| PURPOSE
AND SCOPE |
| 1 |
The
purpose of the procedure is to ensure investigations
are conducted and reported on in accordance with
FOD policy. The principles apply across FOD. However,
it is recognised that there are significant differences
between the legal systems of Scotland, and England
and Wales. Whenever possible, these are identified
in the text, but if additional interpretation
of legal matters is required then inspectors should
consult the relevant enforcement handbook. |
| 2 |
During
all investigations, inspectors must:
| (1) |
consider
all stages in the investigation process
and conduct the investigation in accordance
with the work instructions (WIs) and key
activities (KAs) required by the particular
circumstances of the incident being investigated.
Each stage of the investigation is documented
as a WI. The KAs which may be required during
each stage are identified within each WI; |
| (2) |
achieve
the performance standards relevant to each
required stage of the procedure; |
| (3) |
be
able to demonstrate that they have considered
all stages and used those required by the
particular circumstances. |
|
| 3 |
Investigations
will not always follow precisely the stage-by-stage
process illustrated in Figure 1. Investigation
is an iterative, not a linear process: it may
be necessary to revisit earlier stages in the
process. For example
| (1) |
after
interviewing (WI 5, the objectives under
planning could change requiring WI 1 to
be revisited; |
| (2) |
when
assessing the evidence (WI 8) it may be
identified that there is a need to re-interview
witnesses (WI 5). |
|
| 4 |
Many
of the actions will be carried out together and
at the same visit. |
| 5 |
The
principles of EMM apply throughout the procedure.
The arrangements for the systematic monitoring
of the procedure mirror those for EMM. Key performance
standards are identified for the purposes of systematic
monitoring (see Appendix 1) |
| 6
|
The
procedure applies to the investigation of all
types of incidents. It documents the core investigation
process. Inspectors should apply the relevant
supplementary procedure when conducting investigations
on the topics below:
| (1)
|
major
incidents (as defined in OC 75/1); |
| (2) |
FOD
QS procedure - Complaints Investigation
(in preparation) |
| (3) |
incidents
involving pesticides where there has been
no report o a poisoning under Regulation
5(1) RIDDOR 1995 (see OC 301/9; |
| (4) |
FOD
QS procedure - Gas Investigation (in preparation); |
| (5) |
statutory
notifications of overexposure, release,
spillage, loss or theft made under the Ionising
Radiations Regulations 1999 (OC 560 series). |
|
| POLICY |
| 7
|
It
is FOD policy that investigations will be conducted
in accordance with the principles of proportionality,
consistency, targeting, transparency and accountability.
In particular, investigations will be:
| (1) |
continued
only so far as they are proportionate to
the achievement of the objectives set for
them (see para 2 below); |
| (2) |
conducted
and/or supervised by staff with suitable
and relevant experience, training and expertise;
|
| (3) |
provided
with adequate resources and support, including
information, equipment and staffing; |
| (4) |
conducted
so that efficient and effective use is made
of the resources committed to them; |
| (5) |
timely,
so far as this is within the control of
the investigating inspector(s); |
| (6) |
subject
to suitable management procedures for monitoring
the conduct and outcome of investigations; |
| (7)
|
conducted
in accordance with FOD's obligations under
Service First; and |
| (8) |
conducted
in conformity with the FOD Quality System
procedure |
|
| 8 |
The following factors will be relevant in determining
whether an investigation continues to be proportionate:
| (1) |
public
expectation, for example, where there has
