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Research - HSE

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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:

KA 1 Establish the objectives of the investigation
KA 2 Verify the current status and details of the incident
KA 3 Identification of interested parties
KA 4 Identification of staff competencies
KA 5 Directing or using investigations by dutyholders where appropriate

 


 



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, eg 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 (eg 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 (ie 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 (eg 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 (eg 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, eg 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, contractorsâ representatives.

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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 dutyholderâs 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 eg 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 dutyholderâs 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 dutyholderâs 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 dutyholderâs 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, eg 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 dutyholderâs 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 dutyholderâs 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 (eg the ship on which an incident has occurred has sailed) or where it is inappropriate to visit (eg the tower scaffold has been dismantled) or the site has no material bearing on the incident (eg 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 Îinvestigationâ, 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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