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Research - HSE

HSE's 'Investigation Procedure"

This is an important document setting out how HSE inspectors (from Field Operations Directorate) should undertake investigations. It is produced by the HSE itself.

It is a thorough and detailed set of Guidance for these inspectors - which if followed (along with other guidance produced by the HSE) should ensure that HSE investigations are adequate to identify criminal offences on the part of companies, organisations, directors and other individuals.

HSE' Field Operations Directorate (FOD) are concerned with most workplaces under the jurisdication of the HSE - contruction, manufacturing, agriculture, service and energy sector. It however does not cover mining, large chemical plants or the nuclear industry. It is likely, however that other parts of the HSE will/should follow these procedures.

Although it is a public document (first produced in July 2002) this is the only website where you can access it. It is not yet available on the HSE's own website.

The document forms part of FOD's "Quality System Procedures & Guidance".

There is one part of this procedure which the CCA are not publishing - The Appendix to Work Instruction 5 on 'Interview Structure'. In the CCA's view, publication of this could hinder investigation by the HSE.

We publish it for the following reasons:

It will allow workers, the public, trade unions, lawyers and others to:
understand what are the standards of investigation that should be followed by HSE inspectors
assess whether HSE inspectors are following their own policy when undertaking investigation
judge whether or not the investigation policy itself is adequate. If you think there are ways in which this policy could be improved, contact the CCA as we will be feeding back comments to the HSE.
It will assist lawyers in particular to
consider whether or not an adequate investigation has been undertaken and whether or not a judicial review of the HSE is appropriate.

The investigation procedure is divided into ten different 'Work Instruction' (WI) which are themsleves divided into a number of different 'Key Activities' (KA). These are set out below.

It is too detailed a document to summarise. However, we have set out below some of the key points (Click Here). However we do suggest that you do not rely on these points, and read the document (or that part of the doucment that is relevant) in full.

There are a number of concerns that the HSE has concerning the procedure. Click Here to see these. (If you consider that there are other weaknesses, contact the CCA)

However before accessing these Work Instructions, by clicking below, it is worthwhle reading HSE's own introduction to the Procedure which you can access by Clicking Here. You can also access the different Work Instruction from that document.

Work Instructions (WI)
[KA=Key Activities]

WI 1 Planning
KA1 Establish the objectives of the investigation
KA2 Verify the current status and details of the incident
KA3 Identification of interested parties
KA4 Identification of staff competancies
KA5 Directing or using investigations by duty holders where appropriate
WI 2 Preparation
KA1 Identify relevant legal requirements, standards, guidance and policy to enable benchmarks to be established
KA2 Liaison, if appropriate within FOD and HSE
KA3 Consultation, if appropriate with expert help and other support
KA4 Obtaining necessary equipment
KA5 Communications and Briefing Colleagues
WI 3 Conduct and liaison
KA1 Conduct of initial on-site enquiries
KA2 Contact on site with duty-holders and their representatives
KA3 Contact with those affected and witnesses
KA4 Contact with bereaved relatives
KA5 Contact with employee representatives
KA6 Contact with solicitors representing those involved
KA7 Contact with members of the public, including pressure groups
KA8 Liaison with outside agencies
KA9 Contact with the Media
KA10 Recording information during an investigation
WI 4 Establishing circumstances
KA1 On site investigation methods
KA2 Identification and follow up of all reasonable lines of Enquiry
WI 5 Interviewing
KA1 Preperation for interviews
KA2 Who to interview and in what order
KA3 General conduct and structure of interviews
KA4 Note-taking and R=recording of interviews
KA5 Use of police interviews
KA6 Arrangements for joint interviews with other enforcing authorities
WI 6 Establishing physical evidence
KA1 Identification and preservation of evidence
KA2 Recording factual details
KA3 Recreation of the circumstances at the time of the incident
KA4 Liaison with and use of evidence collected by the police
WI 7 Gathering intelligence
KA1 Information of interest tosSectors and other parts of HSE
KA2 SAPIDS
WI 8 Assessment of evidence
KA1 Assessment and verification of information and evidence obtained
KA2 Investigation review
KA3 Informal review
KA4 Application of Enforcement Management Model (EMM)
WI 9 FOCUS recording and preparation of further reports
KA1 FOCUS recording
KA2 Preperation of further reports


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CCA Key Points
Below are some of the points included in the Investigation Procedure that are particularly noteworthy.

Introduction
Para 7 It is FOD Policy that investigations will be "provided with adequate resources and support, including information, equipment and staffing"

Work Instruction 1 (Planning)
Key Instruction 1, para 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.
Key Instruction 1, Para 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"
Key Instruction 1, Para 8 "Planning should also identify: ...
any history of previous advice, enforcement action or similar incidents involving the dutyholders identified by, eg the incumbent overview;"
Key Instruction 1, Para 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."
Key Instruction 5, Para 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."
Key Instruction 5, Para 29 To qualify as a RIDDOR investigation ... purposes, the investigation should, other than in exceptional circumstances, include a site visit.