been a fatality or fatalities, serious ill
health, or an incident involving multiple
serious injuries; |
| (2) |
the
potential (taking account of reasonable
foreseeability) for a repetition of the
circumstances to result in a fatality or
fatalities, serious ill health, or serious
injuries, either in the activities of a
specific dutyholder or within industry generally; |
| (3) |
the
extent to which the available evidence allows
conclusions as to causation to be drawn
and supported with sufficient certainty,
including conclusions as to responsibility
for alleged breaches of relevant legislation; |
| (4)
|
the
value to HSE of the information to be gathered
by the investigation, for example where
new technology is involved; |
| (5) |
the
extent to which the resources needed for
the investigation are disproportionate to
the hazard(s) or risk(s); |
| (6)
|
the
extent to which the continuation of any
investigation conflicts with the developing
priorities within a FOD division; and;(7)
the prevalence of the event, either in the
activities under the control of a specific
dutyholder, or in an industry sector generally. |
|
| |
DEFINITIONS |
| 9 |
Incident: includes events reportable under RIDDOR
such as accidents dangerous occurrence and cases
of industrial disease. (Purpose and scope defines
circumstances where other procedures apply.) |
| 10 |
Benchmark: the acceptable levels of risk determined
by standards enforceable in law. |
| 11 |
Evidence: information obtained in a legal enquiry
to establish a fact or a point in dispute which
must be admissible in court. |
| 12 |
Investigation: the process of enquiring into the
direct and contributory causes of an event with
a view to HSE deciding on appropriate action. |
| 13 |
Work instruction: this explains in more detail
how to carry out the relevant part of the procedure. |
| 14 |
CPI Act: Criminal Procedures and Investigations
Act 1996. Parts I and II cover criminal investigations,
and the retention and disclosure of prosecution
material. OC 168/4 and OC 168/5 give practical
guidance on provisions relevant to this procedure.
In Scotland, separate legislation applies. |
| 15 |
Dutyholder: an individual, body corporate or unincorporated,
with duties under the HSW Act, other relevant
statutory provisions, or other primary legislation. |
| 16 |
Employee representatives: employees appointed
under The Safety Representatives and Safety Committees
Regulations 1977 or an elected representative
under the Health and Safety (Consultation with
Employees) Regulations 1996 - both sets of regulations
are in file 111. |
| 17 |
Expert help: individuals with knowledge and experience
greater than an inspector in relation to an investigation
who can offer help in determining the circumstances,
causes and relevant benchmarks. Expert help can
be provided by SG, TD, EMAS, HSL, external experts
or more experienced colleagues. |
| 18 |
PACE: Police and Criminal Evidence Act 1984. Inspectors
in England and Wales are required to have regard
to the Codes of Practice (file 168) made under
PACE when collecting evidence in support of potential
prosecutions. Further guidance on questioning
suspects (Code C) or tape-recording interviews
(Code E) is in the Enforcement Handbook - England
and Wales Chapter 2. In Scotland, separate legislation
applies. |
| |
METHOD |
| 19 |
The following are the separate work instructions
(WIs) of the investigation procedure. They are
listed in the table in this paragraph, represented
by Figure 1 and are broken down into a number
of key activities (KAs) which describe how each
part is to be carried out. The circumstances of
the investigation will determine which KAs are
needed. If relevant, then the inspector should
apply all the work instructions appropriate to
the investigation being undertaken.
