (7) |
too high a burden on dutyholder especially
small employers with no access to expertise
or assistance. |
|
| 24 |
Inspectors
should judge the adequacy of dutyholder's investigation
by ensuring that the dutyholder:
| (1) |
has
identified immediate and underlying causes; |
| (2) |
has
taken or has planned adequate remedial measures
in accordance with reasonably practicable
time-scales (providing dutyholder has removed
the risk of immediate reoccurrence); |
| (3) |
has
adequately addressed hardware and management
issues. |
|
| 25 |
Inspectors should seek to confirm or establish
the credibility of the findings of any dutyholder's
report during the course of their investigation. |
| 26 |
If
inspectors direct a dutyholder to carry out an
investigation, they should ensure that any investigation
is within the dutyholder's capabilities and is
proportionate to the scale of the incident. |
| 27 |
Insurance
companies often require dutyholders to carry out
an investigation and produce a report following
an incident. Inspectors should enquire, when appropriate,
whether such a report exists. Inspectors should
also note that there is a proposed change to the
legislation which would require the dutyholder
to:
| (1) |
carry
out an investigation into any reportable
accident, dangerous occurrence or disease; |
| (2) |
make a record showing that an investigation
has been carried out; and |
| (3) |
inform
any person who has made a relevant risk
assessment of the results. |
This
will enable inspectors to request such information
when appropriate. |
| 28 |
Inspectors
should also be aware that under existing legislation,
recognised safety representatives are entitled
to investigate the cause of an incident and an
employer has a duty to assist. Inspectors should
contact safety representatives, when appropriate,
to enquire whether they have made a report, as
this may be a useful source of information. |
| 29 |
To
qualify as a RIDDOR investigation for OPM purposes,
the investigation should, other than in exceptional
circumstances, include a site visit. Such circumstances
will include situations where it is impossible
to visit the site (e.g. the ship on which an incident
has occurred has sailed) or where it is inappropriate
to visit (e.g. the tower scaffold has been dismantled)
or the site has no material bearing on the incident
(e.g. a breathing apparatus failure). In those
circumstances, the decision as to whether the
enquiries have been sufficiently robust to count
as an investigation will depend upon whether the
criteria in para 30 are met - this decision should
be agreed by the FMU leader. |
| 30 |
The
criteria which must be satisfied are:
| (1) |
the
facts should be clearly established (including
the underlying causes) and verified and,
in particular, the accepted working procedures/standards
prior to the incident should be determined,
if possible confirmed by an employee safety
representative; |
| (2) |
all
reasonable efforts should be made to contact
or interview the IP; |
| (3) |
sufficient information should be obtained
by the investigation to enable the EMM to
be applied to the circumstances of the incident;
and |
| (4) |
where
necessary, steps have been/will be taken
to prevent a recurrence of the incident. |
|
| 31 |
If the FMU leader decides that these criteria
have not been met, the time spent should be recorded
under the main activity 'investigation', but the
investigation should not be classified as a completed
RIDDOR incident investigation on FOCUS. |
| 32 |
See
Enforcement Handbook - England and Wales Chapter
2 para 115 or Enforcement Handbook - Scotland
Chapter 2 para 57 concerning potential legal privilege
of dutyholder investigation reports. |
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