Work Instruction 3 (Conduct and Liaison)
Key Instruction 3, Para 16 "If the reported incident has resulted in anybody being hurt then they should be interviewed in every investigation unless there are exceptional circumstances preventing this. Interviews should normally be in person, but may be by phone where this would not hinder the outcome of the investigation. If the inspector proposes, for other reasons, not to contact the IP, they must agree this with their line manager."
Key Instruction 3, Para 17 and 18 The inspector should inform the injured person (IP) of the outcome of the investigation. ...As a general principle, the inspector should interview the IP as soon as possible after the incident.
Key Instruction 3, Para 23 As a general principle, inspectors should always try to establish whether people other than those directly affected were exposed to the same risk(s) at or before the time of the incident. Evidence to this effect can add weight to any subsequent prosecution.
Key Instruction 3, Para 24 As a general principle, inspectors should interview all witnesses as soon as possible after the incident so that:
(1) details will be easier to recall;
(2) there will have been less opportunity for collusion between witnesses, or attempts to influence their evidence;
(3) it should be possible to use their natural desire to co-operate in finding out what has gone wrong.
Key Instruction 5, Para 26 and 27 Inspectors should make early contact with employees' representatives to let them know that an investigation is taking place ... Employee representatives may also be potential witnesses. They may be able to give information about:
(1) working practices and events prior to the incident;
(2) changes in conditions following the incident;
(3)

other witnesses management may be unaware of

(4) previous near misses or similar incidents; and
(5) relevant minutes of safety meetings.

Work Instruction 4 (Establishing Circumstances)
Key Instruction 1, Para 2 In the majority of cases, the objectives of an investigation are achieved by using the following range of methods:
(1) direct observation;
(2) interviewing witnesses;
(3) taking photographs and measurements;
(4) obtaining relevant data, documentation and physical evidence; and
(5) sampling or forensic or other analysis.
Key Instruction 1, Para 3 As the investigation progresses, inspectors should test information and evidence obtained against the lines of enquiry identified, and compare them to the legal requirements relevant to the circumstances, and any relevant benchmarks. They should identify any gaps in the information or evidence together with appropriate source(s) of further information or evidence required.
Key Instruction 1, Para 4 Inspectors should consider issuing enforcement notice(s) (having first applied the principles of EMM) at a first visit, if conditions which led to an incident have been allowed to continue or are repeated elsewhere. If the inspector institutes a prosecution following an incident, it may be appropriate to allege a further offence on the day of the investigation, if suitable preventive measures have not been taken. The issuing of notice(s) will reinforce such action.
Key Instruction 1, Para 5 During an investigation, inspectors should be aware of other potential breaches not related directly to the investigation and consider enforcement action where appropriate.
Key Instruction 1, Para 7and 9 Investigating inspectors should identify, and eliminate or confirm, all reasonable lines of enquiry relevant to the objectives of an investigation.... Failure to identify or adequately follow up all reasonable lines of enquiry can result in a failure to take appropriate enforcement action and result in external criticism.

Work Instruction 5 (Interviewing)
Key Instruction 2. para 5 After initial discussions, inspectors should not interview senior or other managers in depth (unless they are direct witnesses to the accident) until factual matters relating to the accident have been established.
Key Instruction 2. para 6 Inspectors should plan the order in which they interview witnesses to ensure that the findings and outcome of the investigation are not compromised. They should interview the following first (not necessarily in the order given), so far as is relevant and appropriate
(1) any injured people;
(2) workers with knowledge of the particular incident being investigated;
(3) other workers who have knowledge of the same or similar work (on the same day, or before or after the incident), and who can confirm, or contradict, any shortcomings which apparently led to the incident;
(4) any trade union and safety representatives with relevant knowledge; and
(5) other witnesses to the incident, eg members of the public
Key Instruction 2. para 7 Next, inspectors should interview supervisors and similar lower-level management, who have background knowledge and may also be able to describe systems of work and other steps taken to ensure safety. Question them concerning any instructions they had been given about the job and the instructions they had given to those carrying out the work activity. The interview should try to determine whether they were aware of actual as opposed to correct practices. Depending on what information such interviewees provide, reinterviewing of workers etc may be necessary.
Key Instruction 2. para 8 Inspectors should then assess information obtained from employees, if necessary with the assistance of specialist or other expert help. This will clarify the information they can gain from further questioning, before they interview managers.
Key Instruction 2. para 9 Finally, inspectors should interview senior managers, directors and individual dutyholders who can make admissions either in relation to their own or a companyâs liability.
Key Instruction 2. para 10 Inspectors may not decide, until a late stage in an investigation, to collect evidence with a view to legal proceedings. Observing the hierarchy of interviewing described above will help to ensure that the outcome of any investigation is not unwittingly prejudiced before they reach such a decision.