| WI
1 |
Planning |
| WI
2 |
Preparation |
| WI
3 |
Conduct
and liaison |
| WI
4 |
Establishing
circumstances |
| WI
5 |
Interviewing |
| WI
6 |
Establishing
physical evidence |
| WI
7 |
Gathering
intelligence |
| WI
8 |
Assessment
of evidence |
| WI
9 |
FOCUS
recording and preparation of further reports
|
|
| 20 |
Planning (WI 1): 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. |
|
| 21 |
Planning will help determine how an investigation
is carried out so as to ensure a structured approach
to its conduct. The key activities of planning
are:
| (1) |
establish
the objectives of the investigation (KA
1); |
| (2) |
verify
the current status and details of the incident
(KA 2); |
| (3) |
identification
of interested parties (KA 3); |
| (4) |
identification
of staff competencies (KA 4); |
| (5) |
directing
or using investigations by dutyholders where
appropriate (KA 5). |
|
| 22 |
Preparation (WI 2): Before an investigation commences
inspectors must prepare as far as possible to
ensure that they carry it out effectively, efficiently
and safely. This includes obtaining adequate information,
any necessary equipment, and ensuring that lines
of communication have been established and necessary
support has been secured. The key activities of
preparation are set out in WI 2:
| (1) |
identify
relevant legal requirements, standards,
guidance and policy to enable benchmarks
to be established (KA 1); |
| (2) |
liaison,
if appropriate, within FOD and HSE (KA 2); |
| (3) |
consultation,
if appropriate, with expert help and other
support (KA 3); |
| (4) |
obtaining
necessary equipment (KA 4); |
| (5) |
communications
and briefing colleagues (KA 5). |
|
| 23 |
Conduct and liaison (WI 3): All contacts made
during an investigation should be conducted in
accordance with the HSE Board Statement on Openness
and should meet the standards of the Government's
Service First initiative. In particular, inspectors
should:
| (1)
|
meet
the standards set out in HSE34 The Health
and Safety Executive and You (file 35) and
HSE35 The Health and Safety Executive -
Working with Employers (file 80); |
| (2) |
provide
a copy of HSE and You After an Accident
(HSEEW010 in England and Wales, and HSESC020
in Scotland); |
| (3) |
treat
all people fairly; respect their privacy
and dignity; be helpful and courteous; and
pay particular attention to those with special
needs. |
|
| 24 |
Factors to consider are set out in these key activities
within WI 3:
| (1) |
conduct
of initial on-site enquiries (KA 1); |
| (2) |
contact
on site with dutyholders and their representatives
(KA 2); |
| (3) |
contact
with those affected and witnesses (KA 3) |
| (4) |
contact
with bereaved relatives (KA 4); |
| (5) |
contact
with employees' representatives (KA 5) |
| (6) |
contact
with solicitors representing those involved
(KA 6); |
| (7) |
contact
with members of the public, including pressure
groups (KA 7); |
| (8) |
liaison
with outside agencies (KA 8); |
| (9) |
contact
with the media (KA 9); |
| (10) |
recording
information (KA 10). |
;
;
|
| |
25
Establishing circumstances (WI 4): Inspectors
must collect sufficient information and potential
evidence to ensure the given objectives of the
investigation are achieved. This will enable:
(1) identification of immediate and underlying
causes;
(2) identification of potential breaches of the
law;
(3) inspectors to ensure appropriate remedial
action has been taken to prevent a reoccurrence;
(4) identification of reasonable lines of enquiry;
(5) the making of decisions about appropriate
action or further investigation;
(6) HSE to gain knowledge of the causes of incidents. |
| |
26
Establishing circumstances will involve reference
to the following KAs: (1) on-site investigation
methods (KA 1);
(2) the identification and follow-up of all reasonable
lines of enquiry (KA 2). |
| |
27
Interviewing (WI 5): (During an investigation,
inspectors should, whenever possible and if enforcement
action is likely, formalise interviews by taking
statements at the same visit.) The following KAs
within WI 5 provide guidance on: (1) preparation
for interviews (KA 1);
(2) who to interview and in what order (KA 2);
(3) the general conduct and structure of interviews
(KA 3);
(4) note taking and recording of interviews (KA
4);
(5) use of police interviews (KA 5);
(6) arrangements for joint interviews with other
enforcing authorities (KA 6). |
| |
28
Establishing physical evidence (WI 6): Inspectors
should establish the physical evidence necessary
to help determine the circumstances of an investigation.
The following KAs within WI 6 provide guidance
on: (1) identification and preservation of evidence
(KA 1);
(2) recording factual details (KA 2);
(3) recreation of the circumstances at the time
of the incident (KA 3);
(4) liaison with and use of evidence collected
by the police (KA 4). |
| |
29
Gathering intelligence (WI 7): Inspectors should
ensure that relevant information gathered during
the investigation, which may be of use to others
is properly disseminated within the organisation.
The following KAs within WI 7 provide guidance
on: (1) information of interest to sectors and
other parts of HSE (KA 1);
(2) SAPIDs (KA 2). |
| |
30
Assessment of evidence (WI 8): This involves:
(1) reviewing the information and evidence collected
to date to determine whether any conclusions drawn
are supported by the information and evidence
and are robust;
(2) determining the value, quality and reliability
of information and evidence collected so far;
(3) cross-reference to the original objectives
of the investigation to ensure they have been
achieved;
(4) determining whether further investigation
is needed to achieve the objectives and/or to
further establish the circumstances;
(5) applying the principles of EMM to decide on
any appropriate enforcement action;
(6) enabling decisions to be made about stopping
the investigation because the objectives have
been achieved or further investigation is disproportionate
in accordance with the examples given in the investigation
policy. |
| |
31
The following KAs within WI 8 provide guidance
on: (1) assessment and verification of information
and evidence obtained (KA 1);
(2) investigation review (KA 2);
(3) informal review (KA 3);
(4) application of EMM (KA 4). |
| |
32
Inspectors should also refer to the appropriate
parts of the Enforcement Handbook - England and
Wales, and the Enforcement Handbook - Scotland
for guidance concerning taking statements and
taking physical evidence. The Handbooks also contain
information concerning liaison with and use of
expert evidence which may be relevant to the investigation
process. |
| |
33
FOCUS recording and preparation of further reports
(WI 9): Inspectors should complete the relevant
FOCUS entries in accordance with current instructions
and guidance. In addition, other reports may be
required. |
| |
34
The following KAs within WI 9 provide guidance
on: (1) FOCUS recording (KA 1);
(2) preparation of further reports (KA 2). |
| ROLES AND RESPONSIBILITIES |
| |
35 The DFO/FODMB should ensure sufficient
resources are available throughout FOD to operate
the investigation procedure. |
| |
36 The divisional director should
provide sufficient resources to enable inspectors
to carry out investigations in accordance with
this procedure. |
| |
37 The head of operations should:
(1) assist with difficult cases when necessary;
(2) monitor the quality of a sample of investigations
conducted by band 2s; and
(3) review the monitoring undertaken by band 2s
at least annually. |
| |
38 The FMU band 2s are responsible
for: (1) allocating resources once an incident
is selected for investigation;
(2) ensuring their band 3 and 4 inspectors apply
the procedure and achieve performance standards
which are appropriate to the circumstances of
an investigation; and
(3) carrying out monitoring as set out in performance
standards and monitoring arrangements. |
| |
39 Band 3 and 4 inspectors should
apply the investigation procedure to all investigation
work and ensure they achieve relevant performance
standards. |
| |
PERFORMANCE STANDARDS AND MONITORING ARRANGEMENTS |
| |
40 The tables in Appendix 1 list
the performance standards for the investigation
procedure. They are the measures which are used
to judge whether the procedure is being followed
and their achievement will demonstrate the rigour
and effectiveness of investigative effort. |
| |
41 Inspectors should give appropriate
consideration to and achieve all performance standards
which are relevant to an investigation. Appendix
1 lists the KAs of each work instruction which
are associated with most of the performance standards.
Inspectors should carry out the relevant actions
listed in these KAs. If a performance standard
is not relevant or appropriate to an investigation,
then inspectors need not give further consideration
to that performance standard and its associated
KA. If inspectors are unable to follow the procedure
then they should discuss and record the reasons
for this with their line manager. |
| |
42 Two forms of monitoring will
be undertaken: (1) systematic monitoring of all
fatal accidents, prosecutions and band 4 investigations;
and
(2) a sample of other investigations to be undertaken
by the line manager during the first half and
in the second half of the work year. |
| |
43 The investigations sampled should
be the same as those selected under the sample
monitoring arrangements for EMM. |
| |
44 Appendix 2 lists the arrangements
for the systematic monitoring of investigations.
Under such arrangements, the key performance standards
highlighted in bold in Appendix 1, will be monitored.
These key performance standards constitute the
critical elements of the investigation procedure. |
| |
45 Line managers will carry out
monitoring as defined by the table in Appendix
2 once an investigation is complete and prior
to any decision to prosecute. The monitoring arrangements
column in Appendix 1 is where they obtain the
evidence to determine whether the necessary performance
standards have been met. Investigating inspectors
will submit this evidence to their line manager
(as is current practice), with investigation/prosecution
reports, including associated FOCUS entries (see
WI 9). Discussions between line manager and inspector
may be necessary as part of the monitoring process.
They should record any significant discussions
or decisions made following such a meeting. |
| |
46 For investigations not subject
to the monitoring arrangements illustrated by
Appendix 2, the investigating inspector does not
have to submit the necessary evidence associated
with the key performance standards to their line
manager. Inspectors should record investigations
in accordance with existing practice (see WI 9).
Where FOCUS reports alone will not provide sufficient
detail, for example if the investigation is particularly
complex or liable to external scrutiny, an inspector
should provide the level of reporting as detailed
in WI 9, KA 2. This will demonstrate their achievement
of the appropriate performance standards prior
to any decisions on action. |
| |
47 When monitoring in accordance
with Appendix 2 has been carried out, a keyword
ÎINVAPPâ (upper case) should be recorded
on the FOCUS investigation summary record. |
| |
APPENDIX 1
(paras 40, 41, 44, 45) |
| |
WI 1 - PLANNING
Relevant Key Activity
PERFORMANCE STANDARD
(to be met by investigating inspector)
Monitoring arrangements (to be conducted by line
manager)
1 Establish the objectives of the investigation.
Discussions with line manager.
1 Ensure a timely conduct of the investigation
(2 months). FOCUS entries.
1 Allocate sufficient resources to ensure the
expected objectives can be achieved. Discussions
with line manager.
1 Ensure the investigation complies with the HSE
investigation policy, ie proportionality etc.
Discussions with line manager.
2 Verify the current status and details of the
incident where appropriate.
3 Identify and contact interested parties where
appropriate. Discussions with line manager.
4 Ensure inspector's competence and experience
are suitable for the investigation. Discussions
with line manager.
5 Direct or use an investigation by a dutyholder
where appropriate. FOCUS entries. |
| |
WI 2 - PREPARATION
Relevant Key Activity
PERFORMANCE STANDARD (to be met by investigating
inspector)
Monitoring arrangements (to be conducted by line
manager)
1 Identify relevant benchmarks before the investigation
begins, or as soon as possible after the investigation
commences. FOCUS entries.
2 Liaise, if appropriate, within FOD and HSE.
3 Consider whether expert help is required. SG
Request, discussions with line manager.
4 Obtain all necessary equipment.
5 Communicate with and brief colleagues when appropriate.
|
| |
WI 3 - CONDUCT AND LIAISON
Relevant Key Activity
PERFORMANCE STANDARD (to be met by investigating
inspector)
Monitoring arrangements (to be conducted by line
manager)
1 Commence enquiry within 2 weeks of receipt of
F 2508. Date of initial notification form or 2508
and FOCUS entries.
2 Contact dutyholders and their representatives
as soon after arrival on site as possible. FOCUS
entries.
3 Contact those affected and witnesses as soon
as practicable once investigation begins and about
the outcome. FOCUS entries.
4 Contact bereaved relatives as soon as possible
following notification of incident. FOCUS entries,
letter with MISC199/MISC200 form enclosed.
5 Contact employees' representatives as soon after
arrival on site as possible. FOCUS entries.
8 Liase with outside agencies but particularly
the police following a fatal(s) if manslaughter
or culpable homicide may be suspected. Discussions
with line manager.
10 Record information. FOCUS entries, notebook,
statements. |
| |
WI 4 - ESTABLISHING CIRCUMSTANCES
Relevant Key Activity
PERFORMANCE STANDARD (to be met by investigating
inspector)
Monitoring arrangements (to be conducted by line
manager)
1 & 2 Identify immediate and underlying causes.
FOCUS entries.
1 & 2 Identify potential breaches of the law.
FOCUS entries.
1 & 2 Ensure appropriate remedial action has
been taken, to prevent immediate reoccurrence.
FOCUS entries, enforcement notices.
2 Identify and follow up reasonable lines of enquiry.
FOCUS entries. |
| |
WI 5 - INTERVIEWING
Relevant Key Activity
PERFORMANCE STANDARD (to be met by investigating
inspector
Monitoring arrangements (to be conducted by line
manager)
1 Prepare appropriately for interviews.
2 Interview in an appropriate order.
3 Conduct interview in a professional manner.
4 Make appropriate records of interviews. FOCUS
entries. Inspector notebook entries.
5 Make appropriate use of any police interviews.
6 Arrange for joint interviews with other enforcing
authorities where appropriate. |
| |
WI 6 - ESTABLISHING PHYSICAL EVIDENCE
Relevant Key Activity
PERFORMANCE STANDARD (to be met by investigating
inspector)
Monitoring arrangements (to be conducted by line
manager)
1 Identify and preserve physical evidence using
appropriate powers as soon as possible once the
investigation begins. Photographs, samples, exhibits.
2 Record factual details. FOCUS entries, inspector
notebooks.
3 Recreate the circumstances of the incident where
appropriate. Photographs, videos.
4 Liaise with and use evidence collected by police/Home
Office forensic scientists when appropriate. |
| |
WI 7 - GATHERING INTELLIGENCE
Relevant Key Activity
PERFORMANCE STANDARD (to be met by investigating
inspector)
Monitoring arrangements (to be conducted by line
manager)
1 Disseminate information to sectors and other
interested parties in HSE when appropriate. Memos,
FOCUS entries including drop-down screens.
2 Generate a SAPID if appropriate given the circumstances
revealed by the investigation. SAPID Form. |
| |
WI 8 - ASSESSMENT OF EVIDENCE
Relevant Key Activity
PERFORMANCE STANDARD (to be met by investigating
inspector)
Monitoring arrangements (to be conducted by line
manager)
1 & 2 Assess evidence obtained and justify
and record any subsequent decisions once sanctioned
by the line manager. Discussions with line manager,
FOCUS entries and investigation reports.
4 Systematically apply EMM in accordance with
Appendix 2 EMM proforma for recording key EMM
outcomes and decisions.
4 Apply the principles of EMM in all other cases.
Discussions with line manager. |
| |
WI 9 - FOCUS RECORDING AND PREPARATION
OF FURTHER REPORTS
Relevant Key Activity
PERFORMANCE STANDARD (to be met by investigating
inspector)
Monitoring arrangements (to be conducted by line
manager)
1 Completion of investigation contacts and reports
on FOCUS within 10 days of contact. FOCUS entries
and FOCUS data quality monitoring.
2 Completion of further reports within one month
of completion of investigation. Review of further
reports by line manager. Discussions with line
manager on outcome. |
| |
|
| |
APPENDIX 2
(paras 44, 45, 46, 47)
ARRANGEMENTS FOR THE MONITORING OF INVESTIGATIONS
BAND 1
BAND 2
BAND 3
BAND 4
Fatal Accidents
All*
All
All
N/A
Prosecutions
All
All
All
All
All Investigations
-
-
Sample
All
Note
All = Line managers will carry out monitoring,
eg a band 3 or 4 investigation will be monitored
by a band 2, and a band 2 investigation will be
monitored by a band 1.
* In addition a band 1 will monitor all fatal
accidents where a prosecution report has not been
submitted.
Sample = One investigation during the first half
and another during the second half of the work
year. |