Work Instruction 6 (Establishing Physical Circumstances)
Key Instruction 1. para 7 Inspectors should identify and preserve physical evidence as early on in the investigation as possible. In cases of fatal or major accidents the police will attend the site first. They will preserve the scene and will make initial enquiries which can establish physical evidence such as which machine or piece of equipment was involved. They can also arrange for their technical support staff to take photographs and measurements should items of plant or equipment need to be removed before an HSE inspector arrives at the scene.
Key Instruction 1. para 9 Inspectors have the power under HSW Act s.20(2)(e) to direct that premises, or any part of them, or anything in them, be left undisturbed for so long as is reasonably necessary for the purposes of the investigation.
Key Instruction 1. para 11 and 12 When appropriate, inspectors should make informal arrangements with the employer to ensure the scene remains undisturbed without issuing a formal notice. ... If an inspector is unable to attend site and the occupier is unable to leave undisturbed for reasonably practicable reasons, then the inspector should tell the occupier to take photographs of the scene and keep any relevant physical evidence, at the very least.
Key Instruction 1. para 16 In most investigations all necessary evidence will be obtained from the dutyholders (particularly documentary evidence), employees, other first-hand witnesses of fact and HSE inspectors. Some investigations, however, will require more complex enquiries, and inspectors should be aware of and utilise, where appropriate, other sources of information and evidence. They include:
(1) manufacturers/suppliers;
(2) other enforcement agencies;
(3) phone records and details of subscribers;
(4) vehicle registered keeper;
(5) bank transaction details (proof of ownership);
(6) plans, drawings and calculations;
(7) reasonably practicable (accepted) industrial practice, confirmed usually by the SG;
(8) Companies House records (annual returns); and
(9) competent persons.

Work Instruction 8 (Assessment of Evidence)
Key Instruction 1. para 2 Inspectors should continually assess the evidence collected in order to determine whether the objectives of the investigation are likely to be achieved (see Work instruction 1 Key activity 1). They should identify potential offence(s) at this stage. They should identify elements necessary to prove an offence(s) against existing evidence. Inspectors should also ask the following questions when assessing evidence; does it:
(1) establish the circumstances satisfactorily or do grey areas or inconsistencies exist?
(2) provide sufficient evidence to prove a breach, ie are all points to prove covered?
(3) provide sufficient information to establish no breach has been made?
(4) identify all reasonable lines of enquiry?
(5) identify any potential defences?
(6) contain sufficient support from other sources such as physical evidence and expert witnesses?
Key Instruction 1. para 4 Assessment of evidence may identify other witnesses who may be able to offer more information concerning underlying causes/management issues, eg supervisors/managers. Evidence from such witnesses may add considerable value.
Key Instruction 1. para 6 Inspectors should also verify information and evidence obtained to date. Interviews with witnesses or statements will usually form the bulk of the information and evidence collected so far. It should be reviewed to ensure it is reliable and accurately reflects the circumstances.
Key Instruction 1. para 8 Inspectors should, so far as possible, and to the extent appropriate in the circumstances, determine the truth and accuracy of a witnessâs evidence by:
(1) checking it against the evidence of others and against independent facts;
(2) assessing and testing the probability and credibility of the allegations against other reasonable explanations for the incident;
(3) where necessary, planning to carry out further interviews with the injured person (IP) or others using suitable questioning techniques aimed at helping the interviewee overcome any difficulty in remembering details.
Key Instruction 1. para 9 If the truth of any personâs evidence is crucial to significant enforcement action, ie prosecution, inspectors should be careful to validate the evidence as described. Inspectors should remember that the conviction with which details are recounted is not a measure of their accuracy. If misleading evidence is not detected during an investigation it may have serious consequences for any prosecution resulting from the investigation.
Key Instruction 2. para 17 If an investigation has not been completed after 2 months, a meeting between the line manager and the investigating inspector should take place. The purpose of the meeting is to carry out an investigation review, decide on future action and identify specific reasonable time-scales, which should normally be at 2-monthly intervals, after which another review will be undertaken if the investigation has not been concluded. The purpose of the review is to ensure an investigation does not stagnate and to take into consideration matters such as witness availability, inquest hearings and expert witness reports, when agreeing any extension.
Key Instruction 2. para 22 The systematic application of EMM is defined by the procedure itself, eg all fatal accidents. Inspectors should apply the principles of EMM to all other investigations to facilitate the enforcement decision-making process in relation to the information and evidence obtained to date. See Enforcement Management Model.

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Weaknesses
There are two concerns:

In work instruction 6 on 'Establishing Physical Evidence' - there is nothing stated about accessing:
Accessing Board Minutes or other such documents:
Electrnoic Documents in the dutyholder's computers;


Also, in work instruction 6 it is stated at para 12
that

"If an inspector is unable to attend site and the occupier is unable to leave undisturbed for reasonably practicable reasons, then the inspector should tell the occupier to take photographs of the scene and keep any relevant physical evidence, at the very least."

There must be some concern that the HSE is delegating an investigative procedure to a duty holder who may be subject to a criminal investigation.

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Page last updated on May 5, 2